James A. Young

Neuroplasticity and Its Applications for Rehabilitation

Stroke represents a major cause of death and disability. In just the last two decades, science has begun to appreciate the central nervous systems attempts to repair itself through a process termed neuroplasticity. The remodeling is a dynamic process subject to endogenous and exogenous forces. Rehabilitation has started to implement approaches based on objective measures such as diffusion tensor imaging and functional magnetic resonance. Newer modalities such as constraint-induced movement therapy and robotic interventions are being used for both short- and long-term functional gains. This review describes the various studies on neuroplasticity and the variety of interventions now available.

Predictors of agitated behavior during inpatient rehabilitation for traumatic brain injury

OBJECTIVE To identify predictors of the severity of agitated behavior during inpatient traumatic brain injury (TBI) rehabilitation. DESIGN Prospective, longitudinal observational study. SETTING Inpatient rehabilitation centers. PARTICIPANTS Consecutive patients enrolled between 2008 and 2011, admitted for inpatient rehabilitation after index TBI, who exhibited agitation during their stay (n=555, N=2130). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Daytime Agitated Behavior Scale scores. RESULTS Infection and lower FIM cognitive scores predicted more severe agitation. The medication classes associated with more severe agitation included sodium channel antagonist anticonvulsants, second-generation antipsychotics, and gamma-aminobutyric acid-A anxiolytics/hypnotics. Medication classes associated with less severe agitation included antiasthmatics, statins, and norepinephrine-dopamine-5 hydroxytryptamine (serotonin) agonist stimulants. CONCLUSIONS Further support is provided for the importance of careful serial monitoring of both agitation and cognition to provide early indicators of possible beneficial or adverse effects of pharmacologic interventions used for any purpose and for giving careful consideration to the effects of any intervention on underlying cognition when attempting to control agitation. Cognitive functioning was found to predict agitation, medications that have been found in previous studies to enhance cognition were associated with less agitation, and medications that can potentially suppress cognition were associated with more agitation. There could be factors other than the interventions that account for these relations. In addition, the study provides support for treatment of underlying disorders as a possible first step in management of agitation. Although the results of this study cannot be used to draw causal inferences, the associations that were found can be used to generate hypotheses about the most viable interventions that should be tested in future controlled trials.

Stroke Evaluation and Treatment

Abstract Cerebrovascular accidents remain the third leading cause of death in the United States, with many left with life-long disabilities. The causes and contributing factors of stroke are beginning to be well defined, but what is not appreciated are the various techniques for assisting recovery. Understanding what parts of the neurological and musculoskeletal exams predict short-term and long-term disabilities helps guide patients and families. Newer and effective rehabilitative approaches are available as are home, outpatient, and hospital-based sites for recovery. Improvements after stroke are now recognized to continue for months to years after the event. Available therapeutic techniques and evaluative studies are presented in this review.

Pharmacotherapy for traumatic brain injury: focus on sympathomimetics.

Traumatic brain injury (TBI) is a devastating neurological injury with broad manifestations. Unfortunately, its diagnosis and efficacious treatments remain elusive. Different post injury symptoms are exhibited at different time frames, indicative of a time-related progression of the pathology. Therefore, particular treatments must be tailored to the post injury time frame. This overview is focused on the secondary chronic phase following TBI and the value of sympathomimetic therapy during this phase. The various direct- and indirect-acting drugs are reviewed, and the treatment protocol employed by the author is described.

Poster 353: Failure of Spinal Fusion Instrumentation Because of a Lack of Preoperative Assessment of Osteoporosis: A Case Report

Disclosures: R. Matias, None. Patients or Programs: A 74-year-old white man with a history of thoracolumbar spondylosis with a failed spinal fusion. Program Description: The patient underwent a T10 to S1 posterior spinal fusion 2 years earlier and later developed progressive low back pain and difficulty walking. CT of the spine showed compression deformities involving T11 to L1 and L5 vertebrae, dislodgment of screws at T10 to L1, and moderately diffuse bone mineral loss. In addition, an extruded left S1 screw was read as “possibly compressing” the left S1 root. Patient underwent removal of old instrumentation and an extension of the fusion from T6 to S2. Before the second procedure, a bone mineral density (BMD) study demonstrated osteopenia. Setting: Hospital-based acute inpatient rehabilitation unit. Results: Before admission, the patient was at the modified independent level, with use of a straight cane and independent for all ADLs. After completion of his rehabilitation, he was able to improve in his gait, endurance, continence, and pain control. Discussion: Spinal fusion failure can be due in part to bone mineral loss, leading to stability and fixation difficulties. As a result, hardware breakthrough can occur with direct compression on the spinal cord and nerve roots. As displayed on this patient’s CT, osteopenia was present along with vertebral instrumentation failure. At present, no consistent preoperative BMD assessments, either by CT or dual energy x-ray absorptiometry, are commonly ordered for males. Risk factors for this patient included cigarette smoking, white ethnicity, and hormonal imbalances. Conclusions: A preoperative screening for BMD for male patients deemed high risk for osteopenia or osteoporosis is strongly suggested before spinal fusions. In addition, routine preoperative assessments may result in aggressive treatment of these conditions in preparation for spinal surgery or other orthopedic procedures.

Poster 88: risk assessment tool: predicting length of stay after elective hip and knee arthroplasty1

Abstract Setting: Tertiary care hospital. Program: Elective hip and knee arthroplasties. Program Description: A risk assessment tool was written to anticipate lengths of stay (LOS) in the acute rehabilitation setting for 113 patients. Categories included the home situation (caregiver presence, stairs, living alone), assistive devices, prior hip or knee procedures, neurologic problems, age, other medical concerns. Category scoring was weighted based on expected posthospital complications. The groups included a stay of ≥14 days; 10 to 14 days; 7 to 10 days; 4 to 7 days; and Assessment/Results: 66 of 113 patients were within the expected LOS for 58% accuracy—63.7% within 1 day and 72.6% within 2 days. The categories most consistently difficult to predict were those Discussion: Predicting acute rehabilitation LOS involves many factors. Advising patients and families about the expected duration assists in their time management. With this data, a bed reservation system can be developed by the rehabilitation unit, to assist with staffing issues, vacation needs, and facility maintenance. Weeks to months before the operation, the risk assessment tool and demographics are sent (electronically) to hospital reservations (to the acute facility and the rehabilitation unit as decided by the patient or family). Those patients with the low to mild risk levels were the most consistently difficult to predict. Other factors, including the expected procedure, may need to be added. Conclusions: A risk assessment tool to anticipate acute rehabilitation LOS was developed to aid patients and families and to provide a basis for a reservation system. The latter might streamline the entire hospitalization process for both patients and rehabilitation units.