Thomas K. Watanabe

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.

Managing Sleepiness After Traumatic Brain Injury

Sleepiness is common in patients who have sustained traumatic brain injuries (TBI). Pharmacologic intervention may be required to help address sleepiness, because problems with sleep regulation have been described in this population. But it is not always appropriate to address sleepiness by initiating such medications, because there are many reasons why a patient may exhibit sleepiness after TBI. In addition, medications commonly used to help with sleep may not necessarily be benign or have the desired outcome. There are no clear guidelines that help clinicians determine when it is appropriate to start medications to enhance sleep. This case scenario and the following point/counterpoint discussion addresses this common problem. A 48-year-old man has been on an inpatient TBI unit for 2 days. He was injured 7 days before his rehabilitation admission as a result of a head-on motor vehicle collision. He was an unrestrained driver and sustained right temporal and bifrontal contusions. The initial Glasgow Coma Scale score was 11. Neurosurgical intervention was not required. He received a 7-day course of phenytoin for seizure prophylaxis. In addition to his TBI, he sustained a left fibula fracture that was treated without surgery. On admission, he was moderately obese and in no acute distress. He was sleepy but arousable, was able to answer simple biographical questions, and was oriented to self only. Posttraumatic amnesia has persisted. He is impulsive and demonstrates little insight regarding his deficits. He also had poor balance, so he has required 1:1 supervision throughout the day and night since admission. His medical history is positive for hypertension. Current medications include subcutaneous heparin for deep vein thrombosis prophylaxis, metoclopramide, famotidine, and metoprolol, as well as acetaminophen for mild pain and oxycodone for moderate-to-severe pain as needed. Admission laboratory studies included complete blood cell count and electrolytes, both within normal limits. The rehabilitation team is reporting that he has difficulty staying awake during the day and that this is hampering his ability to benefit from therapy. He also states that he is having trouble sleeping. The team is asking that you start a medication to help with sleep. What is your decision? Guest Discussants

Driving After Stroke: What Are the Appropriate Criteria?

For most people, driving is a very important activity that enhances opportunities for social interactions. Stroke can result in impairments that potentially make driving unsafe, thus contributing to social isolation, reduced activities, and depression. At times, these impairments are obvious, but often the determination of driving competence is more difficult to ascertain. One solution is to obtain a formal driving evaluation. However, these can be costly and are often not covered by insurance. This case report and following debate highlights some of the challenges in the decision making process, and options to consider when facing a similar situation. A 67-year-old, right-handed man is seen by you for the first time. This is an initial outpatient clinic visit 6weeksafterdischarge fromacute inpatient rehabilitation.Thepatient sustaineda left subcortical stroke 10 weeks earlier with involvement primarily of the posterior limb of the internal capsule. He did not have any seizures or loss of consciousness related to the stroke. Past medical history is notable for hypertension, which the patient reports to be well controlled. His recovery progressed well, and he was discharged independent in performing activities of daily living and ambulating with a straight cane. He was discharged back to his house, where he resides with his wife, who does not drive. A comparison of muscle strength findings at the time of rehabilitation admission and at the 10-week follow-up is shown in Table 1. No sensory or coordination deficits were identified in this patient. No visual deficits were noted both during acute rehabilitation and during the current examination. Cognitively, the patient did not have deficits noted during his rehabilitation stay (“MMSE 30/30” per chart), but his wife mentioned that for the past year or 2 he has seemed to be “more forgetful.” On current examination, he recalls 3 of 3 words at 5 minutes, is fully oriented, and describes accurately events related to the stroke and to subsequent care. Presently, he denies that memory has been a problem, and he is solely focused on receiving clearance to return to driving, emphasizing that he has driven for 50 years without any accidents. He also says that he has been driving in his neighborhood for the past week and has not noted any problems, even though he knew that the inpatient physician had told him that he should not drive until he received clearance by a physician. He originally learned to drive with the right foot on the gas and the left on the brake and resumed this without a problem. When the recommendation of a formal driving evaluation is brought up, he exclaims that it is too expensive and reiterates that he has never had, nor does he now have, a problem with driving. He points out that his wife does not drive, that there is no one else around to drive them anywhere, and that in their area there is no convenient public transportation. He states that, without being able to drive, he would be a “prisoner” in his house. What do you recommend? Guest Discussants:

Use of Methylphenidate During Inpatient Rehabilitation After Traumatic Brain Injury

A 25-year-old man with no significant medical history was admitted to an inpatient traumatic brain injury rehabilitation unit. He was assaulted 8 days before the rehabilitation admission. He sustained blunt trauma to his head, with a computed tomography of the head that revealed bifrontal contusions and a nondepressed skull fracture over the right orbit. The initial Glasgow Coma Scale score was 12. He had a negative admission alcohol and drug screen. He was noted to have a single generalized tonicclonic seizure at the scene and completed a 7-day course of phenytoin during the acute stay without any subsequent seizures. His acute hospital course was also notable for headaches, treated with intravenous morphine, which was subsequently converted to oral hydrocodone with acetaminophen. Oral intake was poor, and he demonstrated significant deficits in self-care, activities of daily living, and mobility. He has a college degree in accounting. He was working full time before the assault. There is no history of substance abuse. He has no history of learning difficulty. Five days into his rehabilitation stay (13 days after injury), his oral intake remains poor, although there is no evidence of dysphagia, and he is on a regular diet, including thin liquids. In all activities, the therapists note that he is better when he is in a nondistracting environment. He is at a moderate level of assistance with dressing and grooming, and is contact guard assistance for ambulation and transfers. In speech therapy, deficits are notable in tasks that require sustained attention and concentration. He is at level VI on the Rancho Los Amigos Scale of Cognitive Functioning. In a team conference, the rehabilitation team voices concern that the cognitive deficits may make it impossible for him to return home because he will need to be independent for periods of time during the day because the only assistance available is from his parents, both of whom work. The neuropsychologist asks whether methylphenidate would be an appropriate intervention at this point. Presenting the argument for methylphenidate is William Walker, MD, and the argument against is Kathleen Bell, MD. Guest Discussants

Venous Thromboembolism Prophylaxis in the Pediatric Population

Pharmacologic prophylaxis for venous thromboembolism (VTE) is the standard of care for most adults who are admitted to inpatient neurorehabilitation units (excluding those believed to be at high risk for bleeding or who have a history of adverse reactions to heparin or Coumadin, for example) However, no such consensus exists in the pediatric population. The complications of VTE are the same for children as for adults, including the risk of fatal pulmonary embolism, but it has been suggested that children are at a lower risk for the development of VTE. Because complications are also associated with the use of medications for VTE prophylaxis, the decision to use these medications is not necessarily straight forward. In addition, it is not clear at what chronological point a child becomes an adult in terms of VTE risk. This case and the following discussion highlight these issues and provide evidence supporting the decision of when medications for VTE prophylaxis should and should not be used. A 14-year-old right-handed boy who has been identified as being at Tanner stage 2 sustained injuries while riding his bicycle 2 weeks ago. He was not wearing a helmet and sustained a right temporal bone fracture with an underlying frontotemporal lobe nonhemorrhagic contusion. Other injuries include a right distal radius fracture, and he is non–weight bearing distal to the right elbow. His initial Glasgow Coma Scale score was 10. He was in the intensive care unit for 2 days, with a total acute length of stay of 6 days. His examination is now notable for left-sided weakness, graded at 4/5 throughout the left upper extremity, 3/5 for left hip flexion and extension, and 4/5 for left knee flexion and extension as well as left ankle dorsiflexion and plantar flexion. Sensory deficits are not identified. Cognitively he is fluent but has decreased insight regarding his deficits and is impulsive at times. He requires at least minimal assistance for transfers and ambulation, and because of his weakness and impaired cognition, he is considered a fall risk. He is participating fully in physical and occupational therapy. He has no history of any medical problems, and the family history is notable only for hypertension. The boy is anxious about being hospitalized. His parents believe that the daily low molecular heparin shots he is getting for VTE prophylaxis (at a standard prophylactic dose) are making the situation worse because he has a fear of injections. They ask you if it is necessary for him to get these shots, especially because they were told by another patient’s family that that their child did not receive prophylaxis because “kids don’t get DVTs” (deep vein thromboses). What is your response? Guest Discussants:

A Review of Stem Cell Therapy for Acquired Brain Injuries and Neurodegenerative Central Nervous System Diseases

Cell‐based therapies have been the subject of much discussion regarding their potential role in enhancing central nervous system function for a number of pathologic conditions. Much of the current research has been in preclinical trials, with clinical trials in the phase I or I/II stage. Nevertheless, there is considerable interest in the public about the potential regenerative role that stem cells may have in improving function for these neurologic conditions. This review will describe the different types of stem cells that are available, review their possible effects, and discuss some of the variables that investigators need to consider when designing their studies. Current clinical research in the areas of stroke, traumatic brain injury, and neurodegenerative diseases (amyotrophic lateral sclerosis and Parkinson disease) will be reviewed. As this article is aimed at a rehabilitation audience, outcome measures, and the role of concurrent rehabilitation therapies will also be mentioned.

The Transformation of the Rehabilitation Paradigm Across the Continuum of Care

As healthcare continues to evolve, there are changes in the delivery of care for patients with severe neurologic injuries. Although the acute hospital stay is shortening, physiatrists can play a key role in preparing patients for rehabilitation, minimizing longer‐term complications and helping to determine the most appropriate paths for further treatment. Inpatient rehabilitation facilities (IRFs) continue to be an important part of the care continuum for patients with severe injuries, but the role of IRFs has also evolved as patients have been admitted with increasing medical and neurologic complexity and length of stay continues to be reduced. Skilled nursing facilities and subacute facilities continue to evolve, in part to fill the gaps that have developed for patients who are “not yet ready for rehabilitation” and for those whose recovery trajectory has been deemed too slow for IRF. Outpatient care is also changing, in part due to the availability of new rehabilitation interventions as highlighted in other sections of the supplement. Furthermore, telemedicine will provide additional options for expanding specialized care beyond prior geographical limitations. Physiatrists need to be aware of these ongoing changes and the roles that they can play outside of the traditional IRF model of care. This article will focus on the innovations in healthcare delivery and opportunities to maximize outcomes in the current and future models of care.

Poster 14: Randomized Supplemental Therapeutic Conventional or Robotic Upper Limb Exercise in Acute Stroke Rehabilitation

Disclosures: Alberto Esquenazi: I Have No Relevant Financial Relationships To Disclose Objective: To maximize improvements on function and activity level in the recovery of the upper limb, we implemented a pilot study to determine the feasibility and impact of supplemental upper limb exercises in an acute stroke population. Design: Blinded, randomized pilot study. Setting: Tertiary rehabilitation hospital, inpatient stroke unit. Participants: Stroke patients with unilateral hemiparesis with minimum Fugl-Meyer Assessment (FMA) score of 8/66 or Modified Ashworth Score of <3 receiving usual minimum of 3 hours of daily therapy. Interventions: Patients were randomized to conventional or robotic additional upper extremity exercise groups. Main Outcome Measures: This study collects the number of completed sessions; withdrawals; serious/adverse events and functional parameters data: FMA, Functional Independence Measure (FIM) and FIM efficiency. Results: Data on 15 acute post stroke patients of <2 months. Mean age was 66 years. More than half of the participants were male (64%) and most participants presented left-sided paresis (79%). Embolic and ischemic strokes were similarly represented (36%) and 29% of hemorrhagic stroke. One patient withdrew for personal reasons prior to his first session. All 14 participants (8 robotic, 6 conventional) continued their training sessions until discharge. Of a total of 80 training sessions, 15 were incomplete. Adverse events ranged from upper limb pain; fatigue; gastrointestinal symptoms interfering with training and falls that occurred unrelated to their study participation. Conclusions: This ongoing study depicts an acute stroke population that received additional upper extremity exercises. Based on the available data thus far, it is feasible to provide a supplemental functional exercise program to acute post stroke patients in an Inpatient Rehabilitation Facility (IRF) without serious adverse effects. We expect to complete and present data analysis on all 40 subjects including functional outcomes. Level of Evidence: Level II

Fully Implantable Peripheral Nerve Stimulation for Hemiplegic Shoulder Pain: A Multi-Site Case Series With Two-Year Follow-Up

To explore the feasibility and safety of a single‐lead, fully implantable peripheral nerve stimulation system for the treatment of chronic shoulder pain in stroke survivors.

The Utility of Routine Screening for Deep Vein Thrombosis Upon Admission to an Inpatient Brain Injury Rehabilitation Unit

You are the chief medical officer of a freestanding rehabilitation hospital. As a part of this hospital, there is a large inpatient traumatic brain injury unit. This unit is staffed by 2 physicians, and patients are admitted to their respective services based on census. Therefore, it appears that the 2 physicians essentially have the same types of patients. However, you note that there is a large discrepancy between the 2 physicians regarding the number of lower extremity venous Doppler ultrasonography tests that are ordered. Further investigation reveals that one of the physicians screens every patient admitted for a possible lower extremity deep vein thrombosis, whereas the other physician does not but relies on a combination of history, examination findings, comorbidities, and functional status to determine relative risk. You are not sure which approach is more appropriate but believe that there should be some standardization of clinical practice regarding this aspect of patient care. Therefore, you ask the 2 physicians to present information that supports their respective practices regarding the screening for deep vein thrombosis to help with the determination of how to proceed in the future. Their responses are now presented. Guest Discussants: