Lisa Carney Anderson

Clinical measurement of limb spasticity in adults: state of the science.

ABSTRACT Spasticity is a neuromuscular dysfunction characterized by tight or stiff muscles. Spasticity occurs across the spectrum of upper motor neuron disease and complicates the course and quality of life of those affected. Accurate and precise assessment of spasticity is the first step in providing safe and effective treatments to patients for management of spasticity. Examiner evaluations (Ashworth Scale, Modified Ashworth, and Visual Analog Scale) and patient self-reports (Visual Analog Scale and Numeric Rating Scale) are used to assess spasticity in clinical practice. We reviewed the biology of spasticity and summarized research that assessed properties of scores obtained from clinical scales when used in a variety of upper motor neuron diseases. The definition of spasticity was inconsistent. Rater reliability or agreement on clinical scales varied widely. Correspondence with electromyogram results was mixed. There was dissimilarity in patient reports and examiner assessments. Scores from clinical scales are responsive (decrease after initiation of treatment with known effectiveness), but the utility of scores for indexing individual change associated with the natural history of upper motor neuron disease is unknown. Future research incorporating patient reports and examiner findings over time will help to clarify the definition and capture the essence of spasticity.

Clinical Understanding of Spasticity: Implications for Practice

Spasticity is a poorly understood phenomenon. The aim of this paper is to understand the effect of spasticity on daily life and identify bedside strategies that enhance patients function and improve comfort. Spasticity and clonus result from an upper motor neuron lesion that disinhibits the tendon stretch reflex; however, they are differentiated in the fact that spasticity results in a velocity dependent tightness of muscle whereas clonus results in uncontrollable jerks of the muscle. Clinical strategies that address function and comfort are paramount. This is a secondary content analysis using a qualitative research design. Adults experiencing spasticity associated with neuromuscular disorder were asked to participate during inpatient acute rehabilitation. They were asked to complete a semistructured interview to explain and describe the nature of their experienced spasticity on daily basis. Spasticity affects activities of daily living, function, and mobility. Undertreated spasticity can lead to pain, immobility, and risk of falls. There were missed opportunities to adequately care for patients with spasticity. Bedside care strategies identified by patients with spasticity are outlined. Uses of alternative therapies in conjunction with medications are needed to better manage spasticity. Patient reports on spasticity are important and should be part of clinical evaluation and practice.

Spasticity over time during acute rehabilitation: a study of patient and clinician scores.

AIMS The aims of this study were to describe spasticity trajectories as a function of time, gender, and diagnosis and to explore the correspondence between patient and clinician scores of spasticity. BACKGROUND Discrepancy between examiner assessment and patient rating of spasticity exists. Assessments that include the patient perspective are critical for patient safety. This mixed-method study provided patient descriptors of spasticity integrated with clinical scales. METHOD Twenty-three participants provided spasticity descriptors and rated their spasticity based on Numeric Rating Scale (NRS) scores. A clinician evaluated spasticity daily using the Modified Ashworth Scale (MAS). This resulted in 1976 points of data for analysis. RESULTS Spasticity was highly variable over time. The empirical correspondence between the clinician-rated MAS and the patient-rated NRS revealed that patient and examiner understanding of spasticity were diverged considerably. CONCLUSIONS Clinical evaluation protocols should include patient reports on spasticity. Knowledge about patient word choice can enhance patient-provider communication.

Perioperative medication withholding in patients with Parkinson's disease: a retrospective electronic health records review.

Background Carbidopa-levodopa (Sinemet), the gold-standard treatment for Parkinsons disease, has a short half-life of one to two hours. When patients with Parkinsons disease are placed on NPO (nil per os, or nothing by mouth) status for surgery, they may miss several doses of carbidopa-levodopa, possibly resulting in exacerbation of Parkinsons disease symptoms. Clear guidelines regarding perioperative symptom management are lacking. Objectives The goals of this study were threefold: to measure the perioperative duration of the withholding of carbidopa-levodopa in patients with Parkinsons disease, to record the time of day surgeries were performed on these patients, and to record perioperative exacerbations of Parkinsons disease symptoms. Methods We conducted a retrospective review of patient electronic health records at a Midwestern public medical center. After applying inclusion and exclusion criteria and evaluating the eligible records, we had a final sample of 89 separate surgical events for 67 discrete patients who had been diagnosed with Parkinsons disease, had undergone any type of surgery excepting Parkinsons disease surgeries, and were taking carbidopa-levodopa. Results The median duration of carbidopa-levodopa withholding was 12.35 hours, with most surgical procedures (86%) starting at 9 AM or later. The most commonly reported exacerbation of Parkinsons disease symptoms was agitation or confusion. Conclusions For best symptom management, careful consideration should be given to scheduling surgery at the earliest possible time, administering medications as close to the patients usual dosing schedule as possible, and providing nursing education about optimal medication management for this patient population.

A survey of student engagement with multiple resources in an undergraduate physiology course: retrieve or look it up

Retrieval practice, a deep-learning technique in which the learner attempts to recall a concept of interest from memory, has been shown to be more effective than surface-learning techniques, such as rereading a textbook. Accordingly, textbook publishers are developing supplemental resources that are purported to improve student learning outcomes by encouraging deep learning and critical thinking. The purpose of this study is to 1) survey students in a physiology course about their use of multiple course resources; and 2) assess the effect of self-reported engagement in course resources on learning outcomes, as assessed by comparing course grades. Students who had completed an undergraduate physiology course were sent an online survey about their course experience; two reminders were e-mailed. Students were asked to report their physiology course grade, satisfaction with how much they had learned, which resources they had used, and how they had completed course assignments (critical thinking exercises and online quizzes), i.e., whether they had 1) looked up answers online, 2) looked up answers in the textbook, 3) tried to figure out the answers before using the textbook, or 4) only used their recall. Categories 1 and 2 were considered nonretrieval strategies, and categories 3 and 4 were considered retrieval strategies. There was no association with the type of resource students used and course grade or course satisfaction. Students who practiced retrieval strategies achieved significantly higher course grades than students who did not for both critical thinking exercises and online quizzes.

Best practices for learning physiology: combining classroom and online methods

Physiology is a requisite course for many professional allied health programs and is a foundational science for learning pathophysiology, health assessment, and pharmacology. Given the demand for online learning in the health sciences, it is important to evaluate the efficacy of online and in-class teaching methods, especially as they are combined to form hybrid courses. The purpose of this study was to compare two hybrid physiology sections in which one section was offered mostly in-class (85% in-class), and the other section was offered mostly online (85% online). The two sections in 2 yr (year 1 and year 2) were compared in terms of knowledge of physiology measured in exam scores and pretest-posttest improvement, and in measures of student satisfaction with teaching. In year 1, there were some differences on individual exam scores between the two sections, but no significant differences in mean exam scores or in pretest-posttest improvements. However, in terms of student satisfaction, the mostly in-class students in year 1 rated the instructor significantly higher than did the mostly online students. Comparisons between in-class and online students in the year 2 cohort yielded data that showed that mean exam scores were not statistically different, but pre-post changes were significantly greater in the mostly online section; student satisfaction among mostly online students also improved significantly. Education researchers must investigate effective combinations of in-class and online methods for student learning outcomes, while maintaining the flexibility and convenience that online methods provide.

Perioperative medication withholding in patients disease: A retrospective electronic health records review

Background Carbidopa-levodopa (Sinemet), the gold-standard treatment for Parkinsons disease, has a short half-life of one to two hours. When patients with Parkinsons disease are placed on NPO (nil per os, or nothing by mouth) status for surgery, they may miss several doses of carbidopa-levodopa, possibly resulting in exacerbation of Parkinsons disease symptoms. Clear guidelines regarding perioperative symptom management are lacking. Objectives The goals of this study were threefold: to measure the perioperative duration of the withholding of carbidopa-levodopa in patients with Parkinsons disease, to record the time of day surgeries were performed on these patients, and to record perioperative exacerbations of Parkinsons disease symptoms. Methods We conducted a retrospective review of patient electronic health records at a Midwestern public medical center. After applying inclusion and exclusion criteria and evaluating the eligible records, we had a final sample of 89 separate surgical events for 67 discrete patients who had been diagnosed with Parkinsons disease, had undergone any type of surgery excepting Parkinsons disease surgeries, and were taking carbidopa-levodopa. Results The median duration of carbidopa-levodopa withholding was 12.35 hours, with most surgical procedures (86%) starting at 9 AM or later. The most commonly reported exacerbation of Parkinsons disease symptoms was agitation or confusion. Conclusions For best symptom management, careful consideration should be given to scheduling surgery at the earliest possible time, administering medications as close to the patients usual dosing schedule as possible, and providing nursing education about optimal medication management for this patient population.

Original Research: Perioperative Medication Withholding in Patients with Parkinsonʼs Disease

Background Carbidopa-levodopa (Sinemet), the gold-standard treatment for Parkinsons disease, has a short half-life of one to two hours. When patients with Parkinsons disease are placed on NPO (nil per os, or nothing by mouth) status for surgery, they may miss several doses of carbidopa-levodopa, possibly resulting in exacerbation of Parkinsons disease symptoms. Clear guidelines regarding perioperative symptom management are lacking. Objectives The goals of this study were threefold: to measure the perioperative duration of the withholding of carbidopa-levodopa in patients with Parkinsons disease, to record the time of day surgeries were performed on these patients, and to record perioperative exacerbations of Parkinsons disease symptoms. Methods We conducted a retrospective review of patient electronic health records at a Midwestern public medical center. After applying inclusion and exclusion criteria and evaluating the eligible records, we had a final sample of 89 separate surgical events for 67 discrete patients who had been diagnosed with Parkinsons disease, had undergone any type of surgery excepting Parkinsons disease surgeries, and were taking carbidopa-levodopa. Results The median duration of carbidopa-levodopa withholding was 12.35 hours, with most surgical procedures (86%) starting at 9 AM or later. The most commonly reported exacerbation of Parkinsons disease symptoms was agitation or confusion. Conclusions For best symptom management, careful consideration should be given to scheduling surgery at the earliest possible time, administering medications as close to the patients usual dosing schedule as possible, and providing nursing education about optimal medication management for this patient population.