Nursing home rehabilitation after acute rehabilitation: predictors and outcomes.

OBJECTIVE: To determine the predictive factors and functional outcomes of patients who were discharged from an acute rehabilitation unit to a nursing home care unit (NHCU) at a Veterans Affairs (VA) hospital. DESIGN: Cohort descriptive study. SETTING: An academically affiliated urban VA Medical Center. PATIENTS: All patients (n = 81, median age 68 years) admitted to a VA rehabilitation unit over a 1-year period. OUTCOME MEASURES: Discharge locations, predictors for NHCU transfer, and functional status as determined by Functional Independence Measure (FIM) scores. RESULTS: Patients discharged to the NHCU (17%) were compared with those discharged to the community (80%). Multiple logistic regression analysis showed that acute rehabilitation length of stay (LOS), admission, and discharge FIM scores were the only independent variables that predicted discharge to the VA NHCU. Although overall FIM gains in both groups during acute rehabilitation were similar, the NHCU group had significantly lower admission FIM scores and lower LOS efficiency because of longer acute rehabilitation LOS. Postacute NHCU rehabilitation resulted in significant gains in FIM scores at a slower rate. Sixty-four percent of these nursing home patients eventually returned to the community. CONCLUSION: Nursing home rehabilitation can result in favorable functional and community outcomes for selected patients.

The thermoplastic Minerva body jacket: a clinical comparison with other cervical spine splinting techniques.

A retrospective analysis of the efficacy of a variety of external stabilization techniques used in 155 cases of unstable cervical spine injuries is presented. The movement at each intervertebral level was evaluated during thermoplastic Minerva body jacket stabilization in 18 additional patients. Many currently available approaches to external stabilization of the cervical spine were, thus, assessed. Thermoplastic Minerva body jacket stabilization offered superior segmental immobilization compared with published data for the halo. It is concluded that some unstable injuries to the high cervical spine might best be treated with a halo device, whereas mid to low cervical injuries and the remaining upper cervical spine injuries appear to be optimally treated with a Minerva jacket. Lesser injuries may be treated with a variety of available orthoses. The thermoplastic Minerva body jacket offers a superior limitation of intervertebral movement compared with other commonly used braces, including the halo jacket, for most cervical spine injuries. The technique of application of the thermoplastic Minerva body jacket is reviewed.

The effect of the thermoplastic Minerva body jacket on cervical spine motion.

In order to determine the extent of cervical spine immobilization provided by the thermoplastic Minerva body jacket (TMBJ) 20 healthy male subjects underwent analysis of cervical spine motion before and after TMBJ placement. Maximal cervical flexion/extension and lateral bending were measured from lateral and anteroposterior roentgenograms, respectively. Maximal cervical rotation was measured from overhead photographs. The TMBJ significantly limited flexion/extension at each level of the cervical spine, as well as rotation and lateral bending (P less than 0.001). Flexion/extension at each cervical level was found to be equal to that allowed by the halo with body jacket at most levels and less at the occiput-C1, C3-C4, and C6-C7 (as reported in studies using similar methodology). The present study suggest that the thermoplastic Minerva body jacket is a valuable option for rigid external immobilization of the cervical spine.

Effects of spinal cord stimulation on spasticity and spasms secondary to myelopathy.

16 subjects with severe spasms secondary to traumatic and nontraumatic myelopathy underwent epidural spinal cord stimulation. 4 patients had a complete motor and sensory spinal cord lesion. 6 of the subjects with an incomplete spinal cord lesion were ambulatory. All patients had previously undergone extensive trials with medications and physical therapy. All 14 subjects in whom a satisfactory placement of the electrode could be obtained had a reduction in the severity of the spasms. In 6 patients, the spasms were almost abolished. Extremity, trunkal and abdominal spasms were affected. Clonus in the upper extremities was consistently reduced. Marked improvement in bladder and bowel function was observed in each of 2 subjects. In over 1-year follow-up, 5 subjects show persistence of the results, with less stimulation required to maintain the therapeutic effects. No neurological deterioration occurred following the procedure or after long-term spinal stimulation. 1 patient showed after several months of continuous stimulation increased voluntary motor control present only when spinal cord stimulation was activated. Complications included 1 system infection, 1 electrode migration, 1 wire breakage and skin breakdown at a connector site, development of high impedance in 1 electrode and 1 skin breakdown over the lead.

Enhancement of voluntary motor function following spinal cord stimulation--case study.

One patient with an incomplete traumatic myelopathy underwent epidural spinal cord stimulation for the management of severe intractable spasms, which were abolished by the stimulation. After several months of stimulation, the patient regained some voluntary motor function in the lower extremities. Voluntary motor control of the left quadriceps was present only when spinal cord stimulation was activated and stopped immediately after it was turned off. The effects could be consistently reproduced. EMG polygraphic recordings confirmed the results.

Immediate effects of spinal cord stimulation in spinal spasticity.

Six patients with intractable spasms after spinal cord injury underwent implantation of an epidural spinal cord stimulation system. All the patients experienced good relief postoperatively. In three patients spinal cord stimulation consistently produced immediate inhibition of the spasms. This was evident within less than 1 minute of stimulation. Conversely, the spasms reappeared within less than 1 minute after cessation of the stimulation. The clinical observations were confirmed by polygraphic electromyographic recordings.