Multimodal Rehabilitation Program Research Articles

A 12-Week Multi-Modal Exercise Program: Feasibility of Combined Exercise and Simplified 8-Style Tai Chi Following Lung Cancer Surgery.

Objective:To assess the feasibility, safety, and preliminary effect of a 12-week multi-modal rehabilitation program targeted at improving health-related quality of life and physical activity levels of patients with lung cancer following treatment.Methods:Patients with stage I to IIIA non-small cell lung cancer were included 6 to 12 weeks following completion of treatment. The intervention comprised of aerobic exercise (brisk walking), resistance training and 8-style Tai Chi. The 12-week program included 2 supervised center-based sessions per week of 90 minutes duration and home-based exercise. The primary outcomes were the feasibility and safety of the intervention. Secondary outcomes (assessed pre and post program) were physical and patient-reported outcomes.Results:Seventy-eight patients were approached during the 6-month recruitment period and 17 (22%) consented to the study. Eight participants (47%) met the definition of adherence to the program (attending at least 70% of supervised sessions). No serious adverse events occurred. A significant reduction in anxiety and depression was observed post-program. In addition, improvements in respiratory function, sleep quality, and some health-related quality of life domains were observed post-program. There were no significant differences in functional capacity or physical activity levels.Conclusion:This multi-modal exercise training program was safe, although the feasibility of the program in its current state is not supported given the low consent rate and low adherence to the intervention.

Effectiveness of adding a workplace intervention to an inpatient multimodal occupational rehabilitation program: A randomized clinical trial.

ObjectivesThis study aimed to evaluate the effectiveness of a workplace intervention (WI) added to an inpatient multimodal occupational rehabilitation program (I-MORE) on sickness absence.MethodsIn this researcher-blinded randomized controlled trial with parallel groups, individuals on sick leave due to musculoskeletal, unspecified- or common mental health disorders were randomized to I-MORE (N=87) or I-MORE+WI (N=88). I-MORE lasted 2+1 weeks (with one week at home in between) and consisted of “acceptance and commitment therapy”, physical exercise, and work-related problem solving. The additional WI consisted of a preparatory part, a workplace meeting involving the sick-listed worker, the employer, and the primary rehabilitation therapist at the rehabilitation center, and follow-up work related to the meeting. The primary outcomes were number of sickness absence days and time until sustainable return to work (RTW) during 12 months of follow-up, measured by registry data.ResultsThe median number of sickness absence days during the 12-month follow-up for I-MORE was 115 days [interquartile range (IQR) 53–183] versus 130 days (IQR 81–212) for I-MORE+WI. The difference between groups was not statistically significant (P=0.084). The hazard ratio for sustainable RTW was 0.74 (95% confidence interval 0.48–1.16; P=0.192) in favor of I-MORE.ConclusionsThis study provided no evidence in favor of I-MORE+WI compared to only I-MORE for long-term sickness absent individuals with musculoskeletal-, common mental- or unspecified disorders.

Impact of mHealth technology on adherence to healthy PA after stroke: a randomized study

ABSTRACT Background Physical activity (PA) is a key health behavior in people with stroke including risk reduction of recurrent stroke. Despite the beneficial effects of PA, many community-dwelling stroke survivors are physically inactive. Information and communication technologies are emerging as a possible method to promote adherence to PA. Objective The aim of this study is to investigate the effectiveness of a mobile-health (mHealth) App in improving levels of PA. Methods Forty-one chronic stroke survivors were randomized into an intervention group (IG) n=24 and a control group (CG) n=17. Participants in the IG were engaged in the Multimodal Rehabilitation Program (MMRP) that consisted on supervising adherence to PA through a mHealth app, participating in an 8-week rehabilitation program that included: aerobic, task-oriented, balance and stretching exercises. Participants also performed an ambulation program at home. The CG received a conventional rehabilitation program. Outcome variables were: adherence to PA, (walking and sitting time/day), walking speed (10MWT); walking endurance (6MWT); risk of falling (TUG); ADLs (Barthel); QoL (Eq-5D5L) and participant’s satisfaction. Results At the end of the intervention, community ambulation increased more in IG (38.95 min; SD: 20.37) than in the CG (9.47 min; SD: 12.11) (p≤.05). Sitting time was reduced by 2.96 (SD 2.0) hours/day in the IG and by 0.53 (SD 0.24) hours in the CG (p≤.05). Conclusions The results suggest that mHealth technology provides a novel way to promote adherence to home exercise programs post stroke. However, frequent support and guidance of caregiver is required to ensure the use of mobile devices.

‘Beyond Cancer’: a study protocol of a multimodal occupational rehabilitation programme to support breast cancer survivors to return work

IntroductionWith more women working and surviving breast cancer, issues concerning sustainable employment must be addressed. Support to transition back to work is a gap in survivorship care. This paper describes...

Building a novel occupational rehabilitation program to support cancer survivors to return to health, wellness, and work in Australia.

With a substantial increase in the population of cancer survivors of working age, issues concerning sustainable employment must be addressed. The health benefits of work are well established; however, the lack of support to transition back to work is a gap in survivorship care. Researchers, occupational rehabilitation and insurance sectors, cancer support services, and consumers have collaborated to develop a tailored, multimodal occupational rehabilitation program to support resumption of meaningful work for cancer survivors. This paper describes intervention development and refinement based on pilot results and expert- and consumer-recommendations. The pilot was conducted within the life insurance sector, a collaboration fostered by global reinsurance company Swiss Re, with cancer survivors referred to an Australian provider of occupational rehabilitation services. Preliminary outcomes from 15 of 72 cancer survivors following adequate engagement (excluding those who withdrew or were still actively engaged) showed 10 (67%) with improved certified capacity to work, translating to 13 (87%) with improved work status. Consultant survey results indicated barriers to participation in and engagement with the program, including referral delays, health concerns, and cancer recurrence. Expert panel recommendations were used to refine the intervention and tailor to breast cancer survivors for the feasibility stage. Strengths include an innovative model of referral and funding, through a life insurance provider, the involvement of a multidisciplinary collaborative team to design, develop and implement the pilot, and considerable consumer involvement. The refined intervention will address a critical gap to improve reintegration into work and society, contributing to improved quality of life for cancer survivors in Australia. Models of referral through insurers to rehabilitation services could be adopted in other jurisdictions.

Frequency of Correct Response and Factors Associated in the Medium Term With a Multimodal Rehabilitation Program for Chronic Low Back Pain

Frequency of Correct Response and Factors Associated in the Medium Term With a Multimodal Rehabilitation Program for Chronic Low Back Pain

Changes in inflammatory plasma proteins from patients with chronic pain associated with treatment in an interdisciplinary multimodal rehabilitation program - an explorative multivariate pilot study.

It has been suggested that alterations in inflammation molecules maintain chronic pain although little is known about how these factors influence homeostatic and inflammatory events in common chronic pain conditions. Nonpharmacological interventions might be associated with alterations in inflammation markers in blood. This study of patients with chronic pain investigates whether an interdisciplinary multimodal rehabilitation program (IMMRP) was associated with significant alterations in the plasma pattern of 68 cytokines/chemokines 1 year after rehabilitation and whether such changes were associated with clinical changes. Blood samples and self-reports of pain, psychological distress, and physical activity of 25 complex chronic pain patients were collected pre-IMMRP and at 12-month follow-up. Analyses of inflammatory proteins (cytokines/chemokines/growth factors) were performed directly in plasma using the multiplex immunoassay technology Meso Scale Discovery. This explorative pilot study found that 12 substances, mainly pro-inflammatory, decreased after IMMRP. In two other relatively small IMMRP studies, four of these proinflammatory markers were also associated with decreases. The pattern of cytokines/chemokines pre-IMMRP was associated with changes in psychological distress but not with pain or physical activity. The present study cannot impute cause and effect. These results together with the results of the two previous IMMRP studies suggest that there is a need for larger and more strictly controlled studies of IMMRP with respect to inflammatory markers in blood. Such studies need to consider responders/non-responders, additional therapies, involved pain mechanisms and diagnoses. This and the two other studies open up for developing biologically measurable outcomes from plasma. Such biomarkers will be an important tool for further development of IMMRP and possibly other treatments for patients w ith chronic pain.

The feasibility of implementing an exercise programme for deconditioned cancer survivors in a national cancer centre: FIXCAS Study

Introduction: As both the number of cancer survivors and the length of survival time are increasing, long-term health issues related to cancer and its treatment are becoming more prevalent. Research suggests that exercise can mitigate several negative health consequences in cancer survivors and improve physical function and quality of life. Multi-modal exercise interventions have been proposed as a cornerstone for survivorship care. However, studies evaluating exercise programmes within the Irish population are lacking. Purpose: To evaluate the introduction, implementation and acceptability of a multi-modal exercise rehabilitation programme for deconditioned cancer survivors in a real-world, standard practice setting. Methods and analysis: In this single-arm prospective feasibility study, cancer survivors (n=40) will undergo a 10-week multi-modal exercise programme. The study population will comprise of cancer survivors attending outpatient services in an Irish national cancer centre. Participants will be aged 18 or older and have completed treatment with curative intent. Feasibility will be evaluated in terms of recruitment, adherence and compliance to the programme. Secondary outcomes will examine physical function and quality of life measures. In addition, the acceptability of the programme will be assessed through patient feedback. Ethics and dissemination: Ethical approval through the St. James’s Hospital and Tallaght University Hospital Research and Ethics Committee is currently pending. The study results will be used to optimise the intervention content and may serve as the foundation for a larger definitive trial. Results will be disseminated through peer-review journals, congresses and relevant clinical groups. Trial registration: ClinicalTrials.gov NCT04026659 (19/07/19)

Laparoscopy is not enough: full ERAS compliance is the key to improvement of short-term outcomes after colectomy for cancer.

The enhanced recovery after surgery (ERAS) programs and laparoscopic techniques both reduce hospital stay and postoperative morbidity in patients undergoing colorectal cancer surgery. Laparoscopic techniques are an integral part of the ERAS program. However, evidence showing that the implementation of a multimodal rehabilitation program in addition to laparoscopy for colonic cancer would improve postoperative outcomes is still lacking. This study aimed to evaluate the impact of ERAS program on postoperative outcomes after elective laparoscopic colonic cancer resection. This is a single-center observational study from a prospectively maintained database. Two groups were formed from all patients undergoing laparoscopic colonic surgery for neoplasm during a defined period before (standard group) and after introduction of an ERAS program (ERAS group). The primary endpoint was postoperative 90-day morbidity. Secondary endpoints were the total length of hospital stay, readmission rate, and compliance with ERAS protocol. A total of 320 patients were included in the analyses, with 160 patients in the standard group and 160 in the ERAS group. There were no differences in the baseline characteristics between the two groups. Overall morbidity was significantly lower in the ERAS group (21.25%) than that in the standard group (34.4%; OR = 0.52 [0.31-0.85], p < 0.01). This difference was not due to the reduction in major complications. Mean total hospital stay was significantly lower in the ERAS group (5.8days) than that in the standard group (8.2days, p < 0.01). There were no differences in readmission rates and anastomotic complications. The ERAS pathway reduced the overall morbidity rates and shortened the length of hospital stay, without increasing the readmission rates. A significant reduction in nonsurgical complications was evident, whereas no significant reduction was found for surgical complications.

Moderate and Stable Pain Reductions as a Result of Interdisciplinary Pain Rehabilitation-A Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP).

Few studies have investigated the real-life outcomes of interdisciplinary multimodal pain rehabilitation programs (IMMRP) for chronic pain. This study has four aims: investigate effect sizes (ES); analyse correlation patterns of outcome changes; define a multivariate outcome measure; and investigate whether the clinical self-reported presentation pre-IMMRP predicts the multivariate outcome. To this end, this study analysed chronic pain patients in specialist care included in the Swedish Quality Registry for Pain Rehabilitation for 22 outcomes (pain, psychological distress, participation, and health) on three occasions: pre-IMMRP, post-IMMRP, and 12-month follow-up. Moderate stable ES were demonstrated for pain intensity, interference in daily life, vitality, and health; most other outcomes showed small ES. Using a Multivariate Improvement Score (MIS), we identified three clusters. Cluster 1 had marked positive MIS and was associated with the overall worst situation pre-IMMRP. However, the pre-IMMRP situation could only predict 8% of the variation in MIS. Specialist care IMPRPs showed moderate ES for pain, interference, vitality, and health. Outcomes were best for patients with the worst clinical presentation pre-IMMRP. It was not possible to predict who would clinically benefit most from IMMRP.

The importance of emotional distress, cognitive behavioural factors and pain for life impact at baseline and for outcomes after rehabilitation - a SQRP study of more than 20,000 chronic pain patients.

Although literature concerning chronic pain patients indicates that cognitive behavioural variables, specifically acceptance and fear of movement/(re)injury, are related to life impact, the relative roles of these factors in relation to pain characteristics (e.g. intensity and spreading) and emotional distress are unclear. Moreover, how these variables affect rehabilitation outcomes in different subgroups is insufficiently understood. This study has two aims: (1) to investigate how pain, cognitive behavioural, and emotional distress variables intercorrelate and whether these variables can regress aspects of life impact and (2) to analyse whether these variables can be used to identify clinically meaningful subgroups at baseline and which subgroups benefit most from multimodal rehabilitation programs (MMRP) immediately after and at 12-month follow-up. Pain aspects, background variables, psychological distress, cognitive behavioural variables, and two life impact variables were obtained from the Swedish Quality Registry for Pain Rehabilitation (SQRP) for chronic pain patients. These data were analysed mainly using advanced multivariate methods. The study includes 22,406 chronic pain patients. Many variables, including acceptance variables, showed important contributions to the variation in clinical presentations and in life impacts. Based on the statistically important variables considering the clinical presentation, three clusters/subgroups of patients were identified at baseline; from the worst clinical situation to the relatively good situation. These clusters showed significant differences in outcomes after participating in MMRP; the subgroup with the worst situation at baseline showed the most significant improvements. Pain intensity/severity, emotional distress, acceptance, and life impacts were important for the clinical presentation and were used to identify three clusters with marked differences at baseline (i.e. before MMRP). Life impacts showed complex relationships with acceptance, pain intensity/severity, and emotional distress. The most significant improvements after MMRP were seen in the subgroup with the lowest level of functioning before treatment, indicating that patients with complex problems should be offered MMRP. This study emphasizes the need to adopt a biopsychosocial perspective when assessing patients with chronic pain. Patients with chronic pain referred to specialist clinics are not homogenous in their clinical presentation. Instead we identified three distinct subgroups of patients. The outcomes of MMRP appears to be related to the clinical presentation. Thus, patients with the most severe clinical presentation show the most prominent improvements. However, even though this group of patients improve they still after MMRP show a complex situation and there is thus a need for optimizing the content of MMRP for these patients. The subgroup of patients with a relatively good situation with respect to pain, psychological distress, coping and life impact only showed minor improvements after MMRP. Hence, there is a need to develop other complex interventions for them.

Walking speed as a predictor of community mobility and quality of life after stroke

ABSTRACTBackground: Community mobility (CM) is considered a part of community reintegration that enhances Quality of Life (QoL). Achieving an appropriate gait speed is essential in attaining an independent outdoor ambulation and satisfactory CM.Objective: The aim of this study was to identify whether gait speed is a predictor of CM and QoL in patients with stroke following a multimodal rehabilitation program (MRP).Methods: This was a baseline control trial with 6-months follow-up in an outpatient rehabilitation setting at a university hospital. Twenty-six stroke survivors completed the MRP (24 sessions, 2 days/wk, 1 hr/session). The MRP consisted of aerobic exercise, task-oriented exercises, balance exercises and stretching. Participants also performed an ambulation program at home. Outcome variables were: walking speed (10-m walking test) and QoL (physical and psychosocial domains of Euroquol and Sickness Impact Profile).Results: At the end of the intervention, comfortable and fast walking speed increased by an average of 0.16 (SD 0.21) (*p < .05) and 0.40 (SD 0.51) (**p < .001) m/s, respectively. After the intervention, all participants achieved independent outdoor ambulation with an increase of 34.14 of walking minutes/day in the community and a decrease of sitting time of 95.45 minutes/day. Regarding QoL there were increased mean scores on the physical and psychosocial dimensions of Euroquol and the Sickness Impact Profile, respectively (**p < .001).Conclusions: The results suggest that improved walking speed after the MRP is associated with CM and higher scores in QoL. These findings support the need to implement rehabilitation programs to promote increased speed.

Detection of systemic inflammation in severely impaired chronic pain patients and effects of a multimodal pain rehabilitation program.

Background and aims Recent research indicates a previously unknown low-grade systemic or neurogenic inflammation in groups of chronic pain (CP) patients. Low-grade inflammation may have an important role in symptoms that have previously not been well depicted: widespread pain, tiredness and cognitive dysfunctions frequently seen in severely impaired CP patients. This study aimed to investigate the plasma inflammatory profile in a group of very complex CP patients at baseline and at a 1-year follow-up after participation in a cognitive behavior therapy (CBT)-based multimodal pain rehabilitation program (PRP). Methods Blood samples were collected from 52 well-characterized CP patients. Age- and sex-matched healthy blood donors served as controls. The samples were analyzed with a multiple Proximal Extension Analysis allowing a simultaneous analysis of 92 inflammation-related proteins consisting mainly of cytokines, chemokines and growth-factors. At follow-up, 1-year after participation in the RPR samples from 28 patients were analyzed. The results were confirmed by a multi-array technology that allows quantitative estimation. Results Clear signs of increased inflammatory activity were detected in the CP patients. Accepting a false discovery rate (FDR) of 5%, there were significant differences in 43/92 inflammatory biomarkers compared with the controls. In three biomarkers (CXCL5, SIRT2, AXIN1) the expression levels were elevated more than eight times. One year after the PRP, with the patients serving as their own controls, a significant decrease in overall inflammatory activity was found. Conclusions Our results indicate that the most impaired CP patients suffer from low-grade chronic systemic inflammation not described earlier with this level of detail. The results may have implications for a better understanding of the cluster of co-morbid symptoms described as the "sickness-syndrome" and the wide-spread pain seen in this group of patients. The decrease in inflammatory biomarkers noted at the follow-up after participation in the PRP may reflect the positive effects obtained on somatic and psycho-social mechanisms involved in the inflammatory process by a rehabilitation program. Besides the PRP, no major changes in medication or lifestyle factors were implemented during the same period. To our knowledge, this is the first study reporting that a PRP may induce inflammatory-reducing effects. Further studies are needed to verify the objective findings in CP patients and address the question of causality that remains to be solved. Implications The findings offer a new insight into the complicated biological processes underlying CP. It may have implications for the understanding of symptoms collectively described as the "sickness-syndrome" - frequently seen in this group of patients. The lowering of cytokines after the participation in a PRP indicate a new way to evaluate this treatment; by measuring inflammatory biomarkers.

Searching for the “Active Ingredients” in Physical Rehabilitation Programs Across Europe, Necessary to Improve Mobility in People With Multiple Sclerosis: A Multicenter Study

Background. Physical rehabilitation programs can lead to improvements in mobility in people with multiple sclerosis (PwMS). Objective. To identify which rehabilitation program elements are employed in real life and how they might affect mobility improvement in PwMS. Methods. Participants were divided into improved and nonimproved mobility groups based on changes observed in the Multiple Sclerosis Walking Scale–12 following multimodal physical rehabilitation programs. Analyses were performed at group and subgroup (mild and moderate-severe disability) levels. Rehabilitation program elements included setting, number of weeks, number of sessions, total duration, therapy format (individual, group, autonomous), therapy goals, and therapeutic approaches. Results. The study comprised 279 PwMS from 17 European centers. PwMS in the improved group received more sessions of individual therapy in both subgroups. In the mildly disabled group, 60.9% of the improved received resistance training, whereas, 68.5% of the nonimproved received self-stretching. In the moderately-severely disabled group, 31.4% of the improved, received aerobic training, while 50.4% of the nonimproved received passive mobilization/stretching. Conclusions. We believe that our findings are an important step in opening the black-box of physical rehabilitation, imparting guidance, and assisting future research in defining characteristics of effective physical rehabilitation.

A qualitative study among women immigrants from Somalia – experiences from primary health care multimodal pain rehabilitation in Sweden

Background: Immigrants often experience difficulties with acculturation and post migratory stress after arrival in a host country and studies report poor health, chronic pain and depression. This is a challenge for primary health care and interventions need to be evaluated.Objectives: To explore the experiences of a group of women from Somalia who took part in a multimodal pain rehabilitation programme in primary healthcare in Northern Sweden.Methods: Seven individual interviews a few months after participation, and a focus group discussion one year after the programme were conducted and analysed with Grounded theory.Results: A core category regained life emerged from the data. This was described as a process in two categories: panic and connection. The participants experienced that the programme was helpful and that the pain was reduced. They became more open-minded; got new ideas and knowledge; were helped to improve their societal adaptation and integration; experienced that they were not alone; and learned that there is benefits when a group of people share experiences and feelings.Conclusions: Multimodal pain rehabilitation can be helpful for women immigrants from Somalia. The programme triggered positive changes in their lives and they received knowledge about how to manage pain and improved their self-confidence and health.

Effect of Methylphenidate and Duloxetine on Neurotoxicity in CAR-T: A Case Study

Introduction Chimeric Antigen Receptor (CAR) T-cell therapy is a promising therapy for B-cell malignancies; however, it is associated with serious adverse effects including cytokine release syndrome and neurotoxicity. The incidence of neurotoxicity in two landmark trials ranged from 40-64%.1,2 Common signs and symptoms of neurotoxicity may include confusion, delirium, tremor, agitation, headache, personality changes, somnolence and dysphasia/aphasia. We report a case of severe neurotoxicity followed by significant depression and abulia. Methods We reviewed the case of a patient who experienced neurotoxicity after CD19 directed CAR T-cell therapy. The patient developed grade 2 neurotoxicity by CTCAE v4.0 consisting of aphasia, facial droop, nystagmus, tongue fasciculations, handwriting changes, and paranoid delirium. The patient was treated with intravenous dexamethasone 10mg every 6 hours with worsening of neurotoxicity during steroid taper. The patient was discharged on oral dexamethasone when medically stable then subsequently readmitted with different neurocognitive manifestations including failure to thrive, profound personality changes, passive suicidal ideation, abulia, paranoia, depression, and weakness. The patient had stopped taking all medications, including steroids, and refused all medical care. Steroids were not restarted due to steroid myopathy and psychosis. Infectious and structural complications were ruled out. Physical Medicine and Rehabilitation (PMR) was consulted. Based on evidence-based neuro-rehabilitation interventions, methylphenidate and duloxetine were recommended. Results The patient was started on methylphenidate 10mg twice daily and duloxetine extended release 30mg daily. Within 24 hours, the patient showed marked improvement with motivation to participate in medical care, improvement in anhedonia, and resolution of passive suicidal ideation. The patient showed significant improvement in physical function after participation in a multimodal inpatient rehabilitation program. Conclusion Significant improvement in neurocognitive function was seen within 24 hours after the initiation of methylphenidate and duloxetine. We propose this drug combination as a potential treatment in CAR-T patients with neurocognitive dysfunction as sequelae of neurotoxicity.

Improvements in Cognition, Chronic Migraine Headaches with Aura and Benign Paroxysmal Positional Vertigo (BPPV) in a 35-year-old Female Patient Following Neurological and Vestibular Rehabilitation.

Event Abstract Back to Event Improvements in Cognition, Chronic Migraine Headaches with Aura and Benign Paroxysmal Positional Vertigo (BPPV) in a 35-year-old Female Patient Following Neurological and Vestibular Rehabilitation. Trevor D. Eason1* 1 Carrick Institute, United States Presentation: A 35-year-old female patient presented with cognitive decline, persistent episodes of benign paroxysmal positional vertigo, and chronic, persistent migraine headaches. The history included episodes of chronic migrainous headaches originating when she was 12-years-old. The migraine headaches are normally preceded by scintillations. The patient stated that she had never been able to ride in the back of a car, participate at amusement parks and has frequent dizziness and described oscillopsia. The origination of the episodes of benign paroxysmal positional vertigo occurred 2 years ago spontaneously upon arising one morning. The patient stated that medication she has been prescribed does not have the same effect as it once did concerning her migraine episodes. Findings: During neurocognitive testing on the C3 Logix program, upon intake, Trails A time was measured at 40.8 seconds while Trails B time was measured at 45.2 seconds. Her simple reaction time was 383 milliseconds and her choice reaction time was 411 milliseconds. Her initial symptom severity score was 86% based on the associated subjective questionnaire where 0% is no symptoms. A Comprehensive Assessment of Postural Systems (CAPS®) (Pagnacco 2014) was performed assessing the patient's balance and stability, on both a solid and foamed surface, with his eyes opened, eyes closed, and with multiple head positions. Her average balance and stability score on intake was calculated as 27.12%. Videonystagography (VNG®) demonstrated mixed torsional, geotropic, upbeat nystagmus when placed in a Dix-Halpike maneuver for the right posterior canal. A 2-3 Hz. left beat nystagmus was also observed with gaze fixation eliminated in primary position. Methods: A 12-day multi-modal neurological rehabilitation program was administered in 12 one-hour treatment sessions (Carrick, 2017). Initial treatment consisted of an Epley maneuver to alleviate the right posterior canal debris. Each session after consisted of neurological and vestibular rehabilitation exercises directed towards the right vestibular apparatus and cerebellum integration, somatosensory evoked potentials, cognitive exercises, orthoptic training, and off-vertical axis rotation (Gdowski 1999) using a multi-axis rotational chair. Initially, she was placed on a paleo diet and a supplement protocol. Based on clinical symptoms indicating alterations in energy production, she was placed on multiple nutrient formulas containing Vitamin E (11 mg), docosahexaenoic acid (1200 mg), Phosphatidylcholine (60 mg) 1 x daily. CoQ10 (200 mg) and Pyrroloquinoline quinone disodium salt (PQQ) (5 mg) were also administered in a 5 ml. dose 1 x daily. She was advised to reduce smoking and enroll in smoking cessation counseling. Outcomes: Upon discharge, Trails A time decreased to 23.5 seconds (-42.4%), and Trails B time decreased to 32.7 seconds (-27.7%). Simple reaction time decreased to 277 seconds (-27.7%), and choice reaction time decreased to 312 seconds(-24.1%). Symptom severity score decreased to 7 (-91.9%) where 0 is no symptoms. The average balance and stability score improved resulting in a score of 85.37% (+214.9%). Upon Videonystagography (VNG®), no mixed torsional, geotropic, upbeat nystagmus was observed when placed in a Dix-Halpike maneuver for the right posterior canal. No nystagmus was observed with gaze fixation eliminated in a neutral gaze or primary ocular position. Concurrently, full resolution of her migraine headaches occurred after the BPPV was eliminated. Conclusions: The author suggests further investigation into the use of multi-modal neurological, vestibular rehabilitation strategies and supplemental clinical nutrition strategies for the treatment of BPPV, and migraine headaches with aura. The author also suggests further investigation into multi-modal, intensive approaches to improve stability scores, simple and choice reaction times, symptom severity scores and stability of eye movements associated with proper neurological and vestibular function. Acknowledgements The author would like to thank and acknowledge Professor Frederick Carrick and his pioneering work in the field of clinical neuroscience. The author would also like to thank the Carrick Institute for providing the education utilized to create the multi-modal treatments implemented in this case study.

Improvements in Social Cognition, Executive Functioning, and Trichotillomania with Characteristics of Trichophagia in a 26-year-old Female Patient Following Neurological Rehabilitation.

Event Abstract Back to Event Improvements in Social Cognition, Executive Functioning, and Trichotillomania with Characteristics of Trichophagia in a 26-year-old Female Patient Following Neurological Rehabilitation. Trevor D. Eason1* 1 Carrick Institute, United States Presentation: A 26-year-old female patient presented with social cognitive impairment, memory decline, executive function limitations, persistent episodes of pica via trichophagia, and trichotillomania. The history included episodes of hair pulling and ingestion with no memory or recollection of the episode. Social cognition and executive functioning cues were slow and mild cognitive impairment had been made evident in the previous diagnosis. The patient stated that she had never been able to act appropriately in society after a history of multiple streptococcus A and mycoplasma pneumonia infections when she was 2 years old. The patient's mother stated that the mental processing of the patient is evident yet slower than the expected norm. Findings: During neurocognitive testing on the C3 Logix program, upon intake, Trails A time was measured at 49.1 seconds while Trails B time was measured at 55.9 seconds. Her simple reaction time was 423 milliseconds and her choice reaction time was 511 milliseconds. Her initial symptom severity score was 56% based on the associated subjective questionnaire where 0% is no symptoms. A Comprehensive Assessment of Postural Systems (CAPS®) (Pagnacco 2014) was performed assessing the patient's balance and stability, on both a solid and foamed surface, with his eyes opened, eyes closed, and with multiple head positions. Her average balance and stability score on intake was calculated as 67.12%. Comprehensive behavioral Intervention score of 23.5%. Videonystagography (VNG®) demonstrated saccadic oscillations. These eye movements were observed with similar frequency (15-20 Hz.) and equality sided to side with gaze fixation eliminated in primary position. Methods: A 12-day multi-modal neurological rehabilitation program was administered in 12 one-hour treatment sessions (Carrick, 2017). Each session consisted of neurological and vestibular rehabilitation exercises directed towards the cerebellum and basal ganglia integration, somatosensory evoked potentials, comprehensive behavioral intervention for tics (CBIT) treatment associated with habit reversal training and function-based treatments, orthoptic training, and off-vertical axis rotation (Gdowski 1999) using a multi-axis rotational chair. Based on clinical symptoms indicating alterations in energy production, she was placed on multiple nutrient formulas containing pantothenic acid (300 mg), L-α glycerylphosphorylcholine (100 mg), acetyl L-carnitine hydrochloride (25 mg), Butyric acid and calcium propionate blend (575 mg) and Huperzia serrata (75 mcg) 3 times daily. Also, the patient administered a gastrointestinal tissue repair compound containing a proprietary blend of sodium (10 mg), L-Glutamine (3.5 g), deglycyrrhizinated licorice extract (500 mg), aloe vera gel concentrate (50 mg), ginger extract (40 mg), and an enzymatic blend once daily with a meal. Outcomes: Upon discharge, Trails A time decreased to 37.6 seconds (-23.4%), and Trails B time decreased to 42.7 seconds (-23.6%). Simple reaction time decreased to 347 seconds (-18.0%), and choice reaction time decreased to 386 seconds (-24.5%). Symptom severity score decreased to 23 (-58.9%) where 0 is no symptoms. The average balance and stability score improved resulting in a score of 79.17% (+18.0%). Upon Videonystagography (VNG®), saccadic oscillation frequency was diminished per time observed with gaze stability in primary position, 20 degrees horizontally and 15 degrees vertically (circumferentially). Comprehensive behavioral Intervention score 49.8% (+111.9 %). No nystagmus was observed with gaze fixation eliminated in primary gaze position. Concurrently, the patient is now able to implement awareness strategies to compete against her trichotillomania and trichophagia episodes which ultimately proves an increase in executive functioning. Conclusions: The author suggests further investigation into the use of multi-modal neurological rehabilitation strategies, comprehensive behavioral interventions and supplemental clinical nutrition strategies for the treatment of trichotillomania with associated trichophagia, and cognitive impairment.​ The author also suggests further investigation into multi-modal, intensive approaches to improve stability scores, simple and choice reaction times, symptom severity scores and multimodal integration associated with proper neurological and cognitive function. Acknowledgements The author would like to thank and acknowledge Professor Frederick Carrick and his pioneering work in the field of clinical neuroscience. The author would also like to thank the Carrick Institute for providing the education utilized to create the multi-modal treatments implemented in this case study.

Improvements in Balance Stability Scores, Cognition, and 67% Reduced Symptom Severity Score Following Neurological Rehabilitation for a 37-year-old Female with Post-Concussive Syndrome

Event Abstract Back to Event Improvements in Balance Stability Scores, Cognition, and 67% Reduced Symptom Severity Score Following Neurological Rehabilitation for a 37-year-old Female with Post-Concussive Syndrome Angela M. Gabella1, 2* 1 Carrick Institute, United States 2 Precision Brain Center, United States Presentation: A 37-year-old female patient presented to Precision Brain Center for evaluation and treatment of post-concussive syndrome (PCS). She presented with the following symptomatology: chronic dizziness, short-term memory loss, confusion, poor concentration, cognitive decline, severe anxiety, Irritability, full body tremors, feels like her insides are vibrating, vision problems, fatigue, brain fog, weakness in her right arm and hand, and bilateral swelling in her legs. Her symptom first started 2 years ago with insidious onset then in 2018 she got dizzy while working out and fell and hit her head on a dumbbell. After suffering a concussion her symptoms immediately worsen. Findings: A comprehensive neurological examination revealed a right ocular esotropia, left ocular hypertropia, corectasia of right pupil, a decreased perception of pinprick on right face when compared to the left, decreased palate elevation on the right. Anti-saccade test revealed multiple ocular pro-saccadic errors. Fundoscopic exam with occluded vision revealed up beating nystagmus with right square wave jerks. In accordance to the UPDRS guidelines finger tapping test was a grade 2 on the left, finger to nose test was grade 2 left with dysmetria, supination-pronation arm test was grade 2 on the left, gait test grade 2 left decrease arm swing, gait with dual tasking test was grade 3, abolished left arm swing & freezing. When asked to rate her symptoms on a Post-Concussion Symptoms Scale (PCSS) (SCAT5 2017), she reported a score of 104 (0-132 scale). On the standardized assessment of concussion (SAC), she scored 14 out of 30. An Assessment of the balance system using The Balance Error Scoring System (BESS) was performed assessing balance and stability, on a solid and foamed surface, with eyes closed, and in double leg, single leg, and in tandem stance. The BESS score was 22 (total errors) out of 60. Methods: A multi-modal program of neurological exercises was administered in 18 one-hour treatment sessions over a 9 week period. Each session consisted of various combinations of eye-head vestibular motion therapy, repetitive peripheral somatosensory stimuli, proprioception retraining, vestibular rehabilitation, cognitive training, and eye movement exercises. All exercises were precisely designed and modified to address the patient’s individual neurological deficits and physical exam findings were continually reassessed throughout treatment. Outcome: Upon exit, the symptom severity score (PCSS) decreased to 34 (-67.3%). Her SAC score increased to 26 out of 30 (85.7%). BESS balance scores improved to 10 (total errors) (-54.54%) out of 60. A 67% improvement in total symptom score was recorded after a multimodal neurological rehabilitation program was performed in 18 one-hour treatment sessions. Conclusion: The author suggests further investigation into multi-modal neurological exercises as a clinical approach to decrease symptom severity, improve SAC scores, and increase balance and stability scores in patients with PCS. Acknowledgements The authors would also like to thank the Carrick Institute for providing the clinical education utilized to develop the multi-modal treatments implemented in this case study.

Does validation and alliance during the multimodal investigation affect patients' acceptance of chronic pain? An experimental single case study.

Background and aims Among chronic pain patients who are referred to participation in a multimodal rehabilitation program (MMRP), pain catastrophizing and dysfunctional pain coping is common. In many cases it may have driven the patient to a range of unsuccessful searches for biomedical explanations and pain relief. Often these efforts have left patients feeling disappointed, hopeless and misunderstood. The MMRP process can be preceded by a multimodal investigation (MMI) where an important effort is to validate the patient to create a good alliance and begin a process of change towards acceptance of the pain. However, whether the MMI has such therapeutic effect is unclear. Using a repeated single case experimental design, the purpose of this study was to investigate the therapeutic effect of MMI by studying changes in patients' experience of validation, alliance, acceptance of pain, coping, catastrophizing, and depression before and during the MMI process. Methods Participants were six chronic pain patients with high levels of pain catastrophizing (>25 on the Pain Catastrophizing Scale) and risk for long term disability (>105 on the Örebro Musculoskeletal Pain Screening Questionnaire) who were subjected to MMI before planned MMRP. For each patient, weekly self-report measures of validation, alliance and acceptance of pain were obtained during a 5-10-weeks baseline, before the MMI started. Subsequently, these measures were also obtained during a 6-8 weeks MMI process in order to enable comparative analyses. Additionally, pain coping, depression and pain catastrophizing were measured using standardized questionnaires before and after the MMI. Results Irrespective of experiences of validation and alliance before MMI, all six patients felt validated and experienced a good alliance during MMI. Acceptance of pain improved only in one patient during MMI. None of the patients showed clinically relevant improvement in pain coping, depression or catastrophizing after the MMI. Conclusions The patients did not change their acceptance and pain coping strategies despite of good alliance and experience of validation during the MMI process. Even if the design of this study precludes generalization to chronic pain patients in general, the results suggest that MMI may not have a therapeutic effect.