Vivek Kadyan

The impact of acute care medications on rehabilitation outcome after traumatic brain injury.

Objectives: To examine the impact of medications with known central nervous system (CNS) mechanisms of action, given during the acute care stages after traumatic brain injury (TBI), on the extent of cognitive and motor recovery during inpatient rehabilitation. Design: Retrospective extraction of data utilizing an inception cohort of moderate and severe TBI survivors. Methods: The records of 182 consecutive moderate and severe TBI survivors admitted to a single, large, Midwestern level I trauma centre and subsequently transferred for acute inpatient rehabilitation were abstracted for the presence of 11 categories of medication, three measures of injury severity (worst 24 hour Glasgow Coma Scale, worst pupillary response, intra-cranial hypertension), three measures of outcome (Function Independence Measure (FIM) Motor and Cognitive scores at both rehabilitation admission and discharge and duration of post-traumatic amnesia (PTA)). Main outcome and results: The narcotics, benzodiazepines and neuroleptics were the most common categories of CNS active medications (92%, 67% and 43%, respectively). The three categories of medications appeared to have no significant outcome on the FIM outcome variables. The neuroleptics affected cognitive recovery with almost 7 more days required to clear PTA in the neuroleptic treated group. The presence of benzodiazepines did tend to obscure the impact of neuroleptics on PTA duration but the negative impact of neuroleptics on PTA duration remained significant. Conclusions: The results suggest that the use of neuroleptics during the acute care stage of recovery has a negative impact on recovery of cognitive function at discharge from inpatient rehabilitation. Due to the paucity of subjects with hemiplegia in this cohort, conclusions could not be drawn as to the impact of acute care medications on motor recovery.

Surveillance With Duplex Ultrasound In Traumatic Spinal Cord Injury On Initial Admission To Rehabilitation

Abstract Objective: To determine the prevalence of deep vein thrombosis (DVT) by surveillance duplex ultrasound in the traumatic spinal cord injury (SCI) population on admission to rehabilitation. Design: Retrospective sequential case series. Setting: Midwest regional, university-based, Commission on Accreditation of Rehabilitation Facilities-accredited acute rehabilitation center. Methods: Charts of all patients with traumatic SCI admitted and discharged from january 1, 1996 through December 31, 1998 were reviewed. Preadmission data were collected on demographics, severity of injury, and DVT prophylaxis information, along with rehabilitation duplex ultrasound results and incidence of thromboembolic events. Results: Ninety-two participants met the inclusion criteria. There were 68 men and 24 women with a mean age on admission of 3 2.4 years. On admission, 45 participants (49%) were classified as tetraplegic and 47 (51%) were classified as paraplegic; 63 (69%) had motor-complete lesions and 29 (31 %) had motor-incomplete lesions. Of all the participants, 8 (8.7%) were found to have DVT on admission to rehabilitation. There were no statistically significant differences among participants with regard to age, sex, level of injury, or completeness of injury, when comparing those participants with DVT on admission, those without DVT on admission, and those with thromboembolic events diagnosed later in their hospitalization. Of the 84 participants who had negative duplex ultrasounds on admission, 4 individuals (4.8%) were found to have DVT and 4 (4.8%) had pulmonary emboli subsequently. In these 84 participants, DVT prophylaxis with low-molecular-weight heparin was found to be more effective than was adjusted-dose heparin in preventing thromboembolic phenomenon. Conclusion: Incidence of DVT remains high despite prophylaxis in traumatic SCI patients. Two thirds of DVT diagnosed in rehabilitation was identified on admission and one third was diagnosed later. Duplex ultrasound is an effective and valuable tool that assists in the diagnosis of asymptomatic DVT in patients with traumatic SCI who are initiating in -patient rehabilitation.

Early recognition of neuroleptic malignant syndrome during traumatic brain injury rehabilitation.

Neuroleptic malignant syndrome is a rare disorder that manifests with hyperthermia, muscle rigidity and autonomic instability. Presented is a case series of individuals with traumatic brain injury and agitation who, when treated with neuroleptics, developed neuroleptic malignant syndrome. Although the incidence of this syndrome is rare, it is associated with significant morbidity and mortality. The onset of symptoms inconsistent with the patients current level of recovery should alert the clinician to consider other possible diagnosis and failure to distinguish the features of neuroleptic malignant syndrome from post-traumatic agitation will delay appropriate intervention for this potentially life-threatening disorder.

Intrathecal baclofen for spasticity management in Rett syndrome.

Kadyan V, Clairmont AC, George RJ, Johnson EW: Intrathecal baclofen for spasticity management in Rett syndrome. Am J Phys Med Rehabil 2003;82:560–562.Intrathecal baclofen infusions have proven to be effective for management of spasticity during the last two decades. Efficacy of intrathecal baclofen for spasticity of spinal origin has been well established and has shown promise in treatment of spasticity that is not spinal in origin. Rett syndrome is a neurodevelopmental disorder primarily affecting girls and women. Manifested in the advanced stages of this syndrome is increased spasticity leading to functional decline. Presented is a case report of a 32-yr-old white woman with Rett syndrome, diagnosed before the age of 2 yr, and significant spasticity that was successfully managed with intrathecal baclofen. After placement of an intrathecal baclofen pump, the dose was increased slowly during 1 yr to 800 &mgr;g/day with good clinical response. There was observed a significant decrease in upper and lower limb Ashworth scores, from an average of 3–4 to 2–3, during this 1-yr period. The decrease in spasticity in this patient eventually led to improved range of motion, positioning, skin care, hygiene, and quality of life. Intrathecal baclofen is an effective option in managing severe spasticity from Rett syndrome.

Aerophagia as a cause of ineffective phrenic nerve pacing in high tetraplegia: a case report.

We report an unusual case of aerophagia after traumatic spinal cord injury (SCI), which shows the profound effects of abdominal distension on respiratory ability in such individuals. In this case, abdominal distension resulting from aerophagia reduced the effectiveness of phrenic nerve pacing on diaphragm function necessitating greater use of positive-pressure ventilatory (PPV) support. Reduction of postprandial gastric air and abdominal distension with insertion of a percutaneous endoscopic gastrostomy tube ameliorated the condition and allowed for more effective phrenic nerve pacing and greater PPV-free breathing. We are unaware of a similar case involving an individual with an SCI.

Poster 195: Focal dystonia after stroke leading to trismus: a case report.1

Abstract Setting: Midwest acute inpatient rehabilitation hospital. Patient: A 58-year-old woman. Case Description: The patient was diagnosed with a middle cerebral artery and lacunar stroke on January 9, 2002. She was admitted to acute inpatient rehabilitation on February 14, 2002, and was found to have trismus on the second day of admission. Differential diagnoses included: tetanus, abscess, dislocation, slipped disk, fracture, volitional noncooperation, and dystonia. Plain films followed by facial computed tomography with thin cuts did not reveal pathologic findings. Manipulation at bedside with sedation and bilateral masseter muscle block did not result in resolution of trismus. Treatment for tetanus was initiated while titer results were pending. The patient subsequently underwent exam under anesthesia, where her jaw was opened fully and no evidence of fractures, abscess, or dislocation was noted. Facial electromyography revealed increased activity in the left temporalis muscle, consistent with spastic dystonia. The tetanus titers were negative and the most likely diagnosis was focal spastic dystonia. Aggressive treatment was pursued because the patient was unable to accept oral intake and had been at severe nutrition risk since the onset of trismus. Tizanidine was started, and she received adjunctive treatment with 10U of botulinum toxin type A (BTX) by electromyographic guidance to the left temporalis muscle. 6 days later, she had partial resolution of her trismus and was able to tolerate oral intake. Assessment/Results: Focal dystonia of the left temporalis muscle. Discussion: Alterations in muscle tone are a common finding after acute stroke. However, this case demonstrates an unreported complication of stroke, and the importance of dystonia in the differential diagnosis of trismus. We demonstrate the use of BTX for focal spastic dystonia in the acute rehabilitation setting. Conclusions: Focal dystonia of the temporalis muscle is a rare complication of stroke, and must be considered in the differential diagnosis of trismus.

Poster 32: Rehabilitative outcome after simultaneous bilateral hip replacement: a case report1

Abstract Setting: Acute Midwestern medical center and university-based rehabilitation hospital. Patient: 55-year-old postmenopausal woman with a medical history remarkable for L4-5 laminectomy. Case Description: Bilateral total hip arthroplasty (THA) was performed. Postoperative course was complicated by anemia and pain. The patient was admitted to acute rehabilitation 4 days after surgery. We report on the rehabilitation outcome after simultaneous bilateral THA. Assessment/Results: On admission, the patient ambulated 50ft using a standard walker at a maximum assist level and total assistance for stairs. She did quite well and had a rather short inpatient course. On day 7 of rehabilitation admission, the patient was discharged and was ambulating 400ft using a rolling walker with supervision and was climbing 6 stairs with maximum assistance. At 1-month follow-up, she was ambulating with a cane approximately 0.5 mile daily. At 6 months, she is ambulating without a cane over 1 mile daily, swimming 1 mile daily, and participating in low-impact aerobics twice weekly. Discussion: Osteoarthritis is a major cause of pain and disability in the United States with hip involvement often leading to significant functional impairment. THA, undertaken after conservative management failure, involves invasive surgery followed by a long and demanding rehabilitation program. THA is invariably performed unilaterally and sequentially if both hips are involved. Orthopedic surgical literature reports cases of simultaneous bilateral THA, but provides little information about rehabilitation outcome. Conclusions: This case illustrates that simultaneous THA can be performed with favorable surgical and functional outcome. Our patient had an excellent outcome and this could be attributed, in part, to her age, limited comorbidities, and good physical conditioning prior to surgery. Further prospective research needs to be performed to help determine exact patient criteria, surgical approach, and rehabilitative techniques when performing simultaneous bilateral THA.

Poster 35: Bilateral spontaneous iliacus hematomas presenting as incomplete paraplegia: a case report1

Abstract Setting: A Midwest acute care and subsequent inpatient rehabilitation hospital. Patient: A 54-year-old obese white woman with diabetes mellitus type 2 requiring insulin. Case Description: The patient underwent a Rou-en-Y gastric bypass and had an uncomplicated immediate postoperative course. She was discharged home on postoperative day 4. On postoperative day 8, she was readmitted to the hospital with diabetic ketoacidosis requiring intubation and aggressive supportive care. She was successfully extubated 10 days later, and recalled standing at the bedside with her physical therapists. 2 days after extubation, she had respiratory distress requiring reintubation and the diagnosis of pulmonary emboli (PE) was entertained. The patient was put on anticoagulants for 2 days while the work-up for PE was completed; the work-up was negative for embolic phenomenon. After successful extubation, she reported severe bilateral lower-limb weakness, pain, inability to void, and diarrhea with incontinence. A diagnosis of steroid myopathy was presumed by the primary team and the patient was transferred on postoperative day 40 to acute rehabilitation. On admission to rehabilitation, her examination revealed bilateral proximal greater than distal weakness with primarily femoral nerve involvement. Electrodiagnostic studies revealed diffuse membrane instability in all lower-limb myotomal distributions, including paraspinals. Magnetic resonance imaging of the lumbar spine was unremarkable and computed tomography of the pelvis revealed chronic bilateral iliacus muscle hematomas with compression of the femoral nerves. The patient was not thought to be a surgical candidate and so was managed conservatively. Assessment/Results: Bilateral iliacus hematomas with femoral nerve and lumbar plexus compression. Discussion: Bilateral spontaneous iliacus hematomas are an extremely rare complication. Conclusion: Early surgical intervention may significantly limit morbidity, and therefore, this diagnosis should be considered in all patients with lower-limb weakness presenting after anticoagulation.