James J. Czyrny

Admission balance and outcomes of patients admitted for acute inpatient rehabilitation.

The objective of the study contained herein was to evaluate the clinical use of the Berg Balance Scale in a heterogeneous acute inpatient rehabilitation population and to assess the relationship between balance scores at admission and rehabilitation outcomes, including functional gain and length of stay. This was a prospective study of 45 patients with diagnoses including stroke (n = 15), traumatic brain injury (n = 19), and other impairments (n = 11) who were admitted for acute inpatient rehabilitation. Functional ability was evaluated with the Functional Independence Measure (FIM) instrument, and balance was measured using the 14-item Berg Balance Scale. These measures were assessed both at admission to and discharge from inpatient rehabilitation. Correlation and multiple regression analyses were used to determine the relationship between balance and functional ability scores at admission and rehabilitation outcomes at discharge, including length of stay, functional gain, and efficiency. Analyses of variance comparing impairment groups indicated that patients with traumatic brain injury were younger than the stroke and other groups, but there were no group differences on FIM or balance scores at admission or discharge. There were no significant group differences for any of the outcome measures. When the impairment groups were collapsed into a single heterogeneous group, multiple regression analyses demonstrated that the sitting unsupported item score at admission accounted for 27% of the variation in length of stay, once demographic influences were controlled. The FIM efficiency score was predicted best by the total Berg Balance Scale score, with 22% of the variance accounted for. In contrast, balance scores did not provide predictive information about the FIM gain score beyond that already provided by the FIM-Total score at admission, which accounted for 10% of the variance once demographics were controlled. Balance scores collected at admission to inpatient rehabilitation, in whole and in part, were shown to account for moderate amounts of variation in length of stay and the FIM efficiency score. For several of the rehabilitation outcomes, balance scores at admission accounted for more variation than scores on the FIM instrument. These findings suggest that routine assessment of balance at admission to inpatient rehabilitation may enhance the ability to predict rehabilitation outcomes beyond that provided by assessment of functional status alone.

Nerve palsy during femoral lengthening: MRI, electrical, and histologic findings in the central and peripheral nervous systems--a canine model.

Six dogs femurs were lengthened until complete peroneal palsy was present. Ten-24 days later MRIs of the spinal cords were normal. EMGs located lesions at the spinal foramina in five dogs and at the lumbar plexus in one. In all dogs nerve conduction below the lesions was normal and amplitudes were diminished. Muscle histology confirmed neurogenic atrophy. Nerve histology at the sites of the lesions showed myelin and axon changes, but there was no Wallerian degeneration at or distal to those sites. Thus, the nerve lesions were either a variant of Sunderland first degree injury or were developing into second degree.

Rehabilitation of amputees with end-stage renal disease. Functional outcome and cost.

ABSTRACTA retrospective chart review was performed on 19 lower extremity amputees with end-stage renal disease (ESRD) on dialysis and 19 controls with peripheral vascular disease (PVD) without ESRD to compare functional outcome with costs of rehabilitation. The groups were similar demographically and by etiology, level and side of amputation. Functional outcome as measured by Functional Independence Measure (FIM) scores did not show a significant difference between the groups on admission (P = 0.19), discharge (P = 0.20) or change in FIM (P = 0.94). The percentage of successful prosthetic ambulators (P = 0.74) and the duration of prosthetic training (P = 0.60) were not statistically different between the groups. Cost as measured by total hospital length of stay (LOS) was not significantly different (P = 0.43), but the renal group showed a significantly longer acute hospital LOS (P = 0.02) and a trend for a shorter rehabilitation LOS (P = 0.08). Mortality, discharge setting and home care arrangements on discharge were similar for the groups. The renal group had a significantly greater number of co-morbidities than the non-renal group (P = 0.002). Despite the large number of medical problems, amputees on renal dialysis admitted to acute rehabilitation had similar outcomes with similar costs to amputees with PVD without renal failure.

Monozygotic female twin carriers discordant for the clinical manifestations of Duchenne muscular dystrophy

We studied twin sisters, in their sixth decade, who were obligate carriers of Duchenne dystrophy. One had a slowly progressing limb-girdle myopathy since her mid-20s. The other sister showed no evidence of neuromuscular disease by history or on physical examination but had high serum CK values and degeneration and regeneration of fibers in a muscle biopsy. Otherwise, they were phenotypically identical, karyotypically normal females with cytogenetically normal X-chromosomes. Based on red cell and HLA loci antigen determinations, there was a 99.2% probability that they were monozygotic. The mutant gene segregating in the family is probably linked to the Xp21 DNA marker pERT87.

Functional outcomes of patients with multiple limb trauma.

A retrospective chart review was performed to assess the effects of acute care hospital-based rehabilitation in patients with multiple limb trauma on functional status and length of stay and to determine whether the distribution of limbs involved has any effect on these variables. Admission and discharge motor Function Independence Measure scores and length of stay were compared for all patients and the injury subgroups. Significant functional gains were made between admission motor Functional Independence Measure (45.4+/-11.9) and discharge motor Functional Independence Measure (74.1+/-11.6; P < 0.05) for the group as a whole and across subgroups, with no significant differences between the subgroups. For all patients, the rehabilitation length of stay was 27.7+/-23.0, with again no difference noted between the subgroups. Individuals with functional deficits attributable to multiple limb trauma benefit significantly from comprehensive intensive acute inpatient rehabilitation. The distribution of limbs involved has little effect on functional outcome or length of stay.

Hyperhidrosis as the presenting symptom in post-traumatic syringomyelia

Post-traumatic syringomyelia is now a well known entity and occurs months or years after a spinal cord injury. The presenting symptoms are usually pain, progressive motor weakness, sensory changes, and increased spasticity. Profuse sweating or hyperhidrosis can be a symptom of the post-traumatic syrinx or can occur in autonomic dysreflexia provoked by peripheral stimuli. We present two patients with cervical spine fractures whose presenting symptom of posttraumatic syringomyelia was hyperhidrosis affected by posture. The pathophysiology involved and the management of these patients is discussed.

An unusual location for heterotopic ossification: lumbar anterior longitudinal ligament.

Heterotopic ossification (HO) is a well known complication of spinal cord injury. It usually affects the hips and knees, with less common involvement of the shoulders and elbows. We present a patient with incomplete tetraplegia who developed HO in the left hip and in the plane of the lumbar anterior longitudinal ligament from L3 to L5. During evaluation for the patients complaints of low back pain, a fracture was noted in the HO which was confirmed by three-dimensional CT scan. We postulate that this fracture contributed to his symptoms. Review of the literature on HO in spinal cord injured patients indicates this to be an unusual location for HO. Although HO of the lumbar anterior longitudinal ligament is a rare occurrence, this possibility should be considered in the evaluation of back pain in spinal cord injured patients.

PERIPHERAL NERVE REPAIR USING NON NEURAL SHEATHS AND CONDUITS

The purpose of this study was to evaluate and compare peripheral nerve regeneration following the use of alternative non neural materials to traditional direct repair techniques and autologous nerve graft. Autologous vein and synthetic polytetrafluoroethylene (PTFE) segments were used to repair standardized defects of the tibial nerve in rabbits. The materials served as sheaths for direct primary repairs and as conduits to bridge a gap in the nerve. Evaluations performed at five months revealed that direct primary repairs ensheathed by vein segments produced a significantly greater number of axons regenerating across the repair site, whereas PTFE, either as a sheath or conduit, failed to improve axonal regeneration. Also, vein conduits used to bridge nerve gaps was less effective than traditional nerve grafts.