Jon A. Mukand

Neuronal ensemble control of prosthetic devices by a human with tetraplegia.

Neuromotor prostheses (NMPs) aim to replace or restore lost motor functions in paralysed humans by routeing movement-related signals from the brain, around damaged parts of the nervous system, to external effectors. To translate preclinical results from intact animals to a clinically useful NMP, movement signals must persist in cortex after spinal cord injury and be engaged by movement intent when sensory inputs and limb movement are long absent. Furthermore, NMPs would require that intention-driven neuronal activity be converted into a control signal that enables useful tasks. Here we show initial results for a tetraplegic human (MN) using a pilot NMP. Neuronal ensemble activity recorded through a 96-microelectrode array implanted in primary motor cortex demonstrated that intended hand motion modulates cortical spiking patterns three years after spinal cord injury. Decoders were created, providing a ‘neural cursor’ with which MN opened simulated e-mail and operated devices such as a television, even while conversing. Furthermore, MN used neural control to open and close a prosthetic hand, and perform rudimentary actions with a multi-jointed robotic arm. These early results suggest that NMPs based upon intracortical neuronal ensemble spiking activity could provide a valuable new neurotechnology to restore independence for humans with paralysis.

Incidence of neurologic deficits and rehabilitation of patients with brain tumors.

Mukand JA, Blackinton DD, Crincoli MG, Lee JJ, Santos BB: Incidence of neurologic deficits and rehabilitation of patients with brain tumors. Am J Phys Med Rehabil 2001;80:346–350. ObjectiveTo report and discuss common neurologic problems in adults with brain tumors admitted for inpatient rehabilitation at an acute rehabilitation center. DesignRetrospective, descriptive, case series of 51 consecutive adult patients (65% male), with a variety of tumor types (31.3% glioblastoma, 25.5% meningioma, and 25.5% metastatic). Outcome measures were the functional status as measured by the FIM™ scores, the length of rehabilitation stay, and discharge dispositions. ResultsThe most common deficit was impaired cognition (80%), followed by weakness (78%), visual-perceptual deficit (53%), sensory loss (38%), and bowel and bladder dysfunction (37%). Less common problems, in decreasing incidence, were cranial nerve palsy, dysarthria, dysphagia, aphasia, ataxia, and diplopia. Thirty-eight (74.5%) patients had three or more concurrent neurologic deficits, and 20 (39.2%) patients had five or more deficits. Concurrent deficits among patients with hemi- and tetraparesis involved cognition (n = 29 patients), visual-perceptual function, sensation, cranial nerve palsy, and neurogenic bowel/bladder. The average admission FIM score of 67.2 increased to 87.1 at the time of discharge, with similar gains between patients with primary brain tumor and metastatic disease. Thirty-five patients were discharged home, seven to a nursing home, and one to hospice care; there were eight acute transfers. ConclusionsImpaired cognition, weakness, and visual-perceptual deficits were the most common problems in this study population. Our study supports the benefits of comprehensive and interdisciplinary rehabilitation for patients with primary as well as metastatic brain tumors.

Pathological crying and laughing: Treatment with sertraline

OBJECTIVE To evaluate the efficacy of sertraline for treating pathological laughing and crying after stroke. DESIGN Case series. SETTING Inpatient rehabilitation units of a community and a tertiary-care hospital. PATIENTS One patient was a 62-year-old right-handed man who had two strokes approximately 2 years apart and had computed tomography consistent with a cerebral infarct involving the left middle cerebral artery branches in the left parietal lobe. A second patient was a 72-year-old right-handed man who had a right middle cerebral artery infarct. He had a questionable history of depression prior to the stroke. INTERVENTION Both patients had poststroke labile affect that was interfering with their rehabilitation. Sertraline was prescribed. MAIN OUTCOME MEASURES Pretreatment and posttreatment scores on the Pathological Crying and Laughing Scale and Functional Independent Measure. RESULTS Both patients showed significant improvement after taking sertraline-improvement that was reflected in their pretreatment and posttreatment scores on the Pathological Crying and Laughing Scale and Functional Independent Measure. The staff noted improvements in sleeping, eating, social interaction, and therapy participation. Both patients tolerated the sertraline well and had no significant side effects.

Promoting smoking cessation in the rehabilitation setting

&NA;Guilmette TJ, Motta SI, Shadel WG, Mukand J, Niaura R: Promoting smoking cessation in the rehabilitation setting. Am J Phys Med Rehabil 2001;80:560–562.

Cortically controlled brain-machine interface

Over the past ten years, we have tested and helped develop a multi-electrode array for chronic cortical recordings in behaving non-human primates. We have found that it is feasible to record from dozens of single units in the motor cortex for extended periods of time and that these signals can be decoded in a closed-loop, real-time system to generate goal-directed behavior of external devices. This work has culminated in a FDA clinical trial that has demonstrated that a tetraplegic patient can voluntarily modulate motor cortical activity in order to move a computer cursor to visual targets. Further advances in BMI technology using non-human primates have focused on using multiple modes of control from signals in different cortical areas. We demonstrate that primary motor cortical activity may be optimized for continuous movement control whereas signals from the premotor cortex may be better suited for discrete target selection. We propose a hybrid BMI whereby decoding can be voluntarily switched from discrete to continuous control modes

Common causes of knee effusions in spinal cord injury : A random study

Mukand J, Sniger W, Kaufman J, Biener-Bergman S: Common causes of knee effusions in spinal cord injury: a random study. Am J Phys Med Rehabil 1998; 77:113–117 Patients with spinal cord injury are predisposed to knee effusions owing to osteoporosis, heterotopic ossification, trauma, and benign hydrarthrosis. This retrospective review discusses 11 patients with spinal cord injury and knee effusions seen during two years. One objective is to correlate the initial diagnosis based on clinical findings with the final diagnosis based on synovial fluid analysis and radiographic studies. Another is to describe the variety and complexity of clinical situations that involve knee effusions in spinal cord injury. The initial diagnosis was different from the final diagnosis in all of our cases. The final diagnoses were trauma (6 cases), pseudogout (2 cases), spasticity, fracture of the tibial plateau, septic joint, and tears of the anterior cruciate and lateral collateral ligaments. Knee effusions in this unique population must be carefully investigated to avoid erroneous diagnoses based on the initial clinical presentation, which can be complicated by multiple medical problems.

Family Intervention: Telephone Tracking (FITT): A Pilot Stroke Outcome Study

Abstract Objective: The goal of this study was to preliminarily test the efficacy of a telephone intervention, Family Intervention: Telephone Tracking, designed to assist stroke survivors and their primary caregivers during the first 6 months after stroke. Method: Forty-nine stroke survivors and their caregivers were randomly assigned to treatment as usual or treatment as usual plus the telephone intervention. Global outcomes are reported for health care utilization, family functioning, and general functioning. Results: Family and general functioning were positively and significantly changed at 3 and 6 months. Health care utilization was positively and significantly changed at 3 months. Conclusion: Findings suggest that the model has the potential to decrease health care utilization and improve quality of life for stroke survivors and their caregivers. Further study is warranted.

Tendinopathy and Tendon Rupture Associated with Statins.

Use of statins may be associated with certain tendinopathies and tendon ruptures, especially of the Achilles, quadriceps, and distal biceps tendons.Tendinopathy usually occurs within the first year of statin use and improves after the drug therapy is stopped.Systemic conditions with a higher risk of tendon rupture include diabetes, gout, rheumatoid arthritis, and chronic kidney disease.Certain drugs, such as corticosteroids and fluoroquinolones, have also been implicated in tendon ruptures.Patients with these systemic conditions who are taking statins in combination with other drugs that increase the risk of tendon injury should be educated about this risk and alternative treatments, including diet and exercise.

The Prevalence of Cigarette Smoking in an Acute Inpatient Physical Medicine and Rehabilitation Population.

The purpose of this study was to determine the prevalence of cigarette smoking among patients before and after discharge from an acute inpatient physical medicine and rehabilitation unit and. to assess smokers’ interest in and desire for smoking cessation. A consecutive sample of inpatients (n = 233) admitted over a 5‐month period to a regional rehabilitation inpatient center for acute rehabilitation treatment was surveyed for their smoking patterns. Ten percent of patients admitted to rehabilitation were active smokers prior to their hospitalization. In spite of reporting high motivation to stop smoking, half were not interested in participating in a smoking cessation program if one were offered to them. Following discharge from inpatient rehabilitation, 54% of a small sample of patients who could be contacted had resumed smoking (all within 4 weeks of being home). Given the prevalence of smoking in this population and its adverse consequences on health and quality of life, we suggest that rehabilitation professionals actively address this health problem during the patients hospitalization.

A pilot study of pain management during rehabilitation for hip and knee arthroplasty

UNLABELLED {\it OBJECTIVE } To evaluate the efficacy of pain management in a clinical pathway for rehabilitation after hip and knee arthroplasty, in which scheduled medications are rapidly tapered and prn medications are continued throughout the inpatient stay. {\it STUDY DESIGN } A prospective cross-sectional study. {\it SETTING } General rehabilitation unit of a regional acute rehabilitation center. {\it PATIENTS } Twenty-nine patients admitted consecutively to the rehabilitation unit in three months. {\it OUTCOME MEASURES } Number of pills/day of prn pain medication, pain scores at admission and discharge, frequency of constipation and nausea, Functional Independence Measure (FIM) gain, and length of stay (LOS). {\it RESULTS } For all patients, prn pain medication use was 2.4 pills/day/patient; the mean FIM gain was 22.1; and the average LOS was 9.8 days. In comparison to the Vicodin group, patients on Darvocet N-100 had significantly fewer requests for prn pain medication each day (3.1 vs. 1.1, p < 0.01), significantly better FIM gains better (18.9 vs. 24.1, p < 0.05), and fewer side effects (nausea and constipation). {\it CONCLUSION } Choosing the right pain medication is imperative for achieving optimal efficiency in clinical pathways for orthopedic rehabilitation. In this pilot study, Darvocet N-100 is the preferred narcotic over codeine and its derivatives.