Months Of Inpatient Rehabilitation Research Articles

A - 94 A Case of New Onset Refractory Status Epilepticus (NORSE) Associated with COVID-19.

New Onset Refractory Status Epilepticus (NORSE) is a rare condition of prolonged medication-refractory seizures potentially due to elevated inflammatory molecules in the brain. NORSE can be triggered by a viral infection and is a documented neurologic consequence of COVID-19. A 74-year-old, left-handed, Hispanic male was in his usual state of health until experiencing 1-2weeks of speech decline, which culminated in an episode of altered mental status (disorientation and mumbling speech). He presented to the Emergency Department with drowsiness and complaints of a "funny feeling" on the left side of his head. Upon arrival, he was found to be COVID-19 positive and hyperglycemic with normal CT, MRI, lumbar puncture, and bloodwork. An EEG showed "focal temporal activity" and he was diagnosed with non-convulsant status epilepticus. Hospitalization and medical sedation lasted 2months followed by 8months of inpatient rehabilitation. The patient was discharged shortly before presenting for neuropsychological evaluation. Neuropsychological evaluation showed weaknesses in learning and free recall, visuospatial skills (due to disorganization and poor attention to details), processing speed, and executive functioning. The patient reported elevated anxiety symptoms. Collateral report indicated severe declines in executive organizational abilities, as well as mild memory and divided attention declines. Results suggest frontal cortical and subcortical impairments affecting multiple areas of cognition and functional decline consistent with a diagnosis of major neurocognitive disorder. Similar to the literature, status epilepticus was attributed to inflammatory meningoencephalitis triggered by the prior COVID-19 infection. Interdisciplinary care was an integral factor in this case.

P118 A novel technique for repair of the vertebral artery during cranial surgery

ObjectivesTo demonstrate a novel/alternative technique for repair of the vertebral artery intraoperatively.DesignLeft-sided retromastoid craniotomy in one patient.SubjectsA 61-year-old male patient with meningioma in the foramen magnum encasing the vertebral artery on the left side.MethodsStandard retrosigmoid craniotomy performed with preservation of transverse and sigmoid sinuses. The dura was opened and the cerebellum was retracted with CSF release. The tumour was debulked gradually. The attempt to peel the tumour from the vertebral artery resulted in arterial bleeding. The hole in the artery was sealed using an N-hydroxysuccinimide functionalised polyethylene glycol-coated collagen patch (Hemopatch®, Baxter Healthcare Ltd) as an onlay, applying pressure for 2 minutes. Another patch was applied for further support and the artery checked for haemostasis. The dura was closed with 3–0 vicryl and Hemopatch® onlay after further tumour debulking.ResultsHaemostasis of the vertebral artery was achieved at 140 mmHg SBP and a catheter angiogram found no dissection or false lumen. The patient did not suffer postoperative haemorrhage and after three months of inpatient rehabilitation was discharged with significantly improved cranial nerve function. There was no CSF leak.ConclusionsHaemostasis was successfully achieved in the vertebral artery with this novel technique. It can prove to be important in such scenarios where direct cross-clamping and arterial repair is technically challenging and can lead to brainstem ischemia.

Acute rehospitalisation during the first 3 months of in-patient rehabilitation for traumatic brain injury.

Unplanned re-admission to acute care hospitals during in-patient rehabilitation causes disruption to the rehabilitation program and increases the cost of health care. The aims of the present study were to identify the frequency, reasons and duration of disruption to rehabilitation because of acute re-admissions during the first 3 months of in-patient rehabilitation for traumatic brain injury (TBI) and to investigate the correlation between the duration of acute rehospitalisation and the discharge functional independence measure (FIM) score. A retrospective study was conducted on patients admitted for in-patient rehabilitation following TBI to a rehabilitation hospital in Auckland, New Zealand, between January 2009 and August 2013. Data on duration and reasons for acute rehospitalisation, as well as admission and discharge FIM scores, were obtained from electronic patient records. Pearson correlation was used to evaluate the relationship between the duration of acute rehospitalisation and the discharge FIM score. Of the 628 patients admitted for brain injury rehabilitation, 71 (11.3%) required acute rehospitalisation within the first 3 months. The main reasons for acute rehospitalisation were preventable medical causes (43.8%), including urinary tract infections, respiratory tract infections and coronary artery disease. Of the acute re-admissions, 76.6% were within the first month of admission to the rehabilitation centre and 46.6% needed in-patient treatment in the acute care hospital for > 5 days. There was a moderately strong negative correlation between the duration of stay in the acute care hospital and the discharge FIM score (r = - 0.412; P = 0.0005). A significant number of patients admitted for in-patient rehabilitation following TBI require acute rehospitalisation due to preventable medical causes. Because the duration of acute rehospitalisation has a negative impact on rehabilitation functional gain, preventive measures and surveillance need to be further investigated and optimised.

On the Relative Contribution of the Paretic Leg to the Control of Posture After Stroke

Background. Reduced postural steadiness and asymmetry of weight bearing are characteristic for posture after stroke. Objective. To examine the relative contribution of each leg to postural control in a cohort of 33 stroke patients at 5 stages during 3 months of inpatient rehabilitation, while taking clinical scores of sensory and motor impairments of the paretic leg into account. Methods. Participants were instructed to stand as symmetrically as possible under both sensory and cognitive manipulations, while a dual-plate force platform was used to assess the contribution of each leg to postural control, quantified by the amplitude, velocity, and regularity of recorded center-of-pressure trajectories. A greater contribution of the nonparetic leg was expected, particularly in patients with ankle clonus, disturbed sensibility, and lack of selective muscle control on the paretic side. Results. With follow-up assessments, weight-bearing asymmetry and postural steadiness improved. Patients strongly relied on visual information. When attention was distracted by having the patients perform an arithmetic task, weight-bearing asymmetry increased, suggesting that symmetric weight bearing was attention demanding. Patients with severe motor impairments of the paretic leg showed greater static (weight-bearing) and dynamic (lateralized control) asymmetries than patients with limited motor impairments, whereas postural steadiness did not differ between these subgroups. Disturbed sensation did not affect weight-bearing asymmetry, postural steadiness, or lateralized control. Conclusion. Patients with severe motor impairments of the paretic leg employ an effective compensatory strategy consisting of asymmetric weight bearing and lateralized control.

The relationship between mean flow velocity and functional and neurologic parameters of ischemic stroke patients undergoing rehabilitation

Treger I, Streifler JY, Ring H. The relationship between mean flow velocity and functional and neurologic parameters of ischemic stroke patients undergoing rehabilitation. ObjectiveTo investigate the correlation between mean flow velocity (MFV) as measured by transcranial Doppler ultrasonography (TCD) and functional and neurologic impairment during inpatient rehabilitation after acute stroke. DesignProspective study comparing results of rehabilitation in patients with different TCD findings. SettingAcute neurologic rehabilitation department. ParticipantsTwenty-four consecutive patients admitted to a rehabilitation center with a diagnosis of a first ischemic stroke in the middle cerebral artery (MCA) territory. InterventionsNot applicable. Main outcome measuresImpairment as measured with the National Institutes of Health Stroke Scale (NIHSS) and disability as assessed with the FIM instrument. ResultsNormative or high blood-flow velocity in the MCA of the damaged hemisphere was associated on admission with higher FIM and lower NIHSS scores during 2 months of hospitalization. Absent or low flow velocity correlated with much worse functional and neurologic outcome, especially after 1 and 2 months of inpatient rehabilitation. Statistical correlation was found between MFV in the MCA of the damaged hemisphere, measured by admission TCD, and FIM score on admission and 1 month later. NIHSS scores during hospitalization also correlated with MFV in the MCA of the damaged hemisphere on admission and after 1 month. MFV in the MCA of the undamaged hemisphere 1 month after admission correlated negatively with FIM scores during inpatient rehabilitation. ConclusionsOur data showed a correlation between blood-flow velocity in the MCA of both hemispheres and the parameters of functional and neurologic status at different stages of acute inpatient rehabilitation after first ischemic stroke in MCA territory. Cerebral blood flow as measured by TCD can be an additional tool for monitoring the rehabilitation process after stroke.

Recovery of the precision grip in children after traumatic brain injury

Gölge M, Müller M, Dreesmann M, Hoppe B, Wenzelburger R, Kuhtz-Buschbeck JP. Recovery of the precision grip in children after traumatic brain injury. Arch Phys Med Rehabil 2004;85:1435-44. Objective: To identify quantitative parameters that are sensitive enough to detect impairments and improvements of grasping in children after traumatic brain injury (TBI) by analyzing the isometric fingertip forces of a precision grip-lift task. Design: Follow-up and case-control study. Setting: Tertiary pediatric trauma rehabilitation center in Germany. Participants: Thirteen children (age range, 5–14y) with moderate or severe TBI. Trauma severity was assessed with the Glasgow Coma Scale (score range, 3–9) and the Injury Severity Score (range, 16–66 points). Control data were obtained from 13 age- and gender-matched healthy children. Interventions: Not applicable. Main Outcome Measures: Children were examined 3 times (t0, t1, t2). The first date of examination (t0) was defined by the Barthel Index (part B, >20 points). Reexaminations followed after 1 (t1) and 5 (t2) months of inpatient rehabilitation. Quantitative measures included 3 grip-force parameters, 2 load force parameters, 1 parameter of the coordination between grip force and load force, and 3 timing parameters in a precision grip-lift task. Clinical improvements and recovery of activities of daily living were described with the Barthel Index (qualitative measure). Results: Peak grip force, maximum negative load force, grip force in the static phase and its standard deviation, and grip-force/load-force ratio at maximum grip force showed significant improvements during the observation period (5mo). Also, the preparation phase and preload duration, but not the load duration, changed significantly. Conclusions: Impairments and the recovery of grasping in children after TBI can be objectified with quantitative analyses of the precision grip. Several grip-force and timing parameters were sensitive for the description of restitution processes.

Poster 161: Axonal neuropathy of the extremities after West Nile virus: a case report.

Setting: Free-standing rehabilitation hospital. Patient: A 69-year-old white man. Case Description: The patient was admitted to inpatient rehabilitation after being diagnosed with West Nile virus (WNV) infection. He initially presented to acute care with weakness, fatigue, elevated body temperature. His cerebrospinal fluid was positive for WNV. On initial examination, he had less than antigravity strength in both lower extremities and proximally in the upper extremities. Distal upper-extremity strength was 3/5. He was hyporeflexic and had normal sensation to light touch and proprioception. The patient’s higher-level cognitive and communication skills were within full limits and he was continent to bowel and bladder. He required total assistance for all transfers and toileting. Results: Nerve conduction and electromyography studies were done for the right median, ulnar, deep peroneal, tibial, and sural nerves. The electrodiagnostic findings were consistent with significant axonal neuropathy involving the upper and lower extremities. The patient was discharged after 21/2 months of inpatient rehabilitation. At this time, his strength had improved by 1 grade to 3/5 in the lower and proximal upper-extremities. Distal upper-extremity strength was 4/5. The patient needed maximal assistance with transfers and standing in parallel bars, moderate assistance with lower-body bathing, and minimal assistance with upper-body dressing. He was independent with grooming. Discussion: This is a rare case of WNV infection with axonal neuropathy and no cognitive deficits. Conclusion: Functional recovery of patients with WNV presenting with axonal neuropathy is slower compared with those presenting with encephalitis.

Economic Analysis of Respiratory Rehabilitation

We report on the incremental costs associated with improvements in health-related quality of life (HRQL) following 6 months of respiratory rehabilitation compared with conventional community care. Prospective randomized controlled trial of rehabilitation. A respiratory rehabilitation unit. Eighty-four subjects who completed the rehabilitation trial. Two months of inpatient rehabilitation followed by 4 months of outpatient supervision. All costs (hospitalization, medical care, medications, home care, assistive devices, transportation) were included. Simultaneous allocation was used to determine capital and direct and indirect hospitalization costs. The incremental cost of achieving improvements beyond the minimal clinically important difference in dyspnea, emotional function, and mastery was $11,597 (Canadian). More than 90% of this cost was attributable to the inpatient phase of the program. Of the nonphysician health-care professionals, nursing was identified as the largest cost center, followed by physical therapy and occupational therapy. The number of subjects needed to be treated (NNT) to improve one subject was 4.1 for dyspnea, 4.4 for fatigue, 3.3 for emotion, and 2.5 for mastery. Cost estimates of various approaches to rehabilitation should be combined with valid, reliable, and responsive measures of outcome to enable cost-effectiveness measures to be reported. Comparison studies with the same method are necessary to determine whether the improvements in HRQL that follow inpatient rehabilitation are cheap or expensive. Such information will be important in identifying the extent to which alternative approaches to rehabilitation can influence resource allocation. A consideration of cost-effectiveness from the perspective of NNT may be useful in the evaluation of health-care programs.