Mazlina Mazlan

Return to work after spinal cord injury: factors related to time to first job

Study design:Cross-sectional survey.Objectives:To investigate factors related to length of time between spinal cord injury (SCI) onset and start of first post-injury employment.Setting:Persons living with SCI in the community who are members of a disability support organization.Methods:Participants were randomly selected from the membership list of a non-governmental voluntary organization. They met the following four criteria: traumatic SCI, minimum of 15 years of age at the time of survey, a minimum of 2 years after SCI and had been employed for some time since SCI. The main outcome measure was time (in years) from injury onset to beginning first post-injury job.Results:Participants averaged 4.9 years (s.d. 5.1) from the time of SCI to their first post-injury job, with a range of 3 months to 20 years. Fifty percent of the participants who eventually returned to work had done so by 4 years. Return to pre-injury employer and employment were associated with early return, whereas having less years in education and being older at the time of injury were associated with longer time to return to work.Conclusion:Rehabilitation team need to consider return to employment as a realistic goal even many years after SCI. Perhaps a focus on returning more people to their pre-injury employer and employment with added focus and input from rehabilitation team for those with lower education status and older age at time of injury might expedite the process of reintegration.

Concomitant injuries and its influence on functional outcome after traumatic brain injury.

Abstract Purpose: This study aims to describe the presence and severity of extracranial concomitant injuries in traumatic brain injury (TBI) patients and to ascertain their effect on long-term functional outcome. Method: A retrospective cohort study was performed in a single-center recruiting patients with first episode of TBI. The types and severity of extracranial concomitant injuries were documented for patients who fulfilled the inclusion criteria. Injuries with Abbreviated Injury Scale (AIS) grade 3–6 were considered to be high grade. A cross-sectional functional assessment was conducted at 18 months post-injury using Glasgow Outcome Scale. Results: A total of 100 patients were included in the analysis. Extracranial concomitant injuries were seen in 78% of the patients. Three commonest injuries were facial (44%), lower extremity (20%) and upper extremity (12%) injuries. Among the AIS grade ≥ 3, injury involving the chest was most common (41%). Presence of extracranial concomitant injuries AIS grade ≥ 3 was significantly associated with disability in TBI patients at 18 months (OR 12.74, 95% CI 2.39–67.95, p = 0.003). Conclusion: Presence of extracranial concomitant injuries was high. In TBI survivors, extracranial concomitant injuries AIS grade ≥ 3 influenced the long-term functional outcome at 18 months, causing moderate and severe disabilities. Implications for Rehabilitation Concomitant injuries should be suspected in patients with traumatic brain injury, especially in a high-speed trauma mechanisms as the incidence can be as high as 78% as in this study and may interfere with the long term rehabilitation and outcome. This study shows that severe extra cranial concomitant injuries are associated with a poor long term functional outcome even in the mild traumatic brain injury patients and therefore need to be addressed early in the rehabilitation of this group of patients. Early diagnosis and management of severe concomitant injuries is warranted and may improve the functional gains in the long term after traumatic brain injury.

Effectiveness of a Video-Based Therapy Program at Home After Acute Stroke: A Randomized Controlled Trial

OBJECTIVE To evaluate the effectiveness of an intervention using video to deliver therapy at home for patients with stroke. DESIGN Randomized controlled trial. SETTING The neurology ward and rehabilitation medicine department of a tertiary hospital. PARTICIPANTS Patients with stroke (N=90). There were 44 patients in the intervention group and 46 patients in the control group. INTERVENTIONS The intervention group received a combination of at-home rehabilitation guided by a digital videodisk containing therapy techniques and twice-monthly outpatient follow-up for 3 months. The conventional therapy group (control) attended weekly outpatient therapy sessions. MAIN OUTCOME MEASURES The primary outcome measure was the modified Barthel Index (MBI) score. The secondary measures were the incidence of poststroke complications and the Caregiver Strain Index. RESULTS At 3 months, there were no significant differences with regard to the number of patients with improved MBI score, complication rate, or Caregiver Strain Index score between the 2 groups. Both groups had significant increases in the MBI score at 3 months (P<.001 for both groups). Regression analysis revealed that only stroke severity significantly influenced the MBI score (P<.001), complication rate (P<.01), and caregiver stress level (P<.05). CONCLUSIONS Video-based therapy at home for post-acute stroke patients is safe, does not negatively impact independence, and is not stressful for caregivers.

A Double-Blind Randomized Controlled Trial Investigating the Most Efficacious Dose of Botulinum Toxin-A for Sialorrhea Treatment in Asian Adults with Neurological Diseases

This study aims to determine the most efficacious dose of Botulinum neurotoxin type A (BoNT-A) in reducing sialorrhea in Asian adults with neurological diseases. A prospective, double-blind randomized controlled trial was conducted over 24 weeks. Thirty patients with significant sialorrhea were randomly assigned to receive a BoNT-A (Dysport®) injection into the submandibular and the parotid glands bilaterally via an ultrasound guidance. The total dose given per patient was either BoNT-A injection of (i) 50 U; (ii) 100 U; or (iii) 200 U. The primary outcome was the amount of saliva reduction, measured by the differential weight (wet versus dry) of intraoral dental gauze at baseline and at 2, 6, 12, and 24 weeks after injection. The secondary outcome was the subjective report of drooling using the Drooling Frequency and Severity Scale (DFS). Saliva reduction was observed in response to all BoNT-A doses in 17 patients who completed the assessments. Although no statistically significant difference among the doses was found, the measured reduction was greater in groups that received higher doses (100 U and 200 U). The group receiving 200 U of Dysport® showed the greatest reduction of saliva until 24 weeks and reported the most significant improvement in the DFS score.

Life satisfaction and strain among informal caregivers of patients with traumatic brain injury in Malaysia.

Abstract Purpose: This study aims to determine the life satisfaction and strain on informal caregivers when caring for traumatic brain injury (TBI) patients and to examine the factors predicting the level of strain among the informal caregivers. Method: A cross-sectional survey on a purposive sampling was performed in a single centre in Malaysia recruiting caregivers of patients with TBI. Life Satisfaction Questionnaire-9 and Caregiver Strain Index questionnaires were used to ascertain the life satisfaction and strain of caregivers respectively. Relationship between life satisfaction and strain was analysed, together with factors significantly associated with strain. Results: A total of 141 caregivers (77.3% women, average age of 46.1 years ±12.8 and mean duration of caregiving of 24.8 months ± 14.3) were included in the analysis. Most caregivers (75%) were satisfied with their lives but more than half claimed to have strain (57%). There was a significant relationship between life satisfaction and strain among the caregivers (p < 0.001). From a multiple linear regression analysis, a caregiver’s monthly income of less than RM3000 (OR 6.48, 95% CI 1.48–28.40, p = 0.04), presence of patient’s neurobehavioural disturbances (OR 4.48, 95% CI 1.60–12.55, p = 0.004) and cognitive dysfunctions (OR 31.72, 95% CI 10.27–97.96, p < 0.001) were significant predictors of caregiver’s strain. Conclusion: Caregivers with lower monthly income and caring for TBI patients with cognitive and neurobehavioural disturbances are at higher risk of developing strain. Rehabilitation interventions post-discharge should aim at supporting the caregivers at risk. Implications for Rehabilitation Informal caregivers of patients with traumatic brain injury who are not satisfied with their lives are most likely experiencing strain. Caregivers in Malaysia who are at high risk of experiencing strain are those with lower monthly income and care for patients with significant cognitive and neurobehavioural disturbances. Efforts to reduce strain in caregivers at risk should be included in the post-discharge rehabilitation programme in Malaysia.

The effect of feet position on standing balance in patients with diabetes

Feet displacement is recognized to be an important element in standing and is also linked to postural instability in elderly people with diabetes. This study investigates standing balance in diabetic patients in four asymmetric feet displacements. Quiet standing balance was investigated using the Biodex Balance System in 18 diabetic patients and compared with 18 control elderly subjects. The four standing conditions, namely, comfortable feet position, preferred feet position with a stance width of 17 cm and 15° angle between the medial borders, feet side by side, and heel side by side with a 30° angle between medial edges of feet were evaluated (i.e. eyes opened, eyes closed). The overall stability was calculated by measuring anterior–posterior and medial–lateral indices in standing conditions. Differences among feet positions were compared using an analysis of variance and the independent t-test. The diabetic patients were unstable in the medial–lateral direction when standing with feet side by side versus heel side by side with a 30° angle between medial edges of feet (p = 0.012 and 0.011, respectively), while in controls the anterior–posterior stability scores between standing in preferred foot position with stance width of 17 cm and 15° angle between the medial borders versus feet side by side, and heel side by side with a 30° angle between medial edges of feet versus preferred foot position with stance width of 17 cm and 15° angle between the medial borders had significant difference (p < 0.05). The anterior–posterior stability scores of diabetic subjects with feet side by side versus comfortable foot position (p = 0.047) and heel side by side with a 30° angle between medial edges of feet versus comfortable foot position (p = 0.016) when they closed their eyes during the test had significant difference. Results confirmed that diabetic patients have greater instability in the medial–lateral direction when the base of support reduces and visual clue has an important role in standing balance.

Effect of Modified Otago Exercises on Postural Balance, Fear of Falling, and Fall Risk in Older Fallers With Knee Osteoarthritis and Impaired Gait and Balance: A Secondary Analysis

Osteoarthritis (OA) is considered an established risk factor for falls. Published studies evaluating secondary falls prevention strategies among individuals with OA are limited.

Intracerebral haemorrhage following uncontrolled autonomic dysreflexia post suprapubic catheter placement surgery

Introduction:We describe a case of intracerebral haemorrhage (ICH) following uncontrolled episodes of autonomic dysreflexia (AD) within 24 h of a minor urological procedure.Case presentation:A 33-year-old active paraplegic patient T1 Association Impairment Scale A underwent an elective suprapubic catheter (SPC) placement for bladder management. The surgery was done under general anaesthesia and was uneventful. Four hours after surgery, he developed haematuria and multiple blood clots in the urine, which eventually caused blockage of the SPC and resulted in symptomatic AD. The clots and blockage persisted, which continued to trigger repeated episodes of increased blood pressure (BP) and AD. Despite medical treatment with sublingual nitrate to lower the increased BP, the patient subsequently developed massive left ICH presenting with right upper limb weakness, facial asymmetry and inability to speak. He continued to have fluctuating BP measurements for 11 days post event with severe hypertensive and hypotensive episodes. This presented a challenge in the BP management as well as post-ICH management. He underwent an intensive neurorehabilitation programme as soon as the BP had stabilized.Discussion:Severe neurological complications of AD are rare. In this case report, we highlight the importance of close monitoring of BP and AD symptoms after an SPC procedure, the challenges in BP management and the subsequent importance of an early rehabilitation programme after ICH secondary to uncontrolled AD.

Unilateral ankle dorsiflexor spasticity: an uncommon, disabling complication of transverse myelitis.

Spasticity is a common complication after an upper motor neuron lesion and can involve a single or multiple muscle groups. When spasticity involves muscles around the foot, the typical pattern is ankle plantar flexed and inverted and toes flexed and adducted, giving rise to equinovarus deformity [1]. This pattern occurs due to the involvement of several muscles working in combination. Spasticity of the gastrocnemius, soleus and toe flexor muscles causes the ankle to plantarflex while the posterior tibialis muscle adds to the inward turn of the foot [2, 3]. Spasticity can also occur in a single muscle in the foot, for example spasticity of the extensor hallucis longus (EHL), also known as hitchhikers toe. This condition, albeit focal, occasionally causes pain and discomfort and is worth treating. However, spasticity involving a single muscle group such as the ankle dorsiflexors is rare and the complications are unknown. We report on a patient diagnosed with transverse myelitis presenting an unusual pattern of lower limb spasticity involving unilateral ankle dorsiflexor muscles. The spasticity resulted in foot deformity and difficulty wearing shoes, impairing gait, causing discomfort and generating disabili ties in activities of daily living (ADL). The patient is a 59-year-old woman diagnosed with transverse myelitis following symptoms of acute lower limb weakness and incontinent bladder and bowel. The patients initial clinical findings revealed flaccid tone and areflexia with Medical Research Council (MRC) grade 0/5 motor power in both of the lower limbs. Both upper limbs were intact neurologically. Pin prick sensation was impaired bilaterally from spinal level T8 downwards. Magnetic resonance imaging of the spinal cord disclosed a hyperintense area from the level of T9 vertebra to the conus medullaris. She was treated with 1 g of intravenous (IV) methylprednisolone for 5 days and three courses of intravenous immunoglobulin. The patients neurological impairments improved gradually after treatment. At 18 months, her right lower limb tone was normal with MRC grade 4/5 power. Her left lower limb tone was flaccid proximally. Distally, there was increased tone with ankle dorsiflexors showing Modified Ashworth Scale (MAS) grade 2 spasticity and toe extensors with MAS grade 3 spasticity (Figure 1). Her hip flexion had MRC grade 3/5, knee flexion and extension had MRC grade 2/5, whereas ankle dorsiflexion and plantarflexion had MRC grade 1/5. Pin prick sensation improved markedly with only impairment over bilateral lower legs remaining. Functionally, she was able to stand and walk therapeutically using a walking frame. Figure 1 Anterior view of lower limbs showing left foot ankle dorsiflexion and toes hyperextension The patient complained that her left foot and toes spontaneously hyperextended when she tried to move her left leg. This became more prominent when she was standing. As a result, she had difficulties balancing herself standing and had to bear weight on her left heel during the stance phase of walking. With her foot and toes hyperextended, she was only able to take ten steps before complaining of tiredness and severe discomfort on her left heel. She had to sit on a wheelchair to perform ADL that require standing. She also had difficulty performing lower body dressing because the hyperextended foot got in the way when she tried to put on her pants. She was also unable to put on her shoes due to the foot deformity. These complications caused severe disabilities and impaired her independence. The patient was treated with intramuscular injections of botulinum toxin type A (BTX-A) to the left tibialis anterior, EHL and extensor digitorum longus (EDL) under electromyography guidance followed by a programme of intensive stretching and strengthening exercises. The BTX-A dosages given were 50, 25 and 25 units to each muscle respectively without any complications. One month post-injection, the spasticity decreased a half grade for ankle dorsiflexors (MAS grade 1 + ) and one grade for toe extensors (MAS grade 2) when examined at rest. When assessed during standing and walking, her spasticity decreased significantly with the left foot achieving plantigrade position. Performing lower body dressing was not as cumbersome as before and she could wear shoes comfortably. Spasticity is a common complication following spinal cord lesions from traumatic and non-traumatic aetiologies with reported prevalence between 27% and 36% [4, 5]. It normally affects both lower limbs although the clinical patterns of spasticity are more varied in cases of incomplete lesions or incomplete recovery. In our case, the patient developed an uncommon pattern of ankle spasticity: a focal spasticity of unilateral ankle dorsiflexor muscles (tibialis anterior, EHL and EDL) following incomplete recovery of acute transverse myelitis. Problems have been encountered in patients with ankle spasticity affecting other muscles around the foot such as ankle plantar flexors, invertors or EHL alone [2, 3, 6]. In this case, the ankle dorsiflexor spasticity was causing problems for the patient. Not only did it affect the standing balance, it also reduced her walking tolerance and distance. The discomfort experienced was so severe that it caused her to compensate using a wheelchair to perform certain ADL. Treatment with BTX-A to the ankle dorsiflexors was useful to correct the abnormal foot posture, and thus achieved improved function. Despite the occurrence of disabling ankle spasticity, the patient has shown a marked overall recovery in sensory and motor power following treatment with IV methylprednisolone. Controlled studies of acute myelitis treatment are lacking but current expert consensus favours acute treatment with high-dose corticosteroids for a better outcome as observed in this case [7]. In cases with incomplete myelitis and refractory to steroid therapy, treatable causes such as bacterial infection should be suspected to facilitate appropriate treatments [8]. Spasticity is a common complication after transverse myelitis. However, involvement of unilateral ankle dorsiflexors is uncommon, so its effect on daily function is unknown. The treatment decision to use BTX-A injection relies partly on the pattern of muscle involvement, the spasticity severity and whether it causes problems or offers benefits to patients [9]. BTX-A injection targeting the specific muscles has been reported to reduce spasticity and improve the patients functional outcome [6, 10], which is also relevant in this case even though the spasticity presented is uncommon.

Early AbobotulinumtoxinA (Dysport®) in Post-Stroke Adult Upper Limb Spasticity: ONTIME Pilot Study

The ONTIME study investigated whether early post-stroke abobotulinumtoxinA injection delays appearance or progression of upper limb spasticity (ULS) symptoms. ONTIME (NCT02321436) was a 28-week, exploratory, double-blind, randomized, placebo-controlled study of abobotulinumtoxinA 500U in patients with ULS (Modified Ashworth Scale [MAS] score ≥ 2) 2–12 weeks post-stroke. Patients were either symptomatic or asymptomatic (only increased MAS) at baseline. Primary efficacy outcome measure: time between injection and visit at which re-injection criteria were met (MAS ≥ 2 and ≥1, sign of symptomatic spasticity: pain, involuntary movements, impaired active or passive function). Forty-two patients were randomized (abobotulinumtoxinA 500U: n = 28; placebo: n = 14) with median 5.86 weeks since stroke. Median time to reach re-injection criteria was significantly longer for abobotulinumtoxinA (156 days) than placebo (32 days; log-rank: p = 0.0176; Wilcoxon: p = 0.0480). Eleven (39.3%) patients receiving abobotulinumtoxinA did not require re-injection for ≥28 weeks versus two (14.3%) in placebo group. In this exploratory study, early abobotulinumtoxinA treatment significantly delayed time to reach re-injection criteria compared with placebo in patients with post-stroke ULS. These findings suggest an optimal time for post-stroke spasticity management and help determine the design and sample sizes for larger confirmatory studies.