Michael W. O'Dell

Functional outcome of inpatient rehabilitation in persons with brain tumors

OBJECTIVE To document functional outcome in persons with brain tumors undergoing inpatient rehabilitation and to compare outcomes with a group of traumatically brain injured patients. DESIGN Retrospective, descriptive, and case-matched. SETTING A free-standing inpatient brain injury rehabilitation unit. PARTICIPANTS Forty consecutive patients with a variety of tumor types (40% were either glioblastoma multiforme or meningioma) and a mean age of 53.1 (SD 15.4) years. Sixty percent were men, 25% had recurrent tumors, and 15% had metastatic disease. Also, 40 patients with traumatic brain injury (TBI) matched for age, gender, and admission functional status. MAIN OUTCOME MEASURES Change in Functional Independence Measure (FIM) scores, length of rehabilitation stay (LOS), and discharge disposition. RESULTS The mean LOS for the tumor group was 17.8 (SD 9.9) days, mean FIM gain was 25.4 (SD 20.1) points, and 82.5% were discharged home. No demographic or tumor characteristic was statistically significant in predicting functional outcome at discharge, but greater gains were seen for persons with the diagnosis of meningioma, those with left-sided cerebral lesions, and those not receiving radiation therapy. TBI patients made statistically significant greater gains in total FIM change (34.6 vs 25.4), self-care (12.3 vs 8.5), and social cognition (5.2 vs 3.6). However, FIM efficiency and LOS were not statistically different between the TBI and tumor groups (1.9 vs 1.5 FIM points/day and 22.1 vs 17.8 days, respectively). CONCLUSIONS Daily functional gains made by persons with brain tumor undergoing rehabilitation were similar to those made by a group of persons with TBI matched by age, gender, and admission functional status. Further research should use larger samples and address the impact of psychosocial and team factors on LOS and discharge disposition.

The Mini-Mental State Examination and Montreal Cognitive Assessment in Persons With Mild Subacute Stroke: Relationship to Functional Outcome

OBJECTIVES To compare Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) global and subscores in classifying cognitive impairment in persons with mild stroke and to explore the relationship between admission and discharge functional status and improvement. DESIGN Retrospective analysis of data. SETTING Acute rehabilitation unit of a large urban university-affiliated hospital. PARTICIPANTS Inpatients with stroke (N=72; mean age, 70y; median time poststroke, 8.5d) and mild neurologic (median National Institutes of Health Stroke Scale score, 4) and cognitive deficits (median MMSE score, 25). INTERVENTION Not applicable. MAIN OUTCOME MEASURE Admission cognitive status was assessed by using the MMSE and MoCA. The motor subscale of the FIM instrument (mFIM) and motor relative functional efficiency was used to assess discharge functional status and improvement. RESULTS The MoCA classified more persons as cognitively impaired than the MMSE (89% vs 63%, respectively; using a cutoff score of 27 on the MMSE and 26 on the MoCA). The MoCA also showed less of a ceiling effect than the MMSE, higher internal reliability (Cronbach α=.78 compared with α=.60), and marginally stronger associations with discharge functional status (r=.40; P<.001) than the MMSE (r=0.30; P<.05). The MoCA visuoexecutive subscore was the strongest predictor of functional status (P=.01) and improvement (P=.02) in global and subscores for both tests. CONCLUSIONS The MoCA may be an important cognitive screening tool for persons with stroke and mild cognitive dysfunction on an acute rehabilitation unit. Lower visuoexecutive subscores may assist in identifying persons at risk for decreased functional gains in self-care and mobility (mFIM) during inpatient rehabilitation. The findings justify further validation studies of the MoCA in persons with subacute stroke.

Validity of the Karnofsky performance status in an HIV-infected sample

The Karnofsky Performance Status (KPS) is the most widely used health status measure in human immunodeficiency virus (HIV) medicine and research. Because there are limited data on KPS metric properties in this setting, we present evidence of the construct validity of the KPS in a sample of HIV-infected persons using data from the AIDS Time-Oriented Health Outcome Study (ATHOS). The sample consisted of 160 primarily white, homosexual/bisexual men with a mean age of 45 years and a mean KPS score of 82 (range, 40-100). Ninety percent were classified in Centers for Disease Control (CDC) clinical category B or C. Pearsons product-moment correlations were strong between the KPS and measures of global health status, physical disability, numbers of symptoms, CDC clinical category, social function, days off work, and energy/fatigue (r = 0.39-0.52, p < 0.0001). Correlations with measures of mental health and cognition were less impressive but statistically significant. Analysis of variance followed by Student Newman-Keuls test showed significant differences among three KPS groupings for global health status but not for physical disability. Regression analysis indicated three significant variables accounting for KPS variance: visual analogue global health status (27%), days off work (10%), and energy/fatigue (1.7%). We conclude that the upper range of the KPS reflects global health status better than physical performance and much better than psychosocial constructs, in persons with HIV infection. Further research examining the ability of the KPS to detect clinically significant change over time is needed.

Correlates of fatigue in HIV infection prior to AIDS: a pilot study

Fatigue is widely recognized as a significant source of morbidity in persons with human immunodeficiency virus (HIV) infection, yet there are few data examining fatigue in this population. We present pilot data assessing the relationship between fatigue and various physical and psychosocial measures in 20 men with HIV infection prior to the clinical development of acquired immunodeficiency syndrome (AIDS). Fatigue was measured by a visual analogue scale (VAS) and the Fatigue Assessment Inventory (FAI). No statistically significant associations were found between fatigue measures and physical parameters including haemoglobin, haematocrit, albumin, total protein, and physical dimension score of the Sickness Impact Profile (SIP). The FAI correlated well with Becks Depression Inventory and SIP-Psychosocial Dimension (r = 0.72 and 0.81, respectively; p < 0.001.) Both the FAI and VAS held moderate associations with the total SIP score. The SIP profile was similar to that observed in a sample of persons with chronic fatigue but without HIV infection, reported previously. Although the sample size is small, our data suggest a stronger association with psychosocial, rather than physical, parameters among persons with HIV infection and fatigue. The implications for clinical management and further research are discussed.

Rehabilitation of the patient with brain tumor

Abstract As the incidence of brain tumors increases, the rehabilitation needs of these persons are becoming more prominent. This focused review of the pathophysiology, treatments, and complications associated with brain tumors and radiotherapy and chemotherapy will serve as a resource to physiatrists and other rehabilitation personnel serving this population. The present literature on functional impairments and rehabilitation interventions is critically reviewed, and areas requiring additional research are highlighted.

Physical disability in a cohort of persons with AIDS: data from the AIDS Time-Oriented Health Outcome Study.

Objective Physical disability is one of the more important determinants of health-related quality of life in persons with AIDS, although little information is available on specific physical functional deficits. The purpose of this study was to document the types, frequency, severity, and correlates of physical disability in persons with AIDS. Design The design was cross-sectional with assessment of disability at the initial evaluation for the AIDS Time-Oriented Health Outcome Study, an observational, community-based cohort of persons with AIDS. Methods Disability was measured by the HIV Health Assessment Questionnaire, a self-administered assessment of perceived difficulty in eight functional categories. Additional medical and demographic information was obtained from chart review, in addition to other standardized quality of life measures. Results The sample consisted of 546 persons, primarily white homosexual men, evaluated a mean of 475 days (SD, 474) after an AIDS-defining diagnosis. Ten to 50% of men reported some degree of activity-specific disability, mostly mild or moderate. Disability scores varied widely and tended to be most severe among those items considered to be higher level ‘instrumental activities of daily living’. Univariate correlations were strong between disability and number of symptoms, global health status, and the Medical Outcomes Study HIV fatigue index (r = – 0.4223 to 0.5115 for men). Correlations between disability and either time from AIDS diagnosis or CD4 T-lymphocyte count were not statistically significant. For men, stepwise multiple regression showed that 26.9% of disability variance was explained by symptoms, 3.7% by the Medical Outcomes Study HIV fatigue index, and 1.8% by total number of opportunistic infections. Conclusion We conclude that physical function is variable among persons with AIDS living in the community, with a substantial number experiencing mild to moderate deficits tending to occur in instrumental activities of daily living. Further studies should address the need for and efficacy of appropriate rehabilitation interventions in persons with AIDS experiencing physical disability.

Continuous passive motion in the management of heterotopic ossification in a brain injured patient.

We report a man admitted to inpatient rehabilitation 6 wk after traumatic brain injury, who presented with bilateral knee heterotopic ossification. In addition to conventional physical therapy, we applied a continuous passive motion device during 4 wk increasing the range of motion of the knees. On the basis of the limited current literature and this case, we suggest that the use of continuous passive motion devices for heterotopic ossification may be effective and safe and should be the subject of further study.

Superior Mesenteric Artery Syndrome in Traumatic Brain Injury: Two Cases

One of the many causes of enteral feeding (EF) intolerance after traumatic brain injury (TBI) is superior mesenteric artery syndrome (SMAS). Although it is reported in pediatric brain injury, few cases are noted in adults. To increase awareness of this medically treatable condition, we present two patients who developed SMAS after sustaining severe brain injury. SMAS results from compression of the duodenum by the SMA against the aorta and risk factors include acute weight loss, prolonged recumbency, and spasticity--all frequently encountered in severe TBI. After gastric decompression, symptoms often resolve with weight gain achieved by conservative treatment; including feeding in the left lateral or prone position, hyperalimentation, or extension of a feeding tube beyond the obstruction. SMAS should be considered in the presence of EF intolerance in severe adult TBI because multiple risk factors may be present.

Response and Prediction of Improvement in Gait Speed From Functional Electrical Stimulation in Persons With Poststroke Drop Foot

To describe changes in and predictors of comfortable gait speed (GS‐C) after using a foot‐drop stimulator (FDS; Bioness L300; Bioness Inc, Valencia, CA) for 42 weeks in persons who had sustained a stroke.

Diagnosis and rehabilitation strategies for patients with hysterical hemiparesis: A report of four cases

Conversion disorder is a psychological disturbance that produces subconscious alterations in sensorimotor function. Hysterical hemiparesis is a relatively rare, and difficult to diagnose, form of conversion disorder presenting as unilateral motor weakness with or without sensory deficits. We report four patients who required inpatient rehabilitation for hysterical hemiparesis, a diagnosis for which there is little information regarding rehabilitation management. In all cases, an extensive acute care evaluation including multiple imaging studies failed to identify a new neurologic lesion. All patients had rapid functional improvement using functional and behavioral therapies and extensive psychosocial support (mean length of stay of 11 days; mean Functional Independence Measure [FIM] gain of 22; mean discharge FIM of 112), consistent with other published reports of rehabilitation of conversion disorder. Evaluation of these cases reveals consistencies regarding presentation, psychosocial history, and rehabilitation course that can aid clinicians in making the diagnosis. Rehabilitation strategies for hysterical hemiparesis are reviewed.