Burn Functional Outcomes - Ventilator Usage and Discharge Ambulation Status of Patients in a Burn Wound in-Patient Centre.

Anticipating functional outcomes of patients managed in an in-patient burn wound centre can help in advising patients and their families of prognosis as well as assist case managers in discharge planning. The records of 37 burn patients were reviewed; one patient expired and was removed from further analysis. Data were obtained regarding patient characteristics, types and locations of burns and other wounds, ventilator use, level of mobility at hospital discharge, and disposition; three patients lacked discharge ambulation status and were removed from the outcome comparison analysis. Of the 36 patients, 17 had thermal burns and nine (25%) had associated inhalation injuries. Thermal burn patients (p = 0.02), patients requiring ventilator support during their hospital stay (p = 0.04), and those with inhalation injuries (p = 0.04) were less likely to be ambulating independently or with assistance at discharge from the burn wound centre than other patients. This preliminary study suggests that patients with thermal burns and inhalation injuries and those requiring ventilator support were less likely to be ambulatory at hospital discharge. Further studies appear indicated.

Prayer and meditation as medical therapies.

Prayer and meditation have been used as health-enhancing techniques for centuries. Their use has been investigated more recently in the context of more conventional, allopathic medical approaches. These studies, despite methodological limitations, show some promise for the formal application and integration of these techniques into western medical practice. Some potential benefits from meditation include reduced perceived stress and improvement in mild hypertension. Prayer appears to offer subjective benefit to those who pray; the effects of intercessory prayer on the health status of unknowing individuals requires more investigation.

Sensory and mixed nerve action potential temporal dispersion in median neuropathy at the wrist.

This retrospective pilot study was undertaken to help determine the usefulness of measuring sensory nerve action potential and mixed nerve action potential temporal dispersion in median neuropathy at the wrist (MNW; i.e., carpal tunnel syndrome). The records were reviewed for 34 patients who were referred to an electrodiagnostic medicine laboratory with normal antidromic median sensory nerve action potential (recording from the index finger), median transcarpal mixed nerve action potential, and ulnar transcarpal mixed nerve action potential peak distal latencies (NO group) and 29 patients with prolongation (>2.2 ms) of the left median transcarpal mixed nerve action potential peak distal latency or relative prolongation of this response (>0.4 ms) compared with the ipsilateral normal ulnar transcarpal mixed nerve action potential peak distal latency (MNW group). By using the time difference between onset and negative peak as a measure of waveform temporal dispersion, mean +/- standard deviation of the median transcarpal mixed nerve action potential time difference for the MNW group (0.57 +/- 0.15 ms) was found to be greater than the NO group (0.44 +/- 0.09 ms; P < 0.01). No statistically significant differences were found for the median sensory nerve action potential time difference between the two groups or between the subgroup of MNW patients with concurrent prolongation of the median sensory nerve action potential peak distal latency and the NO group. These findings suggest that increased median transcarpal mixed nerve action potential temporal dispersion may occur in association with median transcarpal mixed nerve action potential peak distal latency prolongation in MNW. The small magnitude of this increase, however, makes the clinical usefulness of this observation unclear.

Heterotopic ossification in moyamoya disease: a case report.

Moyamoya disease is a rare disorder of cerebrovascular circulation. A review of the literature failed to reveal the association of heterotopic ossification in patients with this disease; such a case is now presented. The patient described had atraumatic intracranial hemorrhage, was in a coma for a period of time, underwent ventriculostomy and shunt placement, and was left with residual spastic hemiparesis. Evidence of heterotopic ossification around the hemiparetic shoulder and hip was subsequently noted on radiographic studies and was managed conservatively. Heterotopic ossification may be a rare complication of the neurological deficits associated with moyamoya disease and needs careful consideration when joint stiffness persists, despite usual conservative measures.

Sacral plexopathy and sciatic neuropathy after total knee arthroplasty.

While peroneal and tibial neuropathies have been described as a complication of total knee arthroplasty (TKA), a computerized literature search failed to reveal any previously reported cases of associated sacral plexopathy or sciatic neuropathy. This case report describes the diagnosis and management of a patient found to have evidence of a right sacral plexopathy and a left sciatic neuropathy, following bilateral TKA. This case suggests that these may be rare complications of TKA.

Botulinum toxin treatment of lumbrical spasticity: a brief report.

Botulinum toxin A has been used to treat wrist and finger spasticity mainly through injection of the forearm flexor muscles. This case study describes its first reported use in managing spastic lumbricals of the hand. A 19-year-old male had significant flexion deformity and hypertonicity of the left wrist and hand, particularly the second through fifth metacarpophalangeal joints, after traumatic brain injury. By using the 0-4 Ashworth scale, spasticity of the lumbricals across the second to fourth metacarpophalangeal joints was rated 2, with persistent clonus of the finger flexors as confirmed by electromyography to the middle and ring fingers, even after botulinum toxin A injection of the flexor digitorum sublimis and profundus muscles. By using the electromyography-guided technique, botulinum toxin A was injected into the first lumbrical of the index finger (12 units), second and third lumbricals of the middle and ring fingers, respectively (15 units each), and fourth lumbrical of the little finger (10 units). At follow-up, clinical and electromyographic examination revealed a significant reduction in tone and clonus of the injected lumbricals. Ashworth scores of the lumbricals from the index to little finger improved to 1. Botulinum toxin A injection of the lumbricals can be beneficial in managing spasticity of these muscles. It is well tolerated and effective at doses of 10 to 15 units. Lumbrical injection of botulinum toxin A is a useful adjunct in our percutaneous armamentarium for managing the spastic hand.

The utility of external performance measurement tools in program evaluation.

Many rehabilitation hospitals use formal measurement tools to evaluate program performance. A potential advantage to using the Functional Independence Measure instrument through the Uniform Data System for Medical Rehabilitation (UDSMR) is that it provides information that allows an institution to compare its level of performance to those of other facilities. To assess whether joining UDSMR, along with an institution's continuous quality improvement efforts, could be associated with improved program performance, the records of a rehabilitation hospital's internal inpatient Program Evaluation System (PES) were reviewed for 6 fiscal years (1990-1995). Quality improvement efforts during 1995 (during which a 51% improvement in length of stay efficiency was noted) included education for staff, feedback on team performance, and efforts to formulate clinical pathways. Although external measures of performance do not have a direct effect on quality improvement, they could help identify areas of potential improvement that might not be appreciated when internal assessment systems are used alone.

Use of clonidine for treatment of spasticity arising from various forms of brain injury: a case series.

Spasticity may occurs as a result of different types of brain injury. The experience with six patients, aged 17-73 years, treated with clonidine for spasticity due to brain injuries of various causes is presented. These cases include a patient with traumatic brain injury, three patients with intracranial haemorrhage, a patient with a right basal ganglia stroke 3 years prior to a left subdural haematoma associated with a fall, and a patient with cerebral palsy. To varying degrees for each patient, clonidine was effective in reducing extremity hypertonicity. A possible mechanism of action is discussed. These case findings suggest clonidine may be useful in the management of spasticity associated with various forms of brain injury, and that formal studies of clonidine for this application appear warranted.

Trends in incidence of hospitalization for traumatic brain injury in Wisconsin from 1989 through 1992.

To aid in determining health care service needs, Wisconsin Department of Health and Social Services (DHSS) data on Wisconsin hospital discharges for traumatic brain injury (TBI), using ICD-9-CM codes for intracranial injury with and without skull fracture, and Wisconsin Department of Transportation data on incapacitating non-fatal head injuries (INHI) from traffic accidents from 1989 through 1992 were reviewed. Yearly TBI hospital discharges in Wisconsin declined 15.0%, and by 23.9% for Milwaukee County residents, over 1989 through 1992, correlating closely with changes in yearly INHI in Wisconsin (r = 0.999; p < 0.01) and in Milwaukee County (r = 0.989; p < 0.05). Using 1990 census data the yearly TBI risk ratio for Milwaukee County residents compared to the rest of Wisconsin increased from 1989 (1.76) to 1990 (1.92) and then decreased in 1991 (1.83) and 1992 (1.51). The results of this pilot study suggest there was a decrease in the incidence of hospitalization of patients with TBI in Wisconsin from 1989 through 1992, paralleling a decline in INHI from motor vehicle accidents. There appeared to be a relatively greater decline in these patients in Milwaukee County from 1991 to 1992 as compared to the rest of the state. The techniques employed in this study may be used to help assess rehabilitation service needs in other areas.

Low-intensity, alternate-day exercise improves muscle performance without apparent adverse effect in postpolio patients.

The purpose of this study was to examine the effect of a low-intensity, alternate-day, 12 wk quadriceps muscle-strengthening exercise program on muscle strength and muscle and motor unit integrity in 12 postpolio patients. Patients performed six to ten repetitions of a 5-s duration knee extension exercise with ankle weights. After completing six repetitions, patients rated the perceived exertion (RPE) in the exercised muscle. The patient continued repetitions until RPE was >/= 17 or ten repetitions were performed. The weight was increased the next exercise day whenever the RPE was < 17 after ten repetitions. Before and after the training program, median macroamplitude as well as jitter and blocking were determined electromyographically (EMG), serum creatine kinase (CK) was measured, and quadriceps muscle strength was assessed. The ankle weight lifted after 2 wk of training and at the end of the program were also recorded. Although the ankle weight lifted at the end of the program significantly (P < 0.05) increased from a mean +/- SD of 7.1 +/- 2.7 to 11.2 +/- 4.7 kg, the dynametrically determined muscle strength measures did not significantly (P > 0.05) increase. The EMG and the serum CK variables also did not significantly (P >0.05) change as a result of the exercise program. We conclude that performance was improved, as demonstrated by an increase in the amount of weight the patients lifted in the exercise program. No evidence was found to show that this program adversely affected the motor units or the muscle as the EMG and CK did not change.

Electromyographic and neuromuscular variables in post-polio subjects.

OBJECTIVE: Post-polio subjects experience functional deterioration many years after developing acute poliomyelitis and have been shown previously to have a deficit in strength recovery after isometric activity. This study characterized the size and stability of the motor units in a group of post-polio subjects with macro and single fiber electromyography (EMG) and correlated these variables with isometric strength, endurance, "work capacity," and strength recovery after fatiguing isometric exercise. DESIGN: A cohort of 12 post-polio subjects was tested for neuromuscular function. Electromyographic variables were determined on a separate day. SETTING: Volunteers were recruited from the community and tested in our neuromuscular research laboratory. SUBJECTS: A volunteer sample was obtained from advertisements. All subjects acknowledged post-polio syndrome symptoms. MAIN OUTCOME MEASURES: Neuromuscular variables were isometric knee extension peak torque, endurance (time to exhaustion) at 40% of maximal torque, tension time index, and recovery of torque at 10 minutes. Electromyographic variables were macro EMG and single fiber EMG (percent blocking and jitter). RESULTS: Macro EMG amplitude was ninefold the control value, and both jitter and blocking were greatly increased in comparison to control values. Isometric strength significantly (p < .05) correlated negatively with macro EMG amplitude. CONCLUSIONS: The weakest subjects had the greatest number of muscle fibers within the motor unit (as measured by macro EMG amplitude). Jitter and blocking did not correlate with neuromuscular function.

Beneficial effect of clonidine on spasticity antagonized by baclofen in a stroke patient.

Although Clonidine has recently been described as a useful antispasticity agent, to our knowledge there has not been a previous report of clonidine's antispasticity effect antagonized by baclofen. Using a 0-5 Modified Ashworth Scale to evaluate the right knee extensor tone in a 74-year-old man 5 months following a left middle cerebral artery stroke, tone improved from 3 to 1 on Clonidine 0.6 mg daily in divided doses. The day after addition of baclofen at 15 mg daily in divided doses, tone increased to 4. Baclofen was withdrawn with a decrease in tone to 2. Baclofen alone at the above dose resulted in tone comparable to the clonidine-free baseline. Treatment with Clonidine alone was resumed, and the expected reduction in hypertonicity was again observed. Possible mechanisms of action for baclofen antagonizing the beneficial effect of Clonidine on spasticity after stroke are presented and discussed.

Electromyographic assessment of spasmodic dysphonia patients prior to botulinum toxin injection.

Electromyographic (EMG) evidence of inappropriate muscle activity (IMA) in the cricothyroid (CT) and vocalis (V) (thyroarytenoid) muscles was correlated with clinical voice measures in 32 patients with spasmodic dysphonia (SD). Subjective voice rating and quantified fluency and laryngeal diadochokinesis measures were obtained prior to botulinum toxin (Botox) injection into the V muscles. Pre-Botox EMG was performed using a monopolar needle electrode. Each muscle was sequentially examined at rest, during vocal click, scale, sustained "E" at different pitches, and repeated "E" voicings for brief periods. A three point EMG severity scale was used to grade the amount of IMA seen in each muscle. EMG evaluation showed no evidence of lower motor neuron involvement but did reveal IMA in 81.3% of the subjects. There were no significant correlations for the patients between different EMG-based IMA severity scales and the measures of voice quality and sound production. EMG did discriminate between predominantly adductor and abductor SD pattern types, but could not correctly differentiate a mixed SD group. Those patients with adductor SD displayed IMA in the V and CT muscles, while those with abductor SD displayed more IMA in the CT than the V muscles. Sequential EMG assessment of CT and V IMA in SD did not predict clinical severity or outcome following Botox injection into the V muscles.

Close-proximity concentric and modified single fiber electromyographic recordings using revised techniques with a paired wire electrode.

Using a combined concentric (CN) and modified single fiber (MSF) electromyographic needle electrode with both recording surfaces at the tip approximately 25 microns apart, 24 motor unit potentials (MUPs) were recorded from one extensor digitorum communis muscle, triggering from either the CN or MSF channel in equal numbers and averaging both CN and MSF recordings. Filter settings were 20-10,000 Hz. Correlations of MUP amplitude, phases, turns, negative turns (NTs), and main spike duration, but not rise time or duration, between the CN and MSF recordings were statistically significant (P < 0.05). Mean +/- SD numbers of estimated single fiber potentials (ESFPs) and NTs for the MSF recordings were 1.17 +/- 0.38 and 1.54 +/- 0.72. Correlations between numbers of ESFPs and turns, NTs and phases, NTs and turns, and NT and main spike duration for the MSF and CN MUP recordings, respectively, were statistically significant (P < 0.05). The study findings using these techniques continue to support evidence that one or a few muscle fibers contribute to the main spike component of the MUP.

Sparing of motor function after cortical injury. A new perspective on underlying mechanisms.

Historically, many theories have been offered to explain recovery of function following permanent brain injury. Because specific functional deficits often occur after injury to certain neuroanatomical locations, it has been tempting to suggest that within the brain, structure equals function (this interpretation, of course, has its roots in "phrenology", the 19th-century practice of detecting mental and behavioral traits by examining the skull's shape). Views that were common until recently emphasized structural and functional rigidity in the brain, which would seem to provide little opportunity for the occurrence of compensation. However, the observation that a considerable amount of spontaneous functional recovery occurs after many permanent brain lesions requires some explanation for the recovery that involves modification of intact portions of the brain. Recent research has provided data that reveal several forms of brain plasticity, including changes in neurotransmitter sensitivity, collateral sprouting, and diaschisis. Evidence supporting claims that beneficial behavioral recovery occurs through such physiological modifications in the brain are abundant in the literature, although, in general, there has not been any empirical establishment of causality.

Comparative effects of fluoxetine, amitriptyline and serotonin on functional motor recovery after sensorimotor cortex injury.

A recent investigation of the effects of the antidepressants desipramine and trazodone on behavioral recovery in brain-injured animals suggested that antidepressants, which act to increase noradrenergic activity in the brain, may facilitate the rate of recovery, whereas those that act to increase serotonergic (5-HT) activity may hinder recovery and reinstate deficits in recovered animals. The present study was designed to evaluate these findings further by assessing the effect of a single intraperitoneal injection of fluoxetine (a relatively pure 5-HT reuptake blocker), amitriptyline (a mixed 5-HT and noradrenergic reuptake blocker with alpha 1-adrenergic receptor blocking activity) or a single intraventricular infusion of 5-HT on recovery of beam-walking ability in animals with a unilateral sensorimotor cortex injury. None of the drugs significantly affected the rate of recovery. Although fluoxetine was ineffective in reinstating the motor deficit in recovered animals, amitriptyline reinstated the deficit in a dose-dependent fashion. Infusion of 5-HT resulted in an extremely transient reinstatement of the deficit, which was largely attributable to its short-term sedative properties. These results suggest that 5-HT may be less involved in functional recovery than previously thought. They also add further support to previous findings that indicate that drugs which act to antagonize alpha 1-adrenergic activity (e.g., phenoxybenzamine) may interfere with motor recovery after sensorimotor cortex injury. An appreciation of the potential impact of certain antidepressants on functional recovery in brain-injured patients appears warranted.

Effects of trazodone and desipramine on motor recovery in brain-injured rats.

Rats pretrained to walk a narrow balance beam received unilateral sensorimotor cortex lesions, resulting in a contralateral transient paresis that lasted 14 days. In a dose-dependent manner, a single injection of the antidepressant trazodone given 24 hours after injury transiently slowed motor recovery compared with injured controls. After final recovery level of motor function, a reinjection of trazodone reinstated the hemiparesis for up to 6 hours. In other animals, a single injection of the antidepressant desipramine significantly facilitated motor performance when compared with injured controls. Desipramine had no deleterious motor effect when administered to animals that had recovered on the beam-walking task. These findings would suggest that the predominantly noradrenergic neurotransmitter effects of desipramine may facilitate, and those of the predominantly serotonergic trazodone may hinder, the recovery of locomotor performance after cortical injury in rats. Further studies appear indicated, including applying these findings to the clinical setting.

A comparison of close proximity concentric and modified single fiber electromyographic recordings from extensor digitorum communis.

Using a combined concentric (CN) and modified single fiber (MSF) electromyography (EMG) needle electrode with both recording surfaces at the tip approximately 25 microns apart, 30 motor unit action potentials (MUAP) were recorded from one extensor digitorum communis (EDC) muscle, triggering from the CN and averaging both the CN and MSF recordings. Correlations of MUAP amplitude (r = 0.767), number of turns (r = 0.839), and number of negative-going-positive-going turn (NT) (r = 0.737) between the CN and MSF recordings were statistically significant (p < 0.001). For NTs common to both recordings, correlations of rise time (r = 0.866), amplitude (r = 0.816), and interpeak interval (IPI) (r = 0.999) were statistically significant (p < 0.001). Mean +/- SD single fiber potentials (SFP), approximate SFP with rise times less than 500 microseconds, and NTs for the MSF recordings and NTs for the CN recordings were 0.73 +/- 0.69, 1.20 +/- 0.48, 1.83 +/- 0.87, and 1.93 +/- 0.78, respectively. This study supports evidence that one or a few SFP contribute to the spike component of the MUAP.