Correlation of functional independence measure (FIM) and SPECT Iofetamine (I-123) as a predictor of functional return in stroke.

Function following stroke is often measured using the Functional Independence Measure (FIM). Independence occurs when the patient achieves certain levels of functions. SPECT imaging assesses the regional cerebral blood flow (rCBF). Is it possible to correlate the FIM scores with SPECT imaging and predict functional return? We evaluated total of 69 stroke patients with SPECT imaging using Iofetamine (I-123). Patients were scanned within 14-21 days post-stroke. CT scans were evaluated and correlated with the SPECT images. This information was compared with the admission and discharge FIM scores. The rCBF reperfusion changes and region of stroke were evaluated and correlated with discharge functional status. The right parietal areas demonstrated a strong correlation with SPECT and FIM changes as predictors of return of functional living status (p-value = 0.0438). The right parietal area demonstrated an improvement in ambulation (p-value = 0.0578); the right brain correlated with overall improvement in FIM scores and change in SPECT imaging (p-value = 0.0833); the left brain did not exhibit significant values. Our conclusion was that there were trends seen with the predictive value of stroke recovery using SPECT imaging. The current sample number was not large enough to provide an adequate study, especially for the left brain; a larger study is needed. This information could be useful to help determine patient placement for rehabilitation.

Comparison of two injection techniques using botulinum toxin in spastic hemiplegia.

This study sought to test the hypothesis that injections of botulinum toxin type A (BTX-A) at the mid belly of the gastrocnemius muscle in spastic hemiplegic adults produce superior clinical results to proximal injections directed toward the muscular origin. We designed a randomized, double-blind, placebo-controlled intervention study at a university tertiary care setting. Seventeen subjects with chronic spastic hemiplegic gait were enrolled from a volunteer community sample; time range from acute neurologic insult was 0.75 to 31 yr; age range was 19 to 71 yr; gender consisted of 11 men and 4 women; diagnoses were 12 patients with stroke, 2 with traumatic brain injuries, and 1 with a brain tumor. Two subjects were withdrawn from the study because of (1) acute vascular occlusion before intervention and (2) noncompliance with follow-up visits. After baseline measurements, subjects were injected with 50 units of BTX-A (volume, 0.5 cc) into the medial or lateral gastrocnemius: (1) proximally at one site near the muscular origin; (2) distally at three sites along the mid belly. We measured outcome using the Fugl-Meyer score, Ashworth scale, ankle range of motion, and a timed 50-ft fastest walk. No outcome measures showed a significant effect attributable to site of injections. Confounding variables included physical therapy and varying duration of illness in the study cohort. We conclude that the results failed to support the hypothesis that BTX-A injections at the mid belly of the gastrocnemius produced superior functional improvements to injections located near the muscular origin using localization techniques described. Additional research comparing more precise localization methods for BTX-A injections might further establish the importance of electromyographic guidance using BTX-A in management of spasticity.

Supported employment and compensatory strategies for enhancing vocational outcome following traumatic brain injury.

This paper describes two approaches to improving the employment prospects of those suffering from head injury. It is noted that unemployment within the first 7 years post-head injury is as high as 70% and that this contributes to the long-term difficulties faced by the head-injured and their families. A 'supportive' approach to employment involving the use of job coordinators or job coaches is described and a number of 'compensatory' strategies described. These two approaches are compatible and are derived from the individual needs of the head injured person in relation to retaining or seeking employment.

Post-acute management of head injuries.

Many advances have been made in the last 15 years in the treatment of traumatic brain injuries. This paper reviews the advances not only in the acute management stage but also in the crucial rehabilitation phases, both acute and post-acute. Rehabilitation of the brain-injured patient has been shown to result from therapies rather than spontaneous improvement and take years to accomplish, emphasizing the need for a coordinated continuum of rehabilitation programs. There is now evidence that coma and vegetative states are sometimes reversible with a combination of treatments, among them neuropharmacology.

Return to work for persons with traumatic brain injury: a supported employment approach.

Supported employment was used to place 41 persons into competitive employment during 30 months. All individuals had experienced severe head injuries; almost 70% of injuries were due to motor vehicle accidents. A mean of seven years had passed since injury for all referred clients, who had been unconscious a mean of 53 days. Only 36% of referred clients had achieved any competitive postinjury employment, compared with 91% of the same group who were competitively employed before injury. A job retention rate of 71% was reported, with most jobs in warehouse, clerical, and service-related occupations. A mean of 291 hours of job coaching was required to place and maintain all clients in supported employment.

Incidence of lumbar disc surgery. A population-based study in Olmsted County, Minnesota, 1950-1979.

Age- and sex-specific incidence rates of operation for suspected lumbar disc prolapse were determined for residents of Olmsted County, Minnesota, for the 30-year period 1950 through 1979. The incidence rate (adjusted to the age and sex distribution of the United States white population in 1980) was 52.3 per 100,000 person-years for all such operations and 46.3 per 100,000 person-years for initial operations. These rates remained fairly constant over the study period. A distinction was made between surgically proven and unproven cases of lumbar disc prolapse. Patients with a surgically proven lumbar disc prolapse had about 10 times the risk of another operation for disc prolapse within 10 years after the first operation compared with the general population.

Helping postacute traumatically brain injured clients return to work: three case studies.

This paper presents three case studies of individuals who had sustained a severe brain injury and who are clients of a return to work programme emphasizing a supported employment approach. The case studies illustrate the types of interventions which are utilized, including job placement; job site and off-site training, advocacy, and compensatory strategies; and ongoing assessment and maintenance of social and productive gains in order to assist with job retention. The results of the case studies may be generalized to the population of brain injury survivors who require intensive and long-term intervention and support in order to return to employment.

Helping traumatically brain injured patients return to work with supported employment: three case studies.

Three case studies illustrating the use of supported employment methods to help individuals with severe head injury are presented. Before supported employment intervention, these individuals were unable either to obtain or maintain employment. Neuropsychologic evaluation revealed many intellectual impairments which contributed to diminished employment potential. Through intervention, all three persons were able to obtain and maintain employment. Consecutive number of months employed ranged from 17.5 to 35, and hours worked per week ranged from 30 to 40. Current hourly earnings exceed the minimum wage, ranging from +5.00 to +5.16 per hour. These cases represent a subset within a larger supported employment program, which assists patients with severe traumatic brain injury to reenter the labor force and maintain employment.

Supported employment and compensatory strategies for enhancing vocational outcome following traumatic brain injury.

Epidemiological research clearly indicates that traumatic head injury has reached epidemic proportions. Incidence rates for head injury are greater than those for cerebral palsy, multiple sclerosis, and spinal cord injury combined. Many victims suffer from long-term impairments in functional, neurological, medical, neuropsychological and linguistic status. Emotional and behavioural problems are common as well. Additionally, family problems often ensue as a consequence of the victim's dependency and concomitant emotional changes. Investigations of post-injury vocational status indicate that unemployment rates within the first 7 years post-injury range as high as 70% for those with moderate and severe injuries. Researchers have demonstrated that the emotional and neuropsychological changes arising from injury are the greatest contributors to reduced employability. Relatively high unemployment rates strongly suggest that traditional approaches to physical and vocational rehabilitation have been entirely inadequate. To complement existing services and enhance employment outcome, two approaches have been developed and refined for use with victims of head injury. Supported employment is a unique approach which assists the client to select, obtain and maintain suitable employment on the basis of his/her interests and abilities. Compensatory strategies have been developed to help the individual offset intellectual problems which would otherwise interfere with learning job skills and maintaining production levels. Often, compensatory strategies are used in the context of a comprehensive supported employment programme. The greater use of supported employment and compensatory strategies is likely to enhance employment outcomes for those with traumatic head injury. Nevertheless, additional research is needed to more clearly identify the types of techniques which work best for each unique set of problems.

Effects of scopolamine treatment on long-term behavioral deficits following concussive brain injury to the rat.

Scopolamine (0.1, 1.0, or 10.0 mg/kg) or saline was systemically (i.p.) administered to rats 15 min prior to concussive fluid percussion brain injury. Animals pretreated with the 1.0 mg/kg dose exhibited significantly (P less than 0.05) less motor deficits and less body weight loss and recovered to baseline performance sooner than saline-treated rats. Mortality and associated convulsions were significantly lower in rats pretreated with the 1.0 mg/kg dose of scopolamine. A 1.0 mg/kg dose of scopolamine administered (i.p.) 30 s after injury also significantly reduced behavioral deficits. No differences were observed between saline- and scopolamine-treated animals in either the incidence or duration of transient apnea following injury. A 1.0 mg/kg dose of scopolamine administered (i.p.) 15 min prior to epidural clip compression of the spinal cord had no effect on the severity of motor function deficits assessed by an inclined plane test. The data from these experiments suggest muscarinic cholinergic involvement in at least some of the long-term behavioral deficits following mild and moderate levels of brain injury. These results suggest that muscarinic cholinergic antagonists may prove beneficial in the treatment of human head injury.

Effects of anticholinergic treatment on transient behavioral suppression and physiological responses following concussive brain injury to the rat.

Increasing doses (0.1, 1.0, 10.0 mg/kg) of scopolamine were systemically (i.p.) administered to rats subjected to moderate fluid percussion brain injury. Scopolamine treatment (1.0 mg/kg, i.p.) 15 min prior to trauma significantly reduced mortality and the duration of transient behavioral suppression assessed by a variety of measures. No differences were observed between saline- and scopolamine-treated animals in either the incidence or duration of transient apnea associated with injury. Preinjury treatment with methylscopolamine (1.04 mg/kg) or mecamylamine (1.0 mg/kg) had no effect on transient behavioral suppression. Except for increased heart rate, preinjury treatment with scopolamine (1.0 mg/kg) did not significantly alter systemic physiological responses to injury. Rats treated with scopolamine (1.0 mg/kg, i.p.) 30 s after injury tended to have shorter durations of reflex and response suppression. These experiments suggest that antimuscarinics can attenuate components of transient behavioral suppression associated with concussive brain injury. These findings are consistent with previous experimental and clinical observations and lend further support to the hypothesis that activation of a muscarinic system within the CNS mediates components of reversible traumatic unconsciousness following cerebral concussion.

Physical and psychological outcome after burns.

The relationship between compliance of moderately or severely burned patients with suggested plans of treatment and outcome was examined retrospectively by reviewing medical records. This review was limited to patients admitted to our facilities between 1977 and 1982 with burns in the moderate or major burn category and admitted within seven days of their injuries. The outcome measures included the following: limitation in range of motion (ROM), hypertrophic scar formation, total days of care required, quality of life, and impact of event. Noncompliance was related to the outcome as measured by limitation in ROM (P less than 0.01) and total days of care required (P less than 0.0001). A trend for diminished quality of life was related to noncompliance (P less than 0.08). Extent of injury (measured by total body surface area involved) was not related to ROM, quality of life, or impact of event but was related to total days of care required (P less than 0.01); there was also a trend toward scarring (P less than 0.06).

Changes in regional brain acetylcholine content in rats following unilateral and bilateral brainstem lesions.

Previous research (Adametz, 1959) has shown that two-step bilateral lesions of the reticular formation in cats produce minimal behavioral disruption compared to one-step bilateral lesions, which produce profound behavioral suppression. We systematically examined alterations in forebrain acetylcholine (ACh) content and neurologic tolerance to one-step and two-step bilateral and unilateral lesions of the pontomesencephalic reticular formation (PMRF) in rats. One-step and two-step bilateral lesions separated by 1 or 5 days produced irreversible bilateral motor dysfunction. Survival after lesioning was 10%, 20%, and 0%, respectively. Unilateral lesion or two-step bilateral lesions separated by 15 or 30 days produced transient (less than 3 days) contralateral motor dysfunction. Survival after lesioning was 90%, 90%, and 100%, respectively. Within 24 h after one-step bilateral lesions, ACh content was significantly decreased bilaterally in thalamus, frontal cortex, amygdala, hippocampus, and basal forebrain. Within 5 days after unilateral lesioning, ACh content was significantly decreased ipsilaterally in the thalamus, amygdala, and hippocampus and had returned to control values by day 10 in the thalamus and hippocampus. The increased neurologic tolerance and recovery of ACh content in two-step bilateral PMRF lesions demonstrate important functional and neurochemical plasticity to brain injury. Although not directly addressing mechanisms of neural plasticity, this research examined possible associations between neurologic tolerance to PMRF lesions and neurochemical markers of forebrain ACh activity.

A new model of concussive brain injury in the cat produced by extradural fluid volume loading: I. Biomechanical properties.

This study presents a new device for producing experimental, concussive head injury together with a detailed description of biomechanical features of fluid percussion brain injury in the cat. Anaesthetized cats were subjected to multiple (N = 3) or single injuries (N = 87). The variables studied in repeated injury experiments included the volume of fluid injected intracranially, rate of fluid flow, and the associated pressure transients recorded extracranially in the injury device and intracranially at supratentorial and infratentorial sites. Peak fluid flow increased with increasing volumes of fluid loaded intracranially. Extracranial pressure peaks and durations increased when volume loading was increased. Extracranial and intracranial pressure transients were similar at all recording sites. The form of pressure transients recorded in single injury experiments was similar to that recorded in multiple injury experiments. In single injury experiments, the extracranial pressure peaks and durations also increased with increased intracranial fluid volume loading. The slopes describing the relationships between intracranial volume loading and extracranial pressure transients were significantly different in single and multiple injury experiments. Details of the design and use of the head injury device are also discussed.

A new model of concussive brain injury in the cat produced by extradural fluid volume loading: II. Physiological and neuropathological observations.

This study examined physiological and histopathological changes in the cat produced by a new experimental fluid injury device. Spontaneously breathing (N = 14) and artificially ventilated (N = 45) cats were subjected to systemically varied magnitudes of fluid percussion brain injury. Within certain injury ranges, increasing magnitudes of fluid percussion injury produced increasing durations of apnea, as well as greater transient increases in mean arterial blood pressure, intracranial pressure and cerebral perfusion pressure. Acute increases in intracranial pressure may have been related to cerebral vasodilatation produced by the systemic hypertension following brain injury. Injuries associated with pressure transients greater than 10 atm ms produced concussive responses, including irreversible apnea in spontaneously breathing cats and temporary pupillary dilatation, increases in heart rate and mean arterial blood pressure in artificially ventilated cats. Injuries greater than 39 atm ms frequently produced histopathological and physiological indices of significant irreversible brain damage, including fixed and dilated pupils, systemic cardiovascular hypotension and deteriorating blood gases. Injury magnitudes less than 20 atm ms did not produce macroscopic evidence of histopathology, intermediate injury ranges produced increasing evidence of subarachnoid and petechial hemorrhage while injury levels greater than 40 atm ms frequently produced significant histopathology including massive hematomas. Injury greater than 10 atm ms resulted in opening of the blood-brain barrier, as assessed by extravasation of horseradish peroxidase. Injury greater than 19 atm ms produced suppression of EEG amplitudes which did not recover for up to 40 minutes after injury. These data provide detailed information on the physiological and histopathological consequences of fluid percussion injury in the cat and indicate that this modified fluid percussion apparatus can produce graded levels of brain injury similar to those previously reported for fluid percussion injury.