A technology-enabled multi-disciplinary team-based care model for the management of Long COVID and other fatiguing illnesses within a federally qualified health center: protocol for a two-arm, single-blind, pragmatic, quality improvement professional cluster randomized controlled trial.

BACKGROUND: The clinical burden of Long COVID, myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), and other post-infectious fatiguing illnesses (PIFI) is increasing. There is a critical need to advance understanding of the effectiveness and sustainability of innovative approaches to clinical care of patients having these conditions. METHODS: We aim to assess the effectiveness of a Long COVID and Fatiguing Illness Recovery Program (LC&FIRP) in a two-arm, single-blind, pragmatic, quality improvement, professional cluster, randomized controlled trial in which 20 consenting clinicians across primary care clinics in a Federally Qualified Health Center system in San Diego, CA, will be randomized at a ratio of 1:1 to either participate in (1) weekly multi-disciplinary team-based case consultation and peer-to-peer sharing of emerging best practices (i.e., teleECHO (Extension for Community Healthcare Outcomes)) with monthly interactive webinars and quarterly short courses or (2) monthly interactive webinars and quarterly short courses alone (a control group); 856 patients will be assigned to participating clinicians (42 patients per clinician). Patient outcomes will be evaluated according to the study arm of their respective clinicians. Quantitative and qualitative outcomes will be measured at 3- and 6-months post-baseline for clinicians and every 3-months post assignment to a participating clinician for patients. The primary patient outcome is change in physical function measured using the Patient-Reported Outcomes Measurement Information System (PROMIS)-29. Analyses of differences in outcomes at both the patient and clinician levels will include a linear mixed model to compare change in outcomes from baseline to each post-baseline assessment between the randomized study arms. A concurrent prospective cohort study will compare the LC&FIRP patient population to the population enrolled in a university health system. Longitudinal data analysis approaches will allow us to examine differences in outcomes between cohorts. DISCUSSION: We hypothesize that weekly teleECHO sessions with monthly interactive webinars and quarterly short courses will significantly improve clinician- and patient-level outcomes compared to the control group. This study will provide much needed evidence on the effectiveness of a technology-enabled multi-disciplinary team-based care model for the management of Long COVID, ME/CFS, and other PIFI within a federally qualified health center. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05167227 . Registered on December 22, 2021.

Impacts of Financial Assistance on Quality of Life Among People Living With Burn Injury: Matched Cohort Analysis of the National Institute on Disability, Independent Living and Rehabilitation Research Burn Model System Database.

Disparities in socioeconomic status and minority status affect the risk of burn injury and the severity of that injury, thus affecting the subsequent cost of care. We aimed to characterize the demographic details surrounding receipt of financial assistance due to burn injury and its relationship with health-related quality of life scores. Participants ≥18 from Burn Model System National Longitudinal Database (BMS) with complete demographic data were included (n = 4330). Nonresponders to financial assistance questions were analyzed separately. The remaining sample (n = 1255) was divided into participants who received financial assistance because of burn injury, those who received no financial assistance, and those who received financial assistance before injury and as a result of injury. A demographic and injury-characteristic comparison was conducted. Health-related quality of life metrics (Satisfaction with Life, Short Form-12/Veterans RAND 12-Item Health Survey, Community Integration Questionnaire Social Component, and the Post-Traumatic Growth Inventory) were analyzed preinjury, then 6-months, 1-year, and 2-years postinjury. A matched cohort analysis compared these scores. When compared to their no financial assistance counterparts, participants receiving financial assistance due to burns were more likely to be minorities (19% vs 14%), have more severe injuries (%TBSA burn 21% vs 10%), and receive workers' compensation (24% vs 9%). They also had lower health-related quality of life scores on all metrics except the post-traumatic growth inventory. Financial assistance may aid in combating disparities in posttraumatic growth scores for participants at the greatest risk of financial toxicity but does not improve other health-related quality of life metrics.

Physical function and fatigue recovery at 6 months after hospitalization for COVID-19.

INTRODUCTION: There are an increasing number of individuals with long-term symptoms of coronavirus-19 disease (COVID-19); however, the prognosis for recovery of physical function and fatigue after COVID-19 is uncertain. OBJECTIVE: To report the changes in functional recovery between 1 and 6 months after hospitalization of adults hospitalized for COVID-19 and explore the baseline factors associated with physical function recovery. DESIGN: A prospective cohort study. SETTING: Tertiary care hospital. PARTICIPANTS: U.S. adult COVID-19 survivors. INTERVENTION: N/A. MAIN OUTCOME MEASURES: Telephone interviews assessed three outcome domains: basic and instrumental activities of daily living (ADLs) performance, fatigue, and general physical function (Health Assessment Questionnaire [HAQ]). RESULTS: The age of participants (n = 92) ranged from 22 to 95 years (54.3 ± 17.2). Across outcome domains, a majority (63%-67%) of participants developed new ADL impairment, fatigue, or worsening HAQ severity by 1 month. Of those, 50%-79% partially or fully recovered by 6 months, but 21%-50% did not recover at least partially. Fifteen to 30% developed new impairment between 1 and 6 months. For those without any improvement in ADL impairments at 6 months, lower socioeconomic status was significantly more common (p = .01) and age ≥ 65 (p = .06), trending toward being more common. CONCLUSION: In this cohort, a substantial proportion of the participants who developed new ADL impairment, worsening fatigue, or HAQ severity after hospitalization for COVID-19 did not recover at least partially by 6 months after discharge. Evaluating functional status 1 month after discharge may be important in understanding functional prognosis and recovery after hospitalization for COVID-19.

Surface Electromyography-Driven Therapeutic Gaming for Rehabilitation of Upper Extremity Weakness: A Pilot Study.

SUMMARY: In patients with severe upper extremity weakness that may result from peripheral nerve injuries, stroke, and spinal cord injuries, standard therapy in the earliest stages of recovery consists primarily of passive rather than active exercises. Adherence to prescribed therapy may be poor, which may contribute to suboptimal functional outcomes. The authors have developed and integrated a custom surface electromyography device with a video game to create an interactive, biofeedback-based therapeutic gaming platform. Sensitivity of the authors' custom surface electromyography device was evaluated with simultaneous needle electromyography recordings. Testing of this therapeutic gaming platform was conducted with a single 30-minute gameplay session in 19 patients with a history of peripheral nerve injury, stroke, spinal cord injury, and direct upper extremity trauma, including 11 patients who had undergone nerve and/or tendon transfers. The device was highly sensitive in detecting low levels of voluntary muscle activation and was used with 10 distinct muscles of the arm, forearm, and hand. Nerve and tendon transfer patients successfully activated the donor nerve/muscle and elicited the desired movement to engage in gameplay. On surveys of acceptability and usability, patients felt the system was enjoyable, motivating, fun, and easy to use, and their hand therapists expressed similar enthusiasm. Surface electromyography-based therapeutic gaming is a promising approach to rehabilitation that warrants further development and investigation to examine its potential efficacy, not only for building muscle strength and endurance but also for facilitating motor relearning after nerve and tendon transfer surgical procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Trends and Disparities in Inpatient Rehabilitation of Adolescents: The Effect of Demographics, Injury Characteristics, and Facility Type.

BACKGROUND: Intensive rehabilitation of adolescents occurs in general and pediatric inpatient rehabilitation facilities (IRFs), but differences in admission and outcomes by facility type have not been thoroughly investigated, particularly among persons with spinal cord injury (SCI). OBJECTIVES: To investigate factors related to admission to pediatric or adult IRFs among adolescents and compare the rehabilitation outcomes between facility types. METHODS: Using a single-center retrospective cohort study design, demographic information, medical data, and rehabilitation outcomes were obtained by chart review of patients aged 15 to 18 years who received a rehabilitation medicine consultation at an urban level 1 trauma center between 2017 and 2019 (N = 96). Analysis was performed using R statistical software. RESULTS: SCI was the second most common diagnosis (21% of patients) and accounted for 36% of inpatient rehabilitation admissions. SCI patients were more likely to undergo rehabilitation at the level 1 trauma versus pediatric facility (relative risk [RR] = 2.43; 95% confidence interval [CI] = 1.08-5.44) compared to traumatic brain injury patients. Admission to trauma versus pediatric IRF was also associated with Black compared to White race (RR = 2.5; CI = 1.12-5.56), violence compared to other etiologies of injury (RR = 2.0; CI = 1.10-3.77), and Medicaid compared to private insurance (RR = 2.15; CI = 1.01-4.59). Admission to pediatric IRF was associated with longer length of stay than admission to adult IRF when adjusted for diagnosis (30.86 ± 21.82 vs. 24.33 ± 18.17 days; p = .046), but Functional Independence Measures did not differ. CONCLUSION: Adolescents with SCI and those experiencing systemic disadvantages, including racism and poverty, were more likely to be admitted to trauma compared to pediatric IRF.

Interrater reliability of quantitative ultrasound measures of muscle in critically ill patients.

BACKGROUND: Quantitative neuromuscular ultrasound is increasingly used to study muscle pathology and changes in muscle mass during critical illness. Advantages of ultrasound are high axial resolution, low procedural risks, no ionizing radiation, and ease of use early in the course of disease. However, ultrasound is known to be an operator dependent imaging modality and the intensive care unit setting poses additional challenges to obtaining reliable measurements. There is limited evidence validating the feasibility and reliability of its application in this setting. OBJECTIVE: To conduct a standardized protocol for measuring muscle linear depth and cross-sectional area in critically ill populations with a high degree of interrater agreement and feasibility. DESIGN: Prospective observational cohort study of interrater reliability. SETTING: Medical intensive care unit at an academic medical center and a level one trauma and burn center. PATIENTS: Fifteen critically ill patients were evaluated using a standardized ultrasound protocol measuring total elbow flexor, knee extensor, and tibialis anterior depth, as well as rectus femoris cross-sectional area. Each site was independently scanned by two investigators. Reliability of measurements between observers was determined by calculating intraclass correlation coefficients (ICCs) using a two-way random effects model and absolute agreement. An ICC > 0.75 was considered good and >0.90 was considered excellent. RESULTS: In critically ill patients, interrater reliability of linear depth measured at elbow flexor, knee extensor, tibialis anterior, and cross-sectional area of rectus femoris sites was good to excellent with ICC between 0.87 (0.54-0.97) and 0.99 (0.97-1.00). Interrater reliability was improved by creating a summary index of measures resulting in an ICC of 0.99 (0.98-1.00). Feasibility, as definite by the percentage of each measure that was obtainable, ranged from 75%-100%. CONCLUSIONS: Using a standardized protocol, ultrasound measures obtained in critically ill patients demonstrated high levels of interrater agreement with good to excellent feasibility.

Intensive care unit-acquired weakness and the COVID-19 pandemic: A clinical review.

Patients with severe cases of coronavirus disease 2019 (COVID-19) often become critically ill requiring intensive care unit (ICU) management. These individuals are at risk for developing ICU-acquired weakness (ICUAW), a multifactorial condition in which polyneuropathy, myopathy, and/or disuse muscle atrophy result in motor weakness. This weakness is thought to contribute to the long-term functional disability frequently observed in survivors of critical illness. This review discusses the current evidence regarding the epidemiology, pathophysiology, evaluation, risk factors, and rehabilitation-specific management of ICUAW in patients with COVID-19. Because of the novelty of COVID-19, the exact prevalence of ICUAW is not well delineated among COVID-19 patients. However, ICUAW has been reported in this population with retrospective studies showing weakness occurring in up to 45.5% of patients with severe COVID-19. There are multiple risk factors for developing ICUAW among COVID-19 patients, including premorbid health status, sepsis, multiple organ failure, mechanical ventilation, immobilization, neuromuscular blockade, corticosteroid use, and glycemic control. ICUAW is more likely to occur after prolonged mechanical ventilation and long hospital stays and can be diagnosed with manual muscle and electrodiagnostic testing. Although the long-term sequela of COVID-19 after ICU stays is not fully studied, increasing evidence indicates significant risk for this population developing long-term functional impairments. Establishing postacute rehabilitation programs for COVID-19 survivors will be important for recovery of endurance, mobility, and function.

Intensive care-related cognitive impairment: A biopsychosocial overview.

Advancements in critical care medicine have improved survival rates for patients experiencing critical illness in intensive care units (ICUs). Although mortality has declined, more than half of ICU survivors experience functional impairments that persist beyond discharge. Of particular concern is ICU-related cognitive impairment, which can extend across the care continuum, ranging from acute and transient presentations in the ICU (eg, delirium) to long-term impairments years after discharge. ICU-related cognitive impairment has received increased attention in the literature, particularly as it relates to ICU survivors who have received and survived critical care in the context of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic and are now experiencing postacute sequelae of SARS-CoV-2 infection. The medical complexity and heterogeneity of ICU survivors, coupled with the multifactorial etiology of ICU-related cognitive impairments, lead to challenges in how to optimize care for ICU survivors at various stages of recovery. This review aims to provide an overview of cognitive outcomes associated with critical illness by integrating recent literature focused on etiology, assessment, and interventions in the context of ICU-related cognitive impairments. The narrative review employs a biopsychosocial framework to comprehensively evaluate the multifactorial nature of ICU-related cognitive outcomes. Authors also highlight that multidisciplinary teams composed of key rehabilitation providers are likely best suited for optimizing recovery trajectories of ICU survivors.

Patient-reported functional outcomes 30 days after hospitalization for COVID-19.

BACKGROUND: Many coronavirus disease 2019 (COVID-19) survivors experience persistent symptoms, such as fatigue, dyspnea, and musculoskeletal pain. However, less is known about the impact of COVID-19 on longer term functional outcomes. OBJECTIVE: To evaluate patient-reported activity of daily living (ADL) function and fatigue symptoms 30 days after hospitalization for COVID-19. DESIGN: Cross-sectional study. SETTING: Tertiary care university hospital. PARTICIPANTS: Adults 18 years or older hospitalized for COVID-19 and survived to 30 days after discharge. METHODS: A standardized telephone questionnaire was administered 30 days after hospital discharge. MAIN OUTCOME MEASURES: Ability to perform basic and instrumental ADLs and fatigue symptoms severity (Patient-Reported Outcome Measurement Information System [PROMIS] Fatigue Short Form 7a) were assessed by self-report. RESULTS: Participants (n = 55) were 22-95 years old. Compared to pre-COVID hospitalization, 52% developed new difficulty and 6% new dependence with performing basic ADLs (bADLs), 48% developed new difficulty and 11% new dependence with instrumental ADLs (iADLs), and 69% experienced a clinically significant worsening in their fatigue symptom severity. The average fatigue symptom severity T-score before hospitalization was 44.2 ± 7.4 and after hospitalization was 54.5 ± 9.8. In exploratory multivariate analyses, each additional COVID symptom at presentation was associated with a predicted increase of 1.43 units (95% confidence interval [CI], 0.45-2.42) in the 30-day fatigue symptom severity T-score, each additional day of hospitalization was associated with an 1.2 times increased odds of worsening fatigue (95% CI, 0.98-1.5; p = .08), and each unit increase in baseline body mass index was associated with 0.8 times decreased odds of new bADL or iADL dependence at 30 days (95% CI, 0.65-0.99). CONCLUSIONS: New functional impairments are common at 30 days after discharge among survivors of hospitalization for COVID-19. Early rehabilitation, advance care planning, and referrals to appropriate therapies should be considered in postacute COVID-19 care to maximize patients' functional outcomes. However, ongoing research is still needed regarding management of these patients.

Acceptability of a Mobile Phone-Based Augmented Reality Game for Rehabilitation of Patients With Upper Limb Deficits from Stroke: Case Study.

BACKGROUND: Upper limb functional deficits are common after stroke and result from motor weakness, ataxia, spasticity, spatial neglect, and poor stamina. Past studies employing a range of commercial gaming systems to deliver rehabilitation to stroke patients provided short-term efficacy but have not yet demonstrated whether or not those games are acceptable, that is, motivational, comfortable, and engaging, which are all necessary for potential adoption and use by patients. OBJECTIVE: The goal of the study was to assess the acceptability of a smartphone-based augmented reality game as a means of delivering stroke rehabilitation for patients with upper limb motor function loss. METHODS: Patients aged 50 to 70 years, all of whom experienced motor deficits after acute ischemic stroke, participated in 3 optional therapy sessions using augmented reality therapeutic gaming over the course of 1 week, targeting deficits in upper extremity strength and range of motion. After completion of the game, we administered a 16-item questionnaire to the patients to assess the game's acceptability; 8 questions were answered by rating on a scale from 1 (very negative experience) to 5 (very positive experience); 8 questions were qualitative. RESULTS: Patients (n=5) completed a total of 23 out of 45 scheduled augmented reality game sessions, with patient fatigue as the primary factor for uncompleted sessions. Each patient consented to 9 potential game sessions and completed a mean of 4.6 (SE 1.3) games. Of the 5 patients, 4 (80%) completed the questionnaire at the end of their final gaming session. Of note, patients were motivated to continue to the end of a given gaming session (mean 4.25, 95% CI 3.31-5.19), to try other game-based therapies (mean 3.75, 95% CI 2.81-4.69), to do another session (mean 3.50, 95% CI 2.93-4.07), and to perform other daily rehabilitation exercises (mean 3.25, 95% CI 2.76-3.74). In addition, participants gave mean scores of 4.00 (95% CI 2.87-5.13) for overall experience; 4.25 (95% CI 3.31-5.19) for comfort; 3.25 (95% CI 2.31-4.19) for finding the study fun, enjoyable, and engaging; and 3.50 (95% CI 2.52-4.48) for believing the technology could help them reach their rehabilitation goals. For each of the 4 patients, their reported scores were statistically significantly higher than those generated by a random sampling of values (patient 1: P=.04; patient 2: P=.04; patient 4: P=.004; patient 5: P=.04). CONCLUSIONS: Based on the questionnaire scores, the patients with upper limb motor deficits following stroke who participated in our case study found our augmented reality game motivating, comfortable, engaging, and tolerable. Improvements in augmented reality technology motivated by this case study may one day allow patients to work with improved versions of this therapy independently in their own home. We therefore anticipate that smartphone-based augmented reality gaming systems may eventually provide useful postdischarge self-treatment as a supplement to professional therapy for patients with upper limb deficiencies from stroke.

The Feasibility and Acceptability of Virtual Therapy Environments for Early ICU Mobilization.

BACKGROUND: Early mobilization in critically ill patients has been documented to reduce neuromuscular complications, but access to rehabilitation services is often limited in the intensive care unit (ICU). Virtual platforms that deliver therapy may increase access to rehabilitation services and improve patient motivation to participate. Xbox Kinect Jintronix software delivers interventions using games and activities designed for therapy. OBJECTIVE: To determine the feasibility of the Jintronix virtual therapy system in an ICU setting by observing outcomes related to patient satisfaction, adverse events, and technical applicability. DESIGN: Prospective observational feasibility study. SETTING: Medical ICU at a Level 1 Trauma Center within an academic medical center. PARTICIPANTS: Twenty adults admitted to ICU. INTERVENTION: Participants engaged in one therapy session with a maximum of 14 Jintronix modules targeting arm, leg, and/or trunk strength, range of motion, and endurance. OUTCOME MEASURES: A trained physician-observer recorded events related to adverse events and technical applicability. Participants completed a survey to determine patient satisfaction. RESULTS: A total of 188 modules were completed. Participants completed a median of nine modules each. Five participants completed the maximum of 14 modules. Fatigue was the most common reason for cessation. Mean intervention time was 29 minutes. There were no falls, lines dislodged, or medical events. Participants required physical assistance or verbal cues in 36% of modules. Technical errors affected 25% of modules and led to activity cessation in one case. Nearly all participants reported the activity was enjoyable, comfortable, safe, easy to understand, would improve range of motion and strength, and would motivate them to continue. CONCLUSIONS: Use of a virtual therapy environment in an intensive care setting is feasible.

Prognostic value of needle electromyography in traumatic brachial plexus injury.

INTRODUCTION: In this study we aimed to determine whether needle electromyographic assessment of voluntary motor unit recruitment in traumatic brachial plexus injuries could predict spontaneous motor recovery. METHODS: A retrospective study was performed on patients with brachial plexus injury affecting deltoid, supraspinatus/infraspinatus, and biceps brachii. The outcome measure was strength on manual muscle testing at least 1 year after injury. Good outcome was considered strength >3/5 on the Medical Research Council (MRC) scale. RESULTS: No muscles with no recruitment (n = 27) at 1-9 months improved to MRC 4/5 strength at a mean of 2.0 years postinjury. Twenty-five percent of muscles with discrete or severely reduced recruitment (n = 8) regained strength to >3/5 at a mean of 1.4 years postinjury (P = .047). DISCUSSION: Absent voluntary motor unit potential recruitment at 1-9 months predicted poor prognosis for spontaneous recovery. A high percentage of patients with discrete recruitment did not improve to >3/5 strength. These patients should be considered for early nerve transfer surgery.

Intensive Continuous Positive Airway Pressure Adherence Program During Stroke Rehabilitation.

Background and Purpose- Continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea may improve stroke recovery, but adherence is poor. We assessed the effectiveness of an intensive CPAP adherence program during and after inpatient stroke rehabilitation on 3-month adherence and stroke recovery. Methods- In a single-arm study, 90 stroke rehabilitation patients were enrolled into an intensive CPAP adherence program. CPAP was continued after a run-in among qualifying patients with evidence of obstructive sleep apnea. The primary outcome was CPAP adherence, defined as ≥4 hours of use on ≥70% of days, over 3 months. Results- A total of 62 patients qualified for continued CPAP and 52 of these were willing to continue CPAP after discharge from rehabilitation. At 3 months, the average daily CPAP use was 4.7 hours (SD 2.6), and 32/52 (62%) patients were adherent. Factors significantly associated with adherence included more severe stroke, aphasia, and white race. Compared with nonadherent patients, adherent patients experienced greater improvements in the cognitive component of the Functional Independence Measure ( P=0.02) and in the National Institutes of Health Stroke Scale ( P=0.03). Conclusions- This intensive CPAP adherence program initiated during stroke rehabilitation can lead to CPAP adherence in the majority of patients with evidence of obstructive sleep apnea, including those with more severe stroke and aphasia, and may promote recovery. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT02809430.

Planning Interventions to Treat Brachial Plexopathies.

This article reviews the electrodiagnosis of brachial plexus injury, factors that predict outcome, the utility electrodiagnostic evaluation of potential nerve donors, and commonly used surgical interventions. Electrodiagnostic evaluation begins with a detailed understanding of brachial plexus anatomy and uses a complement of motor and sensory nerve conduction studies and needle electromyography to determine the location of injury and predict severity. Several factors are used to predict prognosis. In injuries with poor prognosis, surgical intervention is indicated. Nerve transfers are increasingly employed to improve functional outcomes. Electrodiagnosis is key to evaluating the viability of potential nerve donors.

Feasibility of a Kinect®-based rehabilitation strategy after burn injury.

INTRODUCTION: The advent of consoles that deliver both interactive games and therapy may augment rehabilitation options in burn patients. The Jintronix software combines therapy-specific software and interactive gaming as a form of coaching and records patient performance on the Kinect® platform. Our objective was to determine the feasibility of a set of Jintronix games and therapy modules in hospitalized adult burn patients. METHODS: We conducted a prospective single center feasibility study from August through October 2016. The study enrolled subjects to conduct 1 supervised session with 6 Jintronix modules targeting their burned areas of the body, with an acceptability survey and a safety analysis. We also performed qualitative analysis to detect major themes from free-text responses. RESULTS: We enrolled 20 participants. Eleven (55%) completed all the modules; reasons for incompletion included baseline shoulder abduction pain and poor balance. Participants responded that the activity was comfortable (90%), safe (100%), easy to understand (95%), and improved strength/range of motion (100%). Mean module completion time was 43±10min. Mean pain score was 3.8±2.8 (out of 10) and localized to burned areas. The wall climbing module had 4 episodes of temporary imbalance. Eight (40%) participants recorded fatigue at completion and noted "sweating" or "feeling stretched". Qualitative analysis highlighted that the activity was "fun/cool" and a "good challenge". Negative themes included "inaccurate depth" sensing and "too lengthy" on a specific module. CONCLUSIONS: A Jintronix-based therapy demonstrated good acceptability and safety in hospitalized burn patients. Feedback from this study led to software modifications implemented by the Jintronix company. This feasibility study has informed the design of a prospective randomized controlled trial to determine whether a virtual-environment home rehabilitation strategy improves functional outcomes after burn injury.

Peer Support as a Novel Strategy to Mitigate Post-Intensive Care Syndrome.

Post-intensive care syndrome, a condition defined by new or worsening impairment in cognition, mental health, and physical function after critical illness, has emerged in the past decade as a common and life-altering consequence of critical illness. New strategies are urgently needed to mitigate the risk of neuropsychological and functional impairment common after critical illness and to prepare and support survivors on their road toward recovery. The present state of critical care survivorship is described, and postdischarge care delivery in the United States and the potential impact of the present-day fragmented model of care delivery are detailed. A novel strategy that uses peer support groups could more effectively meet the needs of survivors of critical illness and mitigate post-intensive care syndrome.

ICU-Acquired Weakness.

Survivorship after critical illness is an increasingly important health-care concern as ICU use continues to increase while ICU mortality is decreasing. Survivors of critical illness experience marked disability and impairments in physical and cognitive function that persist for years after their initial ICU stay. Newfound impairment is associated with increased health-care costs and use, reductions in health-related quality of life, and prolonged unemployment. Weakness, critical illness neuropathy and/or myopathy, and muscle atrophy are common in patients who are critically ill, with up to 80% of patients admitted to the ICU developing some form of neuromuscular dysfunction. ICU-acquired weakness (ICUAW) is associated with longer durations of mechanical ventilation and hospitalization, along with greater functional impairment for survivors. Although there is increasing recognition of ICUAW as a clinical entity, significant knowledge gaps exist concerning identifying patients at high risk for its development and understanding its role in long-term outcomes after critical illness. This review addresses the epidemiologic and pathophysiologic aspects of ICUAW; highlights the diagnostic challenges associated with its diagnosis in patients who are critically ill; and proposes, to our knowledge, a novel strategy for identifying ICUAW.

A retrospective review of safety using a nursing driven protocol for autonomic dysreflexia in patients with spinal cord injuries.

OBJECTIVE/BACKGROUND: Autonomic dysreflexia is a potentially life-threatening condition which afflicts a significant proportion of individuals with spinal cord injuries (SCI). To date, the safety and efficacy of several commonly used interventions for this condition have not been studied. DESIGN: A retrospective chart review of the safety of a previously implemented nursing driven inpatient autonomic dysreflexia protocol. METHODS: Seventy-eight male patients with SCI who experienced autonomic dysreflexia while inpatient at our Veterans Affairs SCI unit over a 3-1/2-year period were included. The safety of a nursing driven protocol utilizing conservative measures, nitroglycerin paste, and oral hydralazine was evaluated. OUTCOME MEASURES: Occurrence of adverse events and relative hypotensive events during all episodes treated with the protocol, and efficacy of attaining target blood pressure for all episodes with protocol adherence and for initial episode experienced by each patient. RESULTS: Four hundred forty-five episodes of autonomic dysreflexia were recorded in the study period, with 92% adherence to the protocol. When the protocol was followed, target blood pressure was achieved for 97.6% of all episodes. Twenty-three total adverse events occurred (5.2% of all episodes). All adverse events were due to hypotension and only 0.9% required interventions beyond clinical monitoring. Of each patient's initial autonomic dysreflexia episode, 97.3% resolved using the protocol without need for further escalation of care. CONCLUSION: This inpatient nursing driven-protocol for treating autonomic dysreflexia utilizing conservative measures, nitroglycerin paste and oral hydralazine achieved target blood pressure with a high success rate and a low incidence of adverse events.

Rehabilitation of a patient with overlap of acute transverse myelitis and Bickerstaff's brainstem encephalitis: a case report.

We report on one patient with Bickerstaff's brainstem encephalitis (BBE) and associated flaccid weakness. Counter to previous studies with BBE which indicate weakness due to Guillain-Barre syndrome, our patient's presentation of paraplegia following BBE is consistent with concomitant acute transverse myelitis. Her findings of BBE largely resolved, although she remained with T6 American Spinal Injury Association (ASIA) A paraplegia. Motor functional impairment measure scores improved from 20 at admission to 66 before discharge home with assistance. This case presents the first potential overlapping case of acute transverse myelitis with BBE and describes how acute inpatient rehabilitation can be effective in facilitating transition back to independence following tetraplegia with BBE.