Physicians

An understanding of the underlying disorder, including the mechanisms of disability, potential outcomes, and natural history of the disease being managed, is critical in planning a rehabilitation program for a patient. This expertise may be provided by the growing number of neurologists with expertise in neurorehabilitation who can bring principles from their increasing storehouse of knowledge to bear on recovery, and by rehabilitation physicians or physiatrists, who also have broad experience in musculoskeletal, orthopedic, and cardiopulmonary rehabilitation issues. Orthopedists, urologists, psychiatrists, plastic surgeons, neurosurgeons, and podiatrists often are consulted during rehabilitation and for long-term management of disabled patients.

The clinician superimposes the contributions of neurological, musculoskeletal, cardiopulmonary, and other impairments on a map of the patient’s functional abilities and disabilities. For example, does tender musculoligamentous tissue cause pain or limit movement, or does spasticity lead to loss of motor control? Does a medication or metabolic abnormality lessen concentration, the ability to learn, or endurance for exercise? Physicians tend to be the facilitators of the multidisciplinary team, especially during inpatient care. Here, the physician may conduct a weekly team conference that reviews the patient’s progress in reaching the functional goals that will permit a discharge to the home. To do this well, the physician must help build the team’s infrastructure and understand the practices of its disciplines. Rehabilitation physicians should serve as clinician-scientists as well. The physician can encourage therapists to weigh, formulate, and test strategies. Drawing on current literature and collaborating with basic and clinical researchers, the neurological rehabilitation specialist can optimally assess and develop interventions and creative solutions (Dobkin, 2003).

Physicians should explain to both patient and primary care doctor the indications for medications, measures for secondary prevention of complications, management of risk factors for recurrence or exacerbation of the disease, and the type and duration of rehabilitative interventions. Increasingly, doctors must address the risks and possible benefits of not only medications and usual rehabilitative approaches to care but also potential research interventions such as cellular transplantation (Dobkin et al., 2006b). During outpatient care, physicians must provide informed counseling about exercise and home practice for motor and cognitive retraining. The clinician reviews the details of what the patient is practicing to improve walking, the functional use of an affected upper extremity, language and memory skills, and socialization. Education should be offered about how task-specific practice may alter the brain’s representations of these activities and improve the patient’s abilities, even years after the initial neurological illness. For patients with chronic diseases that progress, such as multiple sclerosis (MS), practice is perhaps even more important because it may spur gradual neural reorganization to maintain function. Clinicians can encourage patients to increase their strength, speed, and precision of multijoint movements and to build cardiovascular fitness. The physician also should monitor outcomes with serial tests of the activities that are targeted to best determine the optimal dose of a treatment. For example, if the gait pattern is suboptimal, the clinician can test walking speed for 50 feet or the distance walked in 2 minutes to reassess progress in mobility at each visit. By documenting the effects of treatment, the physician can best advocate the continuing goals of rehabilitation to patients and insurers.

The Internet has many sites from which to develop educational materials that physicians and the therapy team can offer patients (e.g., http://www.uclahealth.org/body.cfm?id=1174), as well as lectures and articles about recovery and about experimental interventions.

Rehabilitation Nursing

Traditionally, the nursing role has been one of providing care and support during a phase of illness and doing for others the things they would normally do for themselves. Nurses have particular expertise in bowel and bladder management and have developed the post of continence advisor, particularly for teaching chronic intermittent self-catheterization (CISC) and scheduled voiding programs. They teach skin care and pressure sore management. In an inpatient unit, nurses are in constant contact with the patient undergoing rehabilitation. This extended contact with patients allows nurses to address the issue of carryover of skills from physical and occupational therapy sessions to other areas fundamental for function in the community. Each activity is integrated with others; for instance, continence management through CISC may require improvements in upper limb coordination, trunk control, mobility, lower limb tone, medications to optimize bladder and sphincter control, and strategies to facilitate problem solving. Nurses in community programs also have become involved in the management of individual chronic diseases including MS, amyotrophic lateral sclerosis (ALS), and Parkinson disease (PD), especially attending to gaps in services needed by patients. A nurse practitioner can be a valuable asset to the physician and team on a busy inpatient service, especially in a university hospital, where patients tend to have complex medical illnesses and needs. The Association of Rehabilitation Nurses has excellent resources for continuing education (www.rehabnurse.org).

Physical Therapists

Physical therapists (PTs), or physiotherapists relate voluntary motor control and patterns of multijoint movements, sensory appreciation, range of motion of joints, strength, balance, and endurance to the training needs for bed and wheelchair mobility, standing up, walking, and functional mobility during activities. PTs bring expertise to the team in wheelchair design, assistive devices, and orthoses. They manage compensatory strategies for carrying out activities of daily living (ADLs) such as the use of a walker and offer interventions to lessen specific impairments. PTs play a primary role in managing musculoskeletal and radicular pain, contractures, spasticity, and deconditioning.

Two broad categories of physical therapy, therapeutic exercise and the so-called neurophysiological and neurodevelopmental techniques, were the bulwark of the approaches used by therapists in the past (Box 48.1). Newer concepts related to practice-induced neuroplasticity, motor control, and skills learning have taken greater hold beginning in the past decade.

Neurophysiological Schools

Many schools of physical therapy have developed approaches that focus on enhancing the movement of paretic limbs affected by UMN lesions. These approaches may be especially valuable when initiating motor therapies in patients with profound weakness. Techniques include using sensory stimuli and reflexes to facilitate or inhibit muscle tone and single- and whole-limb muscle movements in and out of mass actions called synergies. Most approaches try to sequence therapy in a progression reminiscent of the neurodevelopmental evolution in infants from reflexive to more complex movements. The emphasis is on normal postural alignment before any movement. Some techniques permit mass movement patterns early in treatment; others inhibit spastic overflow synergistic movements. For example, mobility activities may proceed in a developmental pattern from rolling onto the side with arm and leg flexion on the same side, followed by extension of the neck and legs while prone, then lying prone while supported by the elbows, and then doing static and weight-shifting movements while crawling on all four extremities. These mat activities are followed by efforts for sitting, standing, and finally walking. This progression is used most often in children with cerebral palsy, but some therapists also apply it to stroke and TBI rehabilitation.

Different schools vary in their attempts to activate or minimize reflexive movements and how they train the functional movements needed for ordinary activities. These schools have not emphasized strengthening exercises. Their use of reflexive movements, vibration to stimulate a muscle contraction, cutaneous stimulation to facilitate a voluntary contraction, and loading a joint to increase extension is reasonable from a physiological point of view, but any carryover of responses into functional or volitional movement is uncertain.

Neurodevelopmental practitioners believe that the optimal facilitation of movement requires normal postural responses, that abnormal motor behaviors are compensatory, and that the quality of motor experiences and the integration of whole-body somatosensory information will train patients for more normalized movements. The Bobath hands-on approach is a particularly popular neurodevelopmental technique. It aims to facilitate normal movement and desired automatic reactions and to restore postural control while inhibiting abnormal tone and reflex activity using specific motor patterns. Bobath therapists avoid provoking mass flexor synergies from the shoulder, elbow, and wrist or extensor synergies at the knee and ankle. The coordination of patterns of muscle group activity is viewed as more important than the actions of individual muscles. Most practitioners take a problem-solving and task-oriented approach with patients. A typical exercise routine may work on stance and trunk control with a large ball and careful hand placement by the therapist to evoke movements out of synergy (Fig. 48.2). These methods originally were developed for children with cerebral palsy but have been adapted for stroke and other neurological disorders. In comparison with other neurophysiological approaches and task-oriented motor learning for gait, upper extremity function, and overall level of functional independence, use of Bobath techniques has led to equivalent outcomes or, in several small trials, modestly inferior outcomes (van Vliet et al., 2005). Given the underlying theory of Bobath, however, outcome measures ought to examine the quality of task-related movements as much as functional gains.

Fig. 48.2 Gymnastic ball used to facilitate standing and postural adjustments for standing up (A) and flexion and extension of the trunk and reaching (B).

Occupational Therapists

Occupational therapists (OTs) facilitate the practical management of disability. The philosophical foundation of OT is that purposeful activity helps prevent and remediate dysfunction and elicits maximum adaptation. Goal-oriented tasks are meant to be culturally meaningful and important to the needs of clients and their families. Activities include daily life and work skills, exercise, recreation, and crafts. Occupational therapy also is concerned with improving the patient’s interaction with the environment and maximizing the patient’s role in society in terms of relationships, occupation, and personal standing. The OT implements a program to enable patients to learn or relearn specific activities, develop new or compensatory skills, adapt their behavior to what is feasible, make adjustments to increase the accessibility of their environment, and perform leisure activities.

A program may include the use of appliances to improve independence, ranging from simple devices (e.g., a thickened grip to better grasp cutlery or a pen) to complex ones (e.g., use of an environmental control unit). Such adaptive aids for daily living are listed in (Box 48.3). Hemicuff and Bobath slings are used to reduce shoulder subluxation and prevent pain in patients with upper limb paralytic disorders (Fig. 48.3). A balanced forearm orthosis can support the upper arm and allow a modest biceps and triceps contraction to swing the arm over a table, which may be especially effective for the patient with a level C5 SCI. For patients with stroke and brain injury, OTs work closely with the neuropsychologist to address visuospatial inattention, memory loss, apraxia, difficulties in problem solving, and the skills needed for return to school or employment. Some OTs manage dysphagia and interpret modified barium swallow (MBS) studies.

Fig. 48.3 A cuff support to prevent pain and lessen the subluxation of the glenohumeral shoulder joint in a patient with left hemiplegia after stroke.

Task-oriented and motor learning strategies have gained attention in formal occupational therapy research. Using this approach, the OT presents activities in a way that elicits the retention and transfer of particular skills for use in a functional setting. For example, in one study, limb kinematics improved in normal and hemiparetic subjects when training included purposeful goals with relevant items used daily. Thus, practice in object-related tasks, rather than simple repetition of reaching and grasping of items that have no significance for the client, may provide more concrete sensory information and offer rewards that motivate performance. In many instances, OT strategies evolve from problems that arise in daily living that require a solution. For example, adaptive equipment and an OT educational intervention in stroke patients to remediate the lack of confidence and increase the amount of information patients had available to them reduced the barriers to outdoor mobility and participation in the community (Logan et al., 2004).

Speech and Cognitive Therapists

Speech and language therapists are trained in many aspects of communication and cognition, including phonetics and linguistics, attention and memory, audiology, and developmental psychology, and provide expertise in the investigation and management of dysphagia. These therapists treat primarily patients with dysarthria, aphasia, and cognitive dysfunction that interferes with daily activities.

Interventions to improve the patient’s speech intelligibility, volume, and fluency include exercises of affected oromotor structures. For example, patients may be trained to slow their articulation, use shorter sentences, maximize breath support, extend jaw motion, adjust placement of the tongue, and exaggerate articulatory movements. Communication aids include voice amplification and computer assistive and voice recognition devices. These therapists also provide guidance for persons with swallowing difficulties; assessment may include the MBS study during videofluoroscopy.

Treatment for aphasia generally is based on clinical evaluation of the patient’s cognitive and linguistic assets and deficits. The therapy plan is fine-tuned according to standardized language and neuropsychological test results, knowledge of the cortical and subcortical structures damaged, and the ongoing response to specific therapies. Speech therapists attempt to circumvent, deblock, or help the patient compensate for defective language behaviors. Stimulation-facilitation approaches, listed in (Box 48.4), are commonly employed. Views on the value of speech therapy for aphasia vary. Most randomized controlled trials demonstrate a significant benefit for aspects of expression and comprehension in moderately impaired subjects. The amount of practice is a key variable for enhancing outcomes for any particular approach.

Recreational Therapists

Recreational therapists involve patients on an inpatient unit in group games, crafts, cooking, playing with pets, and other activities to help them socialize, practice skills, and enjoy the physical and emotional value of recreation despite new disabilities. In addition, the recreational therapist joins with the PT and the OT to teach patients how to reintegrate into the home and community. Outpatient recreational activities carried out in a wheelchair or with one hand also foster socialization and fitness. More than 200 local, national, and international organizations have developed rules and equipment for at least 75 sports and recreational activities that take into account a range of functional abilities.

Psychologists

Neuropsychologists with skills in clinical psychology help define and manage cognitive impairments and mood and behavioral disorders. Detailed psychometric testing is fundamental to establishing a rehabilitation program for a patient with cognitive impairment. These tests of aspects of memory, learning, perception, language, and executive function, however, do not represent the range of cognitive skills needed for real-world activities. The neuropsychologist often takes the lead in the management of mild to severe brain injury resulting from trauma or stroke and plays an important role in counseling patients, caregivers, and staff. When working with amnestic patients after TBI, the neuropsychologist may design operant conditioning paradigms or a token economy to reinforce appropriate social interactions, awareness of deficits, and learning. The neuropsychologist also develops relaxation techniques for anxiety states and behavioral approaches for the management of chronic pain.

Social Workers

Social workers deal with the psychosocial aspects of disability and provide counseling and often brief psychotherapy. Their concerns extend to the ability of the patient and family to cope with disability in and out of the hospital. They play a key role in apprising the rehabilitation team about family issues, supports needed for best management of the disabled patient, and appropriate care services in the community. The close interactions of social workers and patients or caregivers during inpatient rehabilitation often provide valuable insight into the dynamics of family involvement and the adequacy of resources. Social workers serve as liaisons to private and government agencies and to case managers from insurance companies. Smooth discharge planning from an inpatient service requires their assistance.

Orthotists and Bracing

Expertise in the manufacture, selection, and application of orthotic devices is another key component of a rehabilitation service. The PT or the OT works with an orthotist to select external devices that modulate directional forces from the body and joints in a controlled manner. Although many orthotic devices are mass-produced, the expertise of a trained orthotist is invaluable in choosing and constructing orthoses and supervising their fitting and adjustment. Orthoses include ankle and ankle-knee braces, finger-wrist and shoulder splints, spinal braces, collars, and corsets. The material most often used in manufacture of these devices is a malleable type of plastic, but light metals may be used when large biomechanical forces have to be managed. The effects of pressure, shear forces, and heat retention with sweating also must be considered during fitting to protect the skin.

With shortened inpatient rehabilitation stays, especially after stroke, ankle-foot orthoses (AFOs) that fit inside a shoe tend to be used early to more quickly assist foot clearance during ambulation in patients with a central or peripheral lesion. Observation of gait usually is enough to determine the need for a trial with an AFO in a patient with hemiparesis or footdrop. Indications include inadequate dorsiflexion for initial heel contact or for toe clearance during early and mid-swing, excessive hip-hiking during swing, medial-lateral subtalar instability during stance, tibial instability during stance, and uncontrolled foot placement caused by sensory loss. An orthosis also may be needed after operative heel cord lengthening. If the knee of the hemiplegic buckles during stance, angling the AFO in slight plantar flexion will extend the knee earlier. Dorsiflexing the AFO by 5 degrees can decrease knee hyperextension and help prevent the snapping back that causes instability and pain in midstance. Ankle inversion may necessitate greater rigidity and longer anterior foot trim. The AFO worn in a shoe ought to improve weight-bearing on the affected leg, increase single-limb stance time, and perhaps lessen postural sway. This may improve safety, especially on uneven surfaces, and walking velocity. Fig. 48.4 shows a thermoplastic AFO that fits in a shoe to limit plantar flexion and rotation and help control the knee. Orthoses may be static, such as a rest splint worn at night, or dynamic, with joints that may be lockable or free moving. Fig. 48.5 shows a thermoplastic AFO with a hinged joint that allows flexibility on rising to stand and at heel strike to start the stance phase of the gait cycle. Toe clawing can be managed with a metatarsal pad that spreads the toes. Some patients who have footdrop from a neuropathy such as Charcot-Marie-Tooth disease or diabetes may find that a fashionable boot with a flat heel that fits snugly above the ankle can improve gait by lessening its steppage quality, yet allow toe clearance. An orthotist can assess the potential for shoe modifications and inserts to improve balance and pressure points. Multiple small trials in patients with hemiplegic stroke show that walking activity increases and impairments in walking and balance decrease with the use of an AFO (Tyson and Kent, 2009). Functional electrical stimulation of the peroneal nerve timed to the gait cycle has equivalent or somewhat better effects on walking speed.

Fig. 48.4 This fabricated ankle-foot orthosis is designed for ankle and knee control of a hemiparetic patient who has minimal hypertonicity. A wider lateral flange and hook-and-loop straps across the front of the ankle would provide greater ankle control.

Fig. 48.5 This thermoplastic orthotic includes a hinged ankle with a stop to allow approximately 5 degrees of dorsiflexion when the subject goes from sitting to standing and in portions of the stance phase.

A metal double-upright brace offers greater rigidity for mediolateral foot instability and allows more versatility in adjustments for the amount of plantar and dorsiflexion but can be expensive, heavy, and cosmetically unappealing to the hemiplegic patient. Metal bracing systems are used more often by selected subjects with paraplegia from spinal injuries and in those with polio. Lightweight plastic knee-ankle-foot orthoses (KAFOs) with locking metal knee joints also can assist patients with severe polyneuropathy, muscular dystrophy, meningomyelocele, or SCI. Reciprocal gait orthoses (RGOs) with wire cables that link flexion of one hip to extension of the opposite hip are available for paraplegics. Short-distance ambulation for exercise also can be aided in the patient with SCI by variations on a KAFO or other devices. Bracing in persons with SCI has been combined with functional electrical stimulation to improve stepping and decrease its energy cost.

The thoracolumbar support shown in Fig. 48.6 was molded to the patient to lessen neck motion after a high thoracic vertebral injury and surgical stabilization. Static orthoses allow no motion of the primary joint. Solid wrist-hand orthoses usually are set between neutral and 30 degrees of extension. Upper limb orthoses, however, have not been shown to improve arm or hand function, increase range of motion or lessen the incidence of pain, based on small trials after stroke. Dynamic orthoses use elastic, wire, or powered levers that compensate for weakness or an imbalance in strength and allow some controlled movement. Fig. 48.7 shows the paretic left hand of a patient with a level C6 SCI holding a playing card with the aid of a thumb opposition splint. The weaker right hand needs wrist extension to mechanically oppose the thumb to the second and third digits. Such custom-made devices can be produced with lightweight metals and plastics. Functional neuromuscular electrical stimulation electrodes can be embedded in a wrist splint to enable grasp and release or over the peroneal nerve to trigger ankle dorsiflexion at appropriate times during the stepping cycle.

Fig. 48.6 This thoracolumbar support orthotic was molded to the patient’s chest to limit upper thoracic vertebral motion after a high spinal cord injury and surgical fusion. The chin brace and stiffness of the jacket limit early progress in mobility tasks for transfers. The riser grips that the patient holds make it easier to practice pushing down into the mat to raise the buttocks.

Fig. 48.7 This card-playing patient with a C6 spinal cord injury uses a molded thumb-opposition splint to pinch better with the right hand, and a lightweight metal tenodesis orthotic that pinches the thumb to the next two fingers when he dorsiflexes his wrist.

Measures

Neurorehabilitation employs measurement tools to characterize the impairments, disabilities, activities, and psychosocial needs of patients, as well as to monitor interventions, assess outcomes, and document services. To provide a comprehensive assessment of the impact of disease, outcomes may be considered at four levels: pathophysiology and related impairments, disability and level of functional activity, handicap and ability to participate, and health-related quality of life. The design and applications of these scales across diseases are described in Table 48.1.

What to measure depends on the clinical setting and must be based on the anticipated effect of the intervention. Quantitative clinical end points such as death and presence or absence of paralysis are important in evaluating early neuroprotective interventions in acute SCI, TBI, and stroke but tell little about disability and quality of life in survivors.

Each outcome level addresses distinct aspects of the disease process. The relationships among them are complex. The first two levels entail physician-oriented outcomes, whereas those at the third and fourth levels are more accurately called patient-based outcomes, although only the fourth incorporates the patient’s perspective. Rehabilitation is especially interested in measures of the impact of disease, which is contained within the World Health Organization (WHO) International Classification of Impairments, Disabilities, and Handicaps. As shown in Table 48.1, the focus is on the consequences of the disease or health condition rather than the disease alone (i.e., a classification of disablements and functioning). A classification available on the WHO website (www.who.int/icidh/) emphasizes whether people actually perform the tasks, especially those that require a lot of time and energy. The dimensions of the WHO classification also include personal and environmental factors that affect functioning. The emphasis on activities, participation, and contextual factors interacting with impairments and disabilities may influence the design of new measurement tools.

Two types of measures exist for each of these domains: measures that are specific to a given disease and generic ones that may, with caution, be applied across a range of diseases (see Table 48.1). The former may be more sensitive in detecting changes particular to the effects of an individual disease, whereas the latter may allow comparisons across different diseases and serve as an off-the-shelf tool. Two generic measures of disability are the 10-item Barthel Index (BI), which can be totaled to a maximum score of 20 or 100 (Table 48.2), and the 18-item Functional Independence Measure (FIM) (Box 48.5), which includes a modestly responsive cognitive component for a total of 126 points (Box 48.6). The FIM is used more often in the United States, especially for studies with large numbers of subjects, than in Europe or Asia, where its applicability for clinical trials has been questioned. The FIM, the BI, and two other scales—the Glasgow Outcome Scale for Recovery of Consciousness and Function and the Rankin Disability Scale (Tables 48.3 and 48.4)—commonly are used in clinical trials. The latter correlate closely with one other, in part because their definitions at the levels of 3 and 4 not well defined in terms of residual impairments and specific disabilities. In many respects, the BI and FIM reflect the level of care needed by patients. These and most scales have floor or ceiling effects and variable sensitivity to change, especially if used during outpatient care.

Table 48.2 Barthel Index

* Score only if patient is unable to walk.

Table 48.3 Glasgow Outcome Scale for Recovery of Consciousness and Function

Table 48.4 Rankin Disability Scale

How to Measure

Irrespective of what is to be measured, two essential issues must be addressed if the data are to be clinically meaningful. The outcome measure must be (1) clinically useful and (2) scientifically sound.

Measures for Documentation of Services

The development of a comprehensive shared system of documentation that reflects the process of the rehabilitation unit’s activity from initial assessment to discharge can provide clear evidence of unit practice and reflect its underlying philosophy regarding patient care and team work. From this commonly agreed-on baseline, proposed innovations can be analyzed in terms of their relative value and how they may affect other aspects of unit activity. A comprehensive system of unit documentation may include integrated care pathways and the Uniform Data Service’s (UDS) FIM and related descriptive measures. An integrated pathway details the expected interventions occurring during a given episode of clinical care. Departures from the expected pathway are documented, coded, and analyzed after a prespecified number of patients have been through the pathway. This identifies areas in the service that need improvement. In addition to documenting the process of care, rehabilitation pathways incorporate the long-term and short-term goals that form the basis of most rehabilitation programs. This audit can have a reciprocal role in describing, guiding, and promoting effective unit practice. The UDS program allows inpatient units to compare their patient population across diseases to other sites for FIM change scores, length of stay, and descriptive data.

Measures for Clinical Trials

Rehabilitation interventions have progressed considerably in conforming to scientifically designed clinical trials. Although the efficacy of general rehabilitation has been the subject of trials in patients with stroke, MS, and other diseases, trials are especially needed to assess a particular intervention for subjects with a particular set of disabilities that are the target of the well-defined intervention. Physical interventions are far more difficult to provide in a reproducible fashion than drug therapies. Outcome measures also are less easy to develop and apply when the primary outcome is levels of disability or severity of a specific disability, rather than outcomes such as mortality, morbidity, survival time, or subjects who survive without disability, which are typical measures of drug and surgical studies. Recent multicenter randomized controlled trials (MRCTs) of locomotor training after stroke (Duncan et al., 2007; Hidler et al., 2009) and SCI (Dobkin et al., 2006a), of constraint-induced movement therapy (Wolf et al., 2006), and of cortical electrical stimulation (Harvey et al., 2009) have demonstrated the feasibility of developing complex treatment strategies provided by many therapists at many cooperating sites. Ordinal scales like the BI dominate the outcome measures for most trials, but continuous or ratio measurement scales such as walking speed or time to complete tasks were the primary outcomes for these MRCTs. The relationship between walking faster over ground after an intervention and how well you can participate in home and community as a result of a mobility intervention is moot. Dichotomous outcome measures (Duncan et al., 2007) that divide subjects into those who achieve walking speeds compatible above or below a level that correlates with levels of home and community ability to ambulate is closer to an ideal measure of participation. Future trials related to mobility and arm use, however, may draw upon tiny triaxial accelerometers, gyroscopes, and global positioning satellite or cell phone devices. Using mathematical algorithms, these and other inexpensive wireless sensors may allow clinicians and trialists to directly monitor the quality and amount of activity and participation.

Service Provision

The way in which services are organized depends to some extent on the disease being managed. The most fundamental differentiation is between acute-onset diseases with different pathophysiological characteristics such as brain and spinal cord trauma and stroke; chronic conditions such as cerebral palsy and polio, in which disability may increase with aging and overuse of muscles and joints; and progressive disorders such as MS, muscular dystrophies, ALS, and PD. Service provision also should be driven by the philosophy underlying rehabilitation: to return the patient home and optimize home and community activities as soon as possible. The speed with which this is done depends as much on the services available in the community and the capacity of the family and caregivers to look after the patient as it does on the severity of the disability. Some tension arises between inpatient services in which all of the necessary ingredients are gathered under one roof, which appeals to patients and families, and community services, which are less centralized but support patients in their own environment. Most important is the smooth interface between these two settings when patients are discharged from an inpatient service.

Complications in Patients with Stroke

Medical complications often interfere with a patient’s ability to participate in therapy (Table 48.5). Medical and neurological complications occur at rates of approximately 4 and 0.6 per patient, respectively, during an average course of inpatient rehabilitation. A urinary tract infection, urinary retention, musculoskeletal pain, or depression will develop in approximately one-third of patients. Up to 20% will experience a fall, exhibit a rash, or need continuous management of blood pressure, hydration, nutrition, and glucose levels. In approximately 10%, a transient toxic-metabolic encephalopathy, pneumonia, cardiac arrhythmias, pressure sores, or thrombophlebitis will develop. Up to 5% will have a pulmonary embolus, seizures, gastrointestinal bleeding, heart failure, or other systemic complications. When feasible, prophylactic measures for these potential problems are essential. Because many patients in the United States are transferred from the acute hospital to a rehabilitation unit less than 7 days after a stroke, the rate of neuromedical complications may be higher at some centers. Side effects during the adjustment of new medications are especially prevalent, including orthostatic hypotension from antihypertensives or dialysis, drowsiness from anticonvulsants and analgesics, and a statin-induced myopathy with normal serum creatine kinase. Across rehabilitation centers, 5% to 15% of patients must be transferred back to an acute hospital setting.

Table 48.5 General Frequency of Inpatient Stroke Rehabilitation Neuromedical Complications

Adapted with permission from Dobkin, B., 2003. The Clinical Science of Neurologic Rehabilitation. Oxford University Press, New York.

Complications in Patients with Spinal Cord Injury

Medical complications of a somewhat different nature are common in the acute and chronic phases after SCI. In this younger group of patients, chronic comorbid systemic medical problems are less common than in patients with stroke. Prior substance abuse and emotional and behavioral disorders, however, are much more likely to complicate therapy. In the first 6 weeks after SCI, reparative operative procedures affect what can be done in rehabilitation. Approximately half of patients undergo spinal fusion and internal fixation. Acute spinal care also entails the use of external stabilization techniques such as a halo vest and Philadelphia collar for cervical injuries and a thermoplastic, custom-molded, thoracolumbar fixation shell (see Fig. 48.6). These devices limit head and trunk mobility, which makes self-care tasks that involve balance, management of the lower extremities, and CISC more difficult. Lower extremity fractures, especially of the femur, occur in about 5% of patients with acute SCI, which can further limit mobility and increase the risk of deep vein thrombosis and skin breakdown. Table 48.6 lists the complications found during a prospective clinical trial of methylprednisolone for acute SCI in 487 patients.

Table 48.6 Medical Complications Within 6 Weeks of Acute Spinal Cord Injury

Early morbidity is greater with cervical and upper thoracic injuries and with complete lesions than with lower level or incomplete lesions. Ventilatory dysfunction, aspiration, dysautonomia with upright hypotension or paroxysmal hypertension, a neurogenic bowel with impactions, a neurogenic bladder with retention and infections, a catabolic state, and gastric atony are especially likely to complicate early inpatient rehabilitation. Hypercalciuria or hypercalcemia related to immobilization may also necessitate therapy. Central and musculoskeletal pain and grief reactions warrant immediate attention.

Complications in Patients with Traumatic Brain Injury

Systemic and neurological complications are common after serious TBI. The older patient carries more systemic comorbidity, whereas the younger patient may have alcohol or drug abuse as a comorbid condition. Unrecognized fractures and heterotopic ossification as a cause of pain, in addition to other bodily injuries may complicate rehabilitation along with any of the complications that may accompany stroke and SCI. Physicians must also monitor for pituitary-hypothalamic dysfunction with endocrinopathies and disorders of homeostasis including cerebral salt wasting and inappropriate secretion of antidiuretic hormone, as well as cerebral hygromas and obstructive hydrocephalus. Ventricular enlargement develops in 30% to 70% of patients with severe TBI. Most have hydrocephalus ex vacuo, which is passive enlargement of the ventricles from the loss of gray and white matter. In the patient with enlarging ventricles who reaches an early plateau or declines in mobility and cognition, a diagnosis of symptomatic normal- or high-pressure hydrocephalus must be considered.

Patients who are in a persistent vegetative state often are evaluated by the rehabilitation team for prognostication and for a trial of stimulation. After TBI, the prognosis is not quite so grim as after hypoxic-ischemic coma unless hypotension accompanied the TBI. Table 48.7 shows the outcomes during the first year after brain injury determined for a 1994 study by the Multi-Society Task Force on Persistent Vegetative State.

Dysphagia

Neurogenic dysphagia is the potential cause of a pulmonary infection in any patient with stroke, TBI, motor neuron disease, MS, advanced PD, cervicomedullary disorders such as a syrinx, Guillain-Barré syndrome, myasthenia gravis, and most neuromuscular diseases. Indeed, swallowing disorders affect 10% of acutely hospitalized older adults and 30% of nursing home residents. Even transient dysphagia can lead to malnutrition, dehydration, aspiration pneumonia, and airway obstruction with asphyxiation. It increases the patient’s risk of death and institutionalization.

The natural history of recovery from dysphagia after stroke and TBI is good. For example, a British study diagnosed dysphagia in 30% of 357 conscious patients within 48 hours of a unilateral hemispheric stroke; the patients were rated as having impaired deglutition if they exhibited delayed and prolonged swallowing or if they coughed on 10 mL of water. Lethargy, gaze paresis, and sensory inattention were present more often than in those who swallowed normally. By 1 week, 16% had dysphagia. At 1 month only 2% and at 6 months only 0.4% of survivors were still impaired. Symptoms and signs that suggest a risk of aspiration include lethargy, coughing or a hoarse and gurgly voice after feeding, slow eating or drinking (<10 mL of water per second drunk from a cup), dysphonia, and poor oropharyngeal movement. The limitations of bedside indicators have led to the use of the MBS with videofluoroscopy as the method of choice to rule out silent aspiration. The relationship between small-volume aspiration as seen on MBS and clinical complications is uncertain, however, and requires clinical judgment. The MBS also visualizes the effects of dietary texture and compensatory techniques. In attentive stroke rehabilitation inpatients, coughing or a wet-hoarse quality of the voice noted within 1 minute of continuously swallowing 90 mL of water from a cup had a sensitivity of 80% and specificity of 54% for aspiration detected by an MBS study. The bedside test had a sensitivity of 88% and specificity of 44% for large-volume aspiration, which may be clinically more significant. Fiberoptic endoscopy also can identify mechanisms of dysphagia and can be performed at the bedside.

Dysphagia management must be addressed through all phases of recovery from stroke and TBI and during the progression of disorders such as PD, ALS, and myasthenia gravis (see Chapter 12B). Lesions in the pathways for swallowing interfere with the oral, oral preparatory, and reflex or pharyngeal phases of deglutition. Common deviations include loss of the ability to form a bolus and inadvertent trapping of liquids in the vallecula, with subsequent trickling over the vocal cords. The initial emphasis for care is placed on protecting the airway and maintaining adequate alimentation and hydration, with use of a nasopharyngeal feeding tube if necessary. A large single-site randomized trial found that a standardized daily therapy for swallowing and dietary modification for up to 1 month after stroke, compared with usual care or with standard care provided only 3 days a week, reduced dysphagia-related medical complications such as pulmonary infection and significantly increased the number of patients who regained swallowing function. As in many other rehabilitation trials, it may be that the intensity of a treatment is as important as the strategy to achieve greatest efficacy.

Swallowing may improve by downsizing a tracheostomy tube or eliminating it as soon as possible. Oral pooling of secretions and drooling, which predispose the patient to aspiration, can be managed with suctioning and sometimes with use of a low titrated dose of an anticholinergic drug such as glycopyrrolate. Good oral hygiene and prevention of tooth caries by oral rinsing with chlorhexidine gluconate and stannous fluoride can lessen the likelihood of carriage of bacterial infection into the lungs by oral secretions. Therapeutic efforts focus on the use of stimulation and compensatory approaches designed to reduce the swallowing impairment or to minimize the functional disability resulting from that impairment (Table 48.8). For example, postural adjustments may be made on the basis of the MBS findings. A chin tuck narrows the airway opening, tilting the head to the stronger side of the pharynx directs a bolus away from the weak side, and head rotation toward the weak pharyngeal muscle channels a bolus toward the stronger side. Modification of diet texture includes choosing thickened or gelled liquids, which are less likely to be aspirated than thin liquids. Purees and formable solids such as applesauce or mashed potatoes usually are safer than foods that require chewing and oral manipulation. Pharyngeal stimulation by the therapist may help drive representational plasticity for these muscles on the unaffected side of the brain after stroke to improve swallowing.

Table 48.8 General Therapies for Dysphagia

The FOOD Trial Collaboration reported that early placement of a nasogastric tube to feed aphagic patients after stroke improved nutrition and reduced deaths and poor outcomes compared with no enteral feeding, but early use of percutaneous gastrostomy caused a 1% absolute increase in complications. Gastrostomy may not lessen the risk of reflux aspiration any more than a nasopharyngeal feeding tube for patients with persisting aphagia. Percutaneous endoscopic gastrostomy can be complicated by gastric perforation, peritonitis, hematoma, fistula formation involving the lung, stomal infection, cellulitis, and bleeding at the insertion site. Jejunostomy may lessen the risk of reflux but increases the risk of the dumping syndrome. Rarely, esophagostomy or pharyngostomy may be better suited for the patient with neurological dysfunction and prior gastrointestinal disease or surgery. Clinical trials related to the efficacy of types of tube feedings and other interventions for dysphagia are monitored by the Cochrane Review. Dysphagia therapies provided by the family under the guidance of a therapist may be as efficacious as hands-on therapy by a professional. With outpatient care, patients and family members assume greater responsibility for integrating and adapting recommended procedures to suit their individual needs and priorities.

Skin Ulcers

Education in skin management during rehabilitation provides an important opportunity for preventing later morbidity and mortality. Ischemia of the skin and underlying tissues occurs particularly in weight-bearing areas adjacent to bony prominences. The American Model Systems data for patients hospitalized within 24 hours of traumatic SCI showed that pressure sores subsequently developed in 4%, and 13% of these were graded as severe. The lesions occurred over the sacrum, heel, scapula, foot, and greater trochanter of the hip. Lower-grade skin lesions developed over the genitals. Sores related to sitting most often are located over the ischial tuberosities, where tissue pressure can exceed 300 mm Hg on an unpadded seat. A 2-inch-thick foam pad decreases the local pressure to 150 mm Hg. Even with the use of cushions designed to distribute pressure evenly over weight-bearing skin surfaces, pressures in the sitting position are far above the pressures of 11 to 33 mm Hg in the capillaries and venules. Raising the head of the bed by only a few inches especially increases shearing forces over the sacrum.

A standard classification for degrees of integument breakdown, prophylactic measures, and wound care is available from the Agency for Health Care Policy and Research in Washington, DC. Rubor, induration, and blistering are signs that precede a break in the skin. Pressure relief by turning and repositioning is the best approach, performed every half hour after a complete SCI and every 2 to 3 hours in patients with intact sensation after stroke or other disabling injuries. Patients must develop a skin care program based on their general health, nutrition, continence, toughness of their skin, most commonly used positions, type of wheelchair seat, presence of old skin scars, and other factors.

Deep Vein Thrombosis and Pulmonary Embolus

In controlled trials of prophylaxis, DVT has been found in 20% to 75% of untreated patients within 2 weeks of stroke; 5% to 20% suffered a pulmonary embolus (PE), which was fatal in approximately 10%. Intermittent calf compression for the paretic leg, intermittent low-dose heparin given as 5000 units every 8 or 12 hours, and low-molecular-weight heparinoid are far more effective than no intervention or the use of antiembolism hose alone. Across several studies, anticoagulants have reduced the incidence of DVT by a factor of two- to sevenfold, and of PE by about two- to fourfold. If a DVT is diagnosed, patients usually can restart activities out of bed after 2 days of intravenous heparin.

For those with SCI or head injury complicated by bone fractures, the incidence of DVT and PE is particularly high. After an SCI without a fracture, the risk of DVT, detected by a radiolabeled fibrinogen scan, impedance plethysmography, or Doppler blood flow study, appears greatest in the first 12 weeks, especially in combination with paraplegia and flaccidity. Symptomatic thrombophlebitis and PE are less common. In one study, thromboembolism was detected in 31% of plegic patients who were randomized to receive 5000 units of subcutaneous heparin twice a day within 72 hours of injury. It was detected in only 7% of patients whose activated partial thromboplastin time was prolonged to 1.5 times control values by dosage adjustment every 12 hours. Over 7 weeks of anticoagulation, the incidence of bleeding complications was greater in the adjusted-dosage group, especially at trauma sites. Most patients with uncomplicated SCI continue anticoagulation until discharge from inpatient rehabilitation.

Contractures

Across studies, approximately 15% of patients with SCI admitted for rehabilitation and 80% admitted after moderate to severe TBI lost more than 15% of the normal range of motion of at least one joint. Hemiparetic patients with stroke fall between these extremes. Contractures are found especially in the lower extremities in neuromuscular diseases, affecting at least 70% of outpatients with Duchenne muscular dystrophy. Contractures limit functional use of a limb and impair hygiene, mobility, and self-care. Serious contractures can cause pressure sores, pain, and, especially in youngsters, emotional distress when odd postures distort the body. After an acute UMN lesion, proper positioning of the arm in abduction and hand in extension and of the leg in hip abduction with knee flexed and ankle in neutral position can protect the affected extremities. Any source of pain will increase tone and predispose to contractures. Serial casting and surgeries occasionally are necessary for contractures that interfere with skin care or functional use of a limb.

Ectopic bone formation—heterotopic ossification (HO)—below the neurological level of injury may cause functional impairment in up to 20% of patients with SCI, usually in the first 4 months after injury. Patients with a complete lesion, pressure sores, spasticity, and age older than 30 years may be at greatest risk. After TBI, HO especially tends to affect the proximal joints of comatose patients. During rehabilitation of less responsive and cognitively impaired or aphasic patients, pain caused by undetected musculoskeletal injury and HO can add greatly to agitation and limit participation. HO develops when multipotential connective tissue cells transform into chondroblasts and osteoblasts, presumably under the influence of locally induced growth factors. The hips, knees, and shoulders are affected most often. Swelling, erythema, and decreasing range of motion are among the first clinical signs. A three-phase technetium 99m–labeled methylene-diphosphonate bone scan reveals focal uptake before radiographic visualization of bone. Early treatment with disodium etidronate suppresses mineralization of the osteoid. Range-of-motion exercises, aspirin, nonsteroidal antiinflammatory drugs, and a wedge resection of mature heterotopic bone can decrease pain and immobility.

Seizures

Seizures occur in 5% to 8% of patients within 24 hours to 2 weeks of an ischemic stroke. The risk of epilepsy after TBI varies with the severity of injury and time after onset of injury. In a population study of more than 2700 patients with mostly nonpenetrating TBI, 2% experienced a seizure in the first 2 weeks after injury. Those with brain contusions, hematomas, or 24 hours of unconsciousness or amnesia had a 7% 1-year and 11.5% 5-year risk of seizures. Within the first 2 weeks in these severe cases, children younger than 15 years of age had a rate of 30%, compared with 10% in adults. After a moderate injury, defined as a skull fracture or 30 minutes to 24 hours of unconsciousness or amnesia, 0.7% of patients at 1 year and 1.6% at 5 years had a seizure. The risk after a mild injury with brief unconsciousness or amnesia was 0.1% to 0.6%, the same as for the general population. With a 25% rate of first seizures regardless of anticonvulsant prophylaxis beyond the first week after serious brain injury, it does not seem productive to continue anticonvulsant therapy beyond the first 2 weeks after a serious TBI, especially because an anticonvulsant medication can increase cognitive impairment.

Dysautonomia

Bedrest, dehydration, cardiac and antihypertensive medications, antidepressants, and autonomic reflex dysfunction from diabetes mellitus contribute to postural hypotension in the patient with stroke and TBI. Supine and standing blood pressures should be checked as mobilization proceeds during rehabilitation. Autonomic reflexes may fail in patients with SCI levels above T6. Symptomatic postural hypotension is common in the first weeks after injury and may persist in quadriplegic patients.

Initial therapies for OH include gradual reconditioning of postural reflexes on a tilt table, sleeping in a reverse Trendelenburg position to prevent overnight diuresis, wearing full compression leg hose, and application of an abdominal binder. In the inpatient setting, fluid loading with saline or albumin may aid the effort to compensate for venous pooling, decreased cardiac output, and impaired vasoconstriction and venoconstriction from interruption of sympathetic outflow. Fludrocortisone increases the intravascular volume and peripheral vascular resistance. The dosage can be pushed gradually to 0.5 mg per day. Salt tablets should be added to the diet. Hypokalemia and edema with pressure sores can complicate use of mineralocorticoids. While the patient is upright, ephedrine, 25 to 100 mg, up to every 3 hours; ergotamine, 2 mg, up to several times daily; or midodrine, up to 10 mg 3 times a day can be tried. Episodic autonomic hyperreflexia related to uninhibited sympathetic outflow may affect 50% to 90% of SCI patients with high-level SCI, usually beginning several months after injury. It is caused by visceral and joint pain, HO, pressure sores, bowel and bladder distention, fecal impaction, urinary infection and cystitis, ingrown toenails, pregnancy and labor, venous thrombosis, and late development of a syrinx. Wearing tight clothing, a particular supine position, or oropharyngeal suctioning also can cause bradyarrhythmias. Often it has no evident precipitating cause. Hypertension, headache, diaphoresis, anxiety, reflexive bradycardia, nasal congestion, flushing above and pallor below the SCI level, extensor spasms, and piloerection can result. The instigating agent must be removed. Acute therapies include upright positioning, search for an unemptied bladder or rectum using lidocaine on a catheter or finger when probing, and treatment of blood pressure that exceeds 180/100 mm Hg. A beta-blocker such as labetalol, a short-acting calcium channel blocker, vasodilators such as hydralazine, and occasionally phenoxybenzamine, prazosin, clonidine, or nitroglycerin usually lower the pressure safely. Some quadriplegic patients have very labile responses to antihypertensive drugs and suddenly become hypotensive with these treatments. For frequent bouts of hypertension, maintenance therapy includes low dosages of any of these oral agents but with dosage adjustments based on the finding of supine hypertension coupled with sitting hypotension. For paroxysmal bradycardia, propantheline or a pacemaker may be needed. Scopolamine and propantheline can prevent bouts of sweating.

Bowel and Bladder Dysfunction

Urinary incontinence occurs in up to 60% of patients in the first week after a stroke, but function tends to improve without a specific medical treatment. This likelihood must be considered in the context of an incidence of urinary dribbling and involuntary emptying of approximately 30% in the population of healthy, noninstitutionalized adults older than 65 years of age. Across studies, about 18% of those who were incontinent at 6 weeks after a stroke are still so at 1 year. By the end of inpatient rehabilitation, the incidence is about 10% in patients with a motor-only stroke and about 30% with large hemispheric strokes. A Cochrane Database systematic review of the prevention and treatment of urinary incontinence after stroke found insufficient evidence for most physical, behavioral, and pharmacological interventions, but specialist management tended to reduce the number of urinary tract infections.

After SCI, the bladder detrusor reflex may not return for 6 weeks to 12 months. In the absence of spontaneous bladder emptying, intermittent catheterization is done on a schedule that prevents the accumulation of more than 400 mL. Patients should measure their output from time to time and develop a voiding schedule that takes into account variations in fluid intake and the use of alcohol and caffeine. Catheters can be washed, stored in a plastic bag, and reused. If sensorimotor impairments persist, nearly all patients with an SCI lesion that spares the S2 to S4 micturition center will develop dyssynergia between the detrusor and the external sphincter. These uncoordinated contractions lead to incontinence and intermittent outlet obstruction. Urodynamic studies and an intravenous pyelogram are indicated as a baseline and to assist in therapy, especially in patients with SCI (see Chapter 50C). Obstruction can cause recurrent infections, urosepsis, vesicourethral reflux, urolithiasis, and hydronephrosis.

Patients should learn the signs of bladder fullness, such as sweating, changes in temperature, increased spasticity, and an increase in heart rate. Some palpate the area of the bladder to determine fullness. Once awareness of fullness develops, the person can aid in initiating or completing micturition by tapping over the bladder, rubbing the skin over the pubis or on the inner thighs, pressing on the abdominal wall (Credé maneuver), and bearing down or coughing. These maneuvers are particularly helpful in those with an LMN bladder with an open sphincter. Most patients with SCI also learn the signs of an early bladder infection, such as a change in clarity or odor, as well as more spasms, and work out a system with their physician to obtain a culture and antibiotics immediately.

Pharmacological treatment can be understood in relation to problems in bladder filling, storage, and bladder emptying with any neurological disease (Table 48.9). Urodynamic studies often aid in the choice of drug trial. The goals are continence and regular emptying that is achieved without high intravesicular pressure and with less than 100 mL of residual volume after voiding. Many males after stroke who have an enlarged prostate benefit from an alpha-blocker. If the goal for micturition is not achieved, several alternatives to the use of an indwelling catheter on a long-term basis are available. To prevent inadequate emptying at low pressure at the price of external sphincterotomy and resultant incontinence, long-term CISC can be used in combination with anticholinergic medications or bladder infusion of botulinum toxin to partially paralyze detrusor function. This procedure has become increasingly accepted as an effective alternative in the management of low intravesicular pressure. An external collecting device also can be used to ensure dryness. The patient must be trained to adjust fluid intake and the timing of catheterization to meet the flexible needs of community living. The absence of an effective external collecting device for female patients makes it necessary to continue long-term intermittent catheterization in women with paralysis of detrusor function. A waterproof undergarment may be worn between catheterizations to avoid embarrassment. The difficulties of this regimen cause many women to choose constant indwelling catheter drainage despite its drawbacks. Augmentation enterocystoplasty, reservoirs, conduits, and electrical stimulation techniques are less often needed. The VOCARE Bladder System for patients with UMN SCI allows patients to stimulate sacral nerves that have been implanted with electrodes to empty the bladder and bowel.

Table 48.9 Pharmacological Manipulation of Bladder Dysfunction

bid, Twice daily; hs, at bedtime; qid, four times daily; tid, three times daily.

The optimal management of spina bifida in children includes self-catheterization. Through cartoons and drawings, children can be taught how to prevent germs from growing in the bladder. Intermittent self-catheterization of the bladder usually can begin by age 5 years or by the time the child starts school.

Bowel evacuation can be brought under control in a majority of cases of SCI or other causes of myelopathy or cauda equina injury. The goals include continence, the prevention of impaction and discomfort caused by inadequate elimination, prevention of rectal bleeding, and a reasonable amount of time for bowel care. Some people with SCI can identify a signal of rectal distention, such as sweating or an increase in spasticity. It is particularly useful to establish a fixed time, usually after a meal, for evacuation. Once a pattern has been established with stimulatory suppositories, patients often get by with dilatation of the anal sphincter, either digitally or by a glycerin suppository. Those who cannot develop enough intraabdominal pressure to defecate may need manual evacuation several times a week.

Fatigue

Although most commonly associated with MS, various forms of fatigue occur in all patients with central and peripheral neurologic diseases. Fatigue may encompass malaise, lack of energy, and depression. Underlying mechanisms may include disease-related autonomic, endocrine, and inflammatory dysregulation, as may occur in MS. Cognitive processing effort that is increased by the presence of cerebral lesions may induce a form of fatigue in carrying out mental and physical activities. One of the least recognized forms of fatigue that will interfere with ADLs occurs with repetitive use of muscles. This fatigability especially affects overused girdle muscles during walking but can be so insidious in the course of a motor activity that patients do not realize why they employ a slow gait with short stride. Clinically, this fatigability can be detected by testing strength immediately before and after 10 leg lifts by a supine or prone subject or after a 30-meter walk. It arises from problems as diverse as the more familiar fatigability found in myasthenia gravis and in lumbar stenosis with intermittent compression of the cauda equina. Impaired drive of motor units from the motor cortex due to less cortical excitability or greater inhibition, loss of corticospinal projections, conduction blocks along the descending projections, spinal mechanisms of reciprocal inhibition, disruption of firing rates of fast and slow motor units, and muscle atrophy can contribute. Medications such as the statins may cause a myopathy that induces weakness and greater fatigability that takes 6 to 12 weeks to resolve. Strengthening and conditioning exercises, as well as use of techniques for energy conservation, may lessen motor fatigability. Medications such as antidepressants, modafinil, and methylphenidate or noradrenergic modulation may reduce symptomatic fatigue.

Central Pain

A major source of disability can be pain from a thalamoparietal stroke or SCI. One of the most common patient complaints a year or more after SCI is burning pain at and below the level of the lesion. Approximately half of these patients gauge their symptoms as moderate or severe. Some patients need only assurance that the pain does not represent a serious complication or a warning signal of another stroke. Others will need the help of the physician in setting goals and identifying interventions to moderate the severity, frequency, and duration of the pain, also taking into consideration the usual time of day for pain onset. Tricyclic and selective serotonin reuptake inhibitor antidepressants, carbamazepine, clonidine, gabapentin, lamotrigine, benzodiazepines, and baclofen are among the drugs that diminish dysesthetic or lancinating pain in some patients. Intrathecal clonidine, baclofen, and morphine can be efficacious when oral approaches fail (see Chapter 44).

Sleep Disorders

During rehabilitation, insomnia, sleep apnea, and excessive daytime sleepiness can interfere with attention and learning. Stimulants, alcohol, medications, pain, anxiety, depression, and chronically poor sleep habits contribute. Central and obstructive sleep apneas have been associated with a higher risk of stroke. Pharyngeal muscle weakness and impaired neural control during sleep of the nasopharyngeal and pharyngolaryngeal muscles caused by a stroke or TBI contribute to the risk of obstructive apnea. Up to one-third of stroke inpatients may have a sleep disorder. Polysomnography is indicated when the rehabilitation team observes a hypersomnolent, confused, and snoring or apneic patient. One study found an average of 52 sleep-disordered breathing events per hour in selected subjects within 1 year of stroke. The number of oxygen desaturation events and the oximetry measures during sleep-disordered breathing correlated with poorer functional recovery scores at 1 and 12 months after stroke. It is especially important to address the possibility of apnea with outpatients with any type of neurological disease, especially stroke, TBI, thoracic SCI, and myasthenia gravis.

Spasticity and Upper Motor Neuron Syndrome

Spasticity is found in less than 20% of hemiplegic patients after stroke. Patients with bilateral weakness from TBI, especially if hypoxic injury occurred, are likely to have signs of spasticity as well. After SCI, spasticity is more prominent with incomplete than with complete motor and sensory impairments, especially with cervical and upper thoracic lesions.

The most important UMN problems that cause disability are the decrement in motor control associated with dyssynergic patterns of muscle activation and the coactivation of agonist and antagonist groups during movements, which are associated with paresis, slow movements, loss of dexterity, and fatigability with repetitive contractions. Spasticity per se does not produce weakness and these other aspects of impaired motor control. Exaggerated cutaneous and autonomic reflexes and involuntary flexor and extensor spasms are the most disabling episodic problems associated with spasticity for patients. During rehabilitation, the most visually striking signs associated with the UMN syndrome tend to be treated, and sometimes overtreated. These include hyperreflexia; flexor synergy of the elbow, wrist, and fingers; plantar flexion of the ankle; and the dystonic postures, rigidity, and contractures that may accompany weakness.

Physical Modalities

Slow stretching movements and daily passive range-of-motion exercises will reduce motion-sensitive symptoms of spasticity and the risk of contractures. Static stretching with splints probably will not prevent contractures when motor control is absent. Serial casting can reduce stretch reflex activity and contractures as the joint angle gradually increases. Muscle cooling, tendon vibration, pressure exerted over a tight muscle belly, postural adjustments, loading a limb by weight bearing on an extended arm or, for paraplegics, standing in a support frame (Fig. 48.9), and electromyographic BFB can complement a stretching program. Electrical stimulation of motor and sensory nerves, muscles, and dermatomes by a variety of paradigms may reduce tone at the ankle and knee and in the forearm and finger flexors. A single session of stimulation usually decreases resistance and clonus for a few hours.

Fig. 48.9 A patient with quadriplegia from a spinal cord injury uses a standing wheelchair to try to reduce ankle and knee contractures and overall muscle tone. Subjects who can use their upper extremities may use a wheelchair like this one to perform tasks while upright, such as washing dishes.