Transcranial direct current stimulation (tDCS) paired with massed practice training to promote adaptive plasticity and motor recovery in chronic incomplete tetraplegia: A pilot study.

OBJECTIVE: Our goal was to determine if pairing transcranial direct current stimulation (tDCS) with rehabilitation for two weeks could augment adaptive plasticity offered by these residual pathways to elicit longer-lasting improvements in motor function in incomplete spinal cord injury (iSCI). DESIGN: Longitudinal, randomized, controlled, double-blinded cohort study. SETTING: Cleveland Clinic Foundation, Cleveland, Ohio, USA. PARTICIPANTS: Eight male subjects with chronic incomplete motor tetraplegia. INTERVENTIONS: Massed practice (MP) training with or without tDCS for 2 hrs, 5 times a week. OUTCOME MEASURES: We assessed neurophysiologic and functional outcomes before, after and three months following intervention. Neurophysiologic measures were collected with transcranial magnetic stimulation (TMS). TMS measures included excitability, representational volume, area and distribution of a weaker and stronger muscle motor map. Functional assessments included a manual muscle test (MMT), upper extremity motor score (UEMS), action research arm test (ARAT) and nine hole peg test (NHPT). RESULTS: We observed that subjects receiving training paired with tDCS had more increased strength of weak proximal (15% vs 10%), wrist (22% vs 10%) and hand (39% vs. 16%) muscles immediately and three months after intervention compared to the sham group. Our observed changes in muscle strength were related to decreases in strong muscle map volume (r=0.851), reduced weak muscle excitability (r=0.808), a more focused weak muscle motor map (r=0.675) and movement of weak muscle motor map (r=0.935). CONCLUSION: Overall, our results encourage the establishment of larger clinical trials to confirm the potential benefit of pairing tDCS with training to improve the effectiveness of rehabilitation interventions for individuals with SCI. TRIAL REGISTRATION: NCT01539109.

Failed Removal of Indwelling Urinary Catheters in Patients With Acute Stroke: Incidence and Risk Factors.

BACKGROUND: Reducing the incidence of indwelling urinary catheter (IUC) use and early removal of the devices that are inserted are appropriate priorities for quality patient care. Just like symptomatic bacteriuria, failed catheter removal as a complication of IUC use is associated with considerable morbidity. In the ideal setting, patients who need IUCs have them, and patients who do not need them will have them removed safely, with the goal of reducing medical complications and facilitating the rehabilitation phase of care. OBJECTIVE: To determine the incidence of failed removal of IUCs and the factors associated with failed removal in persons hospitalized with acute stroke. DESIGN: Retrospective review of medical records and associated clinical data collection platforms. SETTING: Comprehensive stroke center at a tertiary care hospital. PATIENTS: The study cohort included 175 stroke patients admitted to the hospital and managed with IUCs. Mean age was 66.1 years (standard deviation = 15), 55% were female. METHODS: Univariable and multiple logistic regression analyses were performed. Variables assessed included age, gender, race, duration of hospital stay, stroke subtype, National Institutes of Health Stroke Scale, and 6-Clicks Scale, which is a measure of functional status. MAIN OUTCOME MEASUREMENTS: The dependent variable was occurrence of a failed attempt at removal of an IUC, defined as removal followed by a catheter reinsertion. RESULTS: During the study period, 175 of 432 patients with acute hospital admission for new stroke had an IUC removal event. Of these patients, 46 (26%) experienced a failed catheter removal. On univariate analysis, factors significantly associated with failed removal included presence of a hemorrhagic stroke (P = .005), lower level of physical function (by 6-Clicks and NIHSS scores), hospital length of stay (P < .001), and discharge location (P = .005). Bedside bladder ultrasound testing by nursing staff was used more frequently in the group of patients who had unsuccessful IUC removals (95% confidence interval 4.56-21.67, P < .001). Length of stay (P < .001), white race (P = .001), and hemorrhagic stroke (P = .009) were associated independently with failed catheter removal after adjustment for other clinical variables. CONCLUSIONS: This single-site study identified a high incidence of failed urinary catheter removal in patients with stroke, along with factors associated with failed removal. This is the first step in developing a predictive model that could reduce the incidence of this adverse event. Policies, penalties, and protocols designed to reduce catheter days must be sensitive to the special situations in which IUCs are medically necessary and equal consideration given to identifying the patients for which catheter removal poses a greater risk than continued catheter use. LEVEL OF EVIDENCE: III.

Interrater Reliability of AM-PAC "6-Clicks" Basic Mobility and Daily Activity Short Forms.

BACKGROUND: The interrater reliability of 2 new inpatient functional short-form measures, Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" basic mobility and daily activity scores, has yet to be established. OBJECTIVE: The purpose of this study was to examine the interrater reliability of AM-PAC "6-Clicks" measures. DESIGN: A prospective observational study was conducted. METHODS: Four pairs of physical therapists rated basic mobility and 4 pairs of occupational therapists rated daily activity of patients in 1 of 4 hospital services. One therapist in a pair was the primary therapist directing the assessment while the other therapist observed. Each therapist was unaware of the other's AM-PAC "6-Clicks" scores. Reliability was assessed with intraclass correlation coefficients (ICCs), Bland-Altman plots, and weighted kappa. RESULTS: The ICCs for the overall reliability of basic mobility and daily activity were .849 (95% confidence interval [CI]=.784, .895) and .783 (95% CI=.696, .847), respectively. The ICCs for the reliability of each pair of raters ranged from .581 (95% CI=.260, .789) to .960 (95% CI=.897, .983) for basic mobility and .316 (95% CI=-.061, .611) to .907 (95% CI=.801, .958) for daily activity. The weighted kappa values for item agreement ranged from .492 (95% CI=.382, .601) to .712 (95% CI=.607, .816) for basic mobility and .251 (95% CI=.057, .445) to .751 (95% CI=.653, .848) for daily activity. Mean differences between raters' scores were near zero. LIMITATIONS: Raters were from one health system. Each pair of raters assessed different patients in different services. CONCLUSIONS: The ICCs for AM-PAC "6-Clicks" total scores were very high. Levels of agreement varied across pairs of raters, from large to nearly perfect for physical therapists and from moderate to nearly perfect for occupational therapists. Levels of agreement for individual item scores ranged from small to very large.

AM-PAC "6-Clicks" functional assessment scores predict acute care hospital discharge destination.

BACKGROUND: Physical therapists and occupational therapists practicing in acute care hospitals play a crucial role in discharge planning. A standardized assessment of patients' function could be useful for discharge recommendations. OBJECTIVES: The study objective was to determine the accuracy of "6-Clicks" basic mobility and daily activity measures for predicting discharge from an acute care hospital to a home or institutional setting. DESIGN: The study was retrospective and observational. METHODS: "6-Clicks" scores obtained at initial visits by physical therapists or occupational therapists and patients' discharge destinations were used to develop and validate receiver operating characteristic curves for predicting discharge destination. Positive predictive values (PPV), negative predictive values (NPV), and likelihood ratios were calculated. RESULTS: Areas under the receiver operating characteristic curves for basic mobility scores were 0.857 (95% confidence interval [CI]=0.852, 0.862) and 0.855 (95% CI=0.850, 0.860) in development and validation samples, respectively. Areas under the curves for daily activity scores were 0.846 (95% CI=0.841, 0.851) and 0.845 (95% CI=0.840, 0.850) in development and validation samples, respectively. Cutoff scores providing the best accuracy for determining discharge destination were 42.9 for basic mobility and 39.4 for daily activity. For basic mobility, the PPV was 0.748 and the NPV was 0.801 in both development and validation samples. For daily activity, the PPVs were 0.787 and 0.784 and the NPVs were 0.748 and 0.746 in development and validation samples, respectively. LIMITATIONS: Limitations included lack of information on the rater reliability of "6-Clicks" instruments, use of surrogate data for some discharge designations, and use of a clinical database for research purposes. CONCLUSIONS: This study provides evidence of the accuracy of "6-Clicks" scores for predicting destination after discharge from an acute care hospital.

Validity of the AM-PAC "6-Clicks" inpatient daily activity and basic mobility short forms.

BACKGROUND: Standardized assessment of patients' activity limitations in acute care settings can provide valuable information. Existing measures have not been widely implemented. OBJECTIVES: The aim of this study was to provide evidence for validity of scores on Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" measures of basic mobility and daily activity in acute care. DESIGN: A retrospective measurement study was conducted. METHODS: The study used a database from one health system containing "6-Clicks" scores from first and last physical therapist and occupational therapist visits for 84,446 patients. Validity was analyzed by examining differences in "6-Clicks" scores across categories of patient characteristics; the ability of "6-Clicks" scores to predict patients' having more than one therapy visit; correlation of "6-Clicks" scores with Functional Independence Measure (FIM) scores; and internal responsiveness over the episode of care. Internal consistency reliability also was determined. RESULTS: The "6-Clicks" scores differed across patients' age, preadmission living situation, and number of therapy visits. The areas under receiver operating characteristic curves derived using "6-Clicks" scores at the first visit to predict patients receiving more than one visit were 0.703 and 0.652 using basic mobility and daily activity scores, respectively. The "6-Clicks" scores at the final visit were correlated with scores on subscales of the FIM completed on admission to inpatient rehabilitation facilities (r=.65 and .69). Standardized response means were 1.06 and 0.95 and minimal detectable changes with 90% confidence level (MDC90) were 4.72 and 5.49 for basic mobility and daily activity scores, respectively. Internal consistency reliability of basic mobility and daily activity scores was .96 and .91, respectively. LIMITATIONS: Using clinical databases for research purposes has limitations, including missing data, misclassifications, and selection bias. Rater reliability is not known. CONCLUSIONS: This study provides evidence for the validity of "6-Clicks" scores for assessing patients' activity limitations in acute care settings.

Self-inflicted finger injury in individuals with spinal cord injury: an analysis of 5 cases.

OBJECTIVE: To describe the occurrence of finger autophagia in 5 persons with traumatic spinal cord injury and to present a discussion of putative causes and potential treatments. BACKGROUND: Minor self-mutilating actions, such as nail biting and hair pulling, are common in humans and usually benign. In some circumstances, these behaviors are associated with obsessive-compulsive personality traits. In humans, self-injurious biting behaviors are well described in the setting of mental retardation and psychosis and in persons with Lesch-Nyhan syndrome. Rare cases of human autophagia in persons with intact cognition have been reported, most commonly in the setting of acquired nervous system lesions. After spinal cord injury, it has been suggested that this behavior constitutes a human variant of animal autotomy and a response to neuropathic pain. DESIGN: Case presentation narrative. MAIN OUTCOME MEASURES: Photographic and radiological study, administration of Yale-Brown Obsessive-Compulsive Scale (YBOCS). FINDINGS: In 5 patients with complete tetraplegia, pain in the hands was present in only one instance. The severity of autoamputation varied from minor to extreme. In all cases, damage was confined to analgesic body parts. In 3 cases, autophagia behavior was discovered in progress. Treatments included pharmacotherapy, counseling, and behavioral therapy, with mixed results. All patients were intelligent, willing to discuss their issues, and able to identify conditions of stress and isolation in their lives. Mild preinjury obsessive-compulsive behaviors, such as nail biting, were universal. On the YBOCS, only 1 patient scored in a range indicative of mild obsessive-compulsive symptomatology. CONCLUSIONS: This group exhibited heterogeneous medical, social, and cultural characteristics. A link between pain and self-injurious behavior could not be demonstrated. This behavior may be viewed as an extreme variant of nail biting, with potential ominous complications. Treatment strategies have been employed with mixed results.

Intramuscular electrical stimulation for hemiplegic shoulder pain: a 12-month follow-up of a multiple-center, randomized clinical trial.

OBJECTIVE: Assess the effectiveness of intramuscular electrical stimulation in reducing hemiplegic shoulder pain at 12 mos posttreatment. DESIGN: A total of 61 chronic stroke survivors with shoulder pain and subluxation participated in this multiple-center, single-blinded, randomized clinical trial. Treatment subjects received intramuscular electrical stimulation to the supraspinatus, posterior deltoid, middle deltoid, and upper trapezius for 6 hrs/day for 6 wks. Control subjects were treated with a cuff-type sling for 6 wks. Brief Pain Inventory question 12, an 11-point numeric rating scale was administered in a blinded manner at baseline, end of treatment, and at 3, 6, and 12 mos posttreatment. Treatment success was defined as a minimum 2-point reduction in Brief Pain Inventory question 12 at all posttreatment assessments. Secondary measures included pain-related quality of life (Brief Pain Inventory question 23), subluxation, motor impairment, range of motion, spasticity, and activity limitation. RESULTS: The electrical stimulation group exhibited a significantly higher success rate than controls (63% vs. 21%, P = 0.001). Repeated-measure analysis of variance revealed significant treatment effects on posttreatment Brief Pain Inventory question 12 (F = 21.2, P < 0.001) and Brief Pain Inventory question 23 (F = 8.3, P < 0.001). Treatment effects on other secondary measures were not significant. CONCLUSIONS: Intramuscular electrical stimulation reduces hemiplegic shoulder pain, and the effect is maintained for > or =12 mos posttreatment.

Intramuscular neuromuscular electric stimulation for poststroke shoulder pain: a multicenter randomized clinical trial.

OBJECTIVE: To assess the effectiveness of intramuscular neuromuscular electric stimulation (NMES) in reducing poststroke shoulder pain. DESIGN: Multicenter, single-blinded, randomized clinical trial. SETTING: Ambulatory centers of 7 academic rehabilitation centers in the United States. PARTICIPANTS: Volunteer sample of 61 chronic stroke survivors with shoulder pain and subluxation. INTERVENTION: Treatment subjects received intramuscular NMES to the supraspinatus, posterior deltoid, middle deltoid, and trapezius for 6 hours a day for 6 weeks. Control subjects were treated with a cuff-type sling for 6 weeks. Main outcome measure Brief Pain Inventory question 12 (BPI 12), an 11-point numeric rating scale administered in a blinded manner at the end of treatment, and at 3 and 6 months posttreatment. RESULTS: The NMES group exhibited significantly higher proportions of success based on the 3-point or more reduction in BPI 12 success criterion at the end of treatment (65.6% vs 24.1%, P<.01), at 3 months (59.4% vs 20.7%, P<.01), and at 6 months (59.4% vs 27.6%, P<.05). By using the most stringent "no pain" criterion, the NMES group also exhibited significantly higher proportions of success at the end of treatment (34.4% vs 3.4%, P<.01), at 3 months (34.4% vs 0.0%, P<.001), and at 6 months (34.4% vs 10.3%, P<.05). CONCLUSIONS: Intramuscular NMES reduces poststroke shoulder pain among those with shoulder subluxation and the effect is maintained for at least 6 months posttreatment.