Search

Abstract: Vanderploeg RD, Schwab K, Walker WC, Fraser JA, Sigford BJ, Date ES, Scott SG, Curtiss G, Salazar AM, Warden DL, for the Defense and Veterans Brain Injury Center Study Group. Rehabilitation of traumatic brain injury in active duty military personnel and veterans: Defense and Veterans Brain Injury Center randomized controlled trial of two rehabilitation approaches. Objectives: To determine the relative efficacy of 2 different acute traumatic brain injury (TBI) rehabilitation approaches: cognitive didactic versus functional-experiential, and secondarily to determine relative efficacy for different patient subpopulations. Design: Randomized, controlled, intent-to-treat trial comparing 2 alternative TBI treatment approaches. Setting: Four Veterans Administration acute inpatient TBI rehabilitation programs. Participants: Adult veterans or active duty military service members (N=360) with moderate to severe TBI. Interventions: One and a half to 2.5 hours of protocol-specific cognitive-didactic versus functional-experiential rehabilitation therapy integrated into interdisciplinary acute Commission for Accreditation of Rehabilitation Facilities–accredited inpatient TBI rehabilitation programs with another 2 to 2.5 hours daily of occupational and physical therapy. Duration of protocol treatment varied from 20 to 60 days depending on the clinical needs and progress of each participant. Main Outcome Measures: The 2 primary outcome measures were functional independence in living and return to work and/or school assessed by independent evaluators at 1-year follow-up. Secondary outcome measures consisted of the FIM, Disability Rating Scale score, and items from the Present State Exam, Apathy Evaluation Scale, and Neurobehavioral Rating Scale. Results: The cognitive-didactic and functional-experiential treatments did not result in overall group differences in the broad 1-year primary outcomes. However, analysis of secondary outcomes found differentially better immediate posttreatment cognitive function (mean ± SD cognitive FIM) in participants randomized to cognitive-didactic treatment (27.3±6.2) than to functional treatment (25.6±6.0, t 332=2.56, P=.01). Exploratory subgroup analyses found that younger participants in the cognitive arm had a higher rate of returning to work or school than younger patients in the functional arm, whereas participants older than 30 years and those with more years of education in the functional arm had higher rates of independent living status at 1 year posttreatment than similar patients in the cognitive arm. Conclusions: Results from this large multicenter randomized controlled trial comparing cognitive-didactic and functional-experiential approaches to brain injury rehabilitation indicated improved but similar long-term global functional outcome. Participants in the cognitive treatment arm achieved better short-term functional cognitive performance than patients in the functional treatment arm. The current increase in war-related brain injuries provides added urgency for rigorous study of rehabilitation treatments. ( http://ClinicalTrials.gov ID# NCT00540020.) [Copyright &y& Elsevier]

Abstract: Kim BJ, Date ES, Derby R, Lee SH, Seo KS, Oh KJ, Kim MJ. Electromyographic technique for lumbar multifidus examination: comparison of previous techniques used to localize the multifidus. Objectives: To verify and compare established techniques for needle localization in the multifidus muscle and to explore more practical techniques. Design: Human cadaver study. Setting: Anatomy laboratory in a university setting. Cadavers: Six fresh human cadavers. Intervention: A 22-gauge needle was inserted into the multifidus muscle fascicle of 6 cadavers using 2 different techniques described previously in the electrodiagnostic literature by Haig and Stein and colleagues. A mixture of colored latex and contrast dyes (0.1mL) was injected bilaterally into each fascicle at levels L1 to L5. Two electromyographers performed injections into 60 targeted muscles, affording 120 total insertions. Separate investigators dissected the muscles to determine dye position. Main Outcome Measures: Not applicable. Results: A total of 88 (73%) and 79 (66%) injections were successfully delivered to the targeted multifidus muscles using the Haig and the Stein techniques, respectively. With the Haig method, 22 injections (18%) were delivered to different superficial muscles. With the Stein method, 24 injections were delivered to a common tendon and 3 injections were delivered to the spinal canal. Conclusions: This study highlights the nonoptimizing accuracy of previous techniques for multifidus needle electromyography. A modified Haig method involving less acute needle angulation relative to the skin surface and closer insertion from the midline may increase accuracy and safety. [Copyright &y& Elsevier]

Abstract: The affect of muscle length and voluntary contraction upon compound muscle action potentials (CMAPs) in subjects with carpal tunnel syndrome (CTS) has been evaluated. Twenty-five hands in a CTS patient group and 29 hands in a normal subject control group were studied. The CMAPs from the abductor pollicis brevis induced by median nerve stimulation at the wrist were obtained for five thumb positions: neutral, abduction for shortening with and without contraction, and adduction for lengthening with and without contraction. Upon muscle shortening with relaxation, CMAP duration decreased in both groups, whereas waveform amplitude increased in the control group and showed no significant change in the CTS group. Muscle shortening with contraction afforded decreased CMAP duration and increased CMAP amplitude in both groups. Upon muscle lengthening with relaxation, both groups showed a reduction in CMAP amplitude and an increase in CMAP duration. Upon lengthening with contraction, CMAP duration decreased in the control group; in contrast, the CTS group showed further amplitude reduction and the waveform duration returned to the neutral value. These results demonstrate that, in patients with CTS, physiologic CMAP summations by muscle shortening or contraction may be less effective, whereas decreases in amplitude and increases in duration may be accentuated by lengthening and contraction. [Copyright &y& Elsevier]

Abstract: Background context: Lumbar discography has been widely used to evaluate discogenic low back pain. Anecdotal evidence suggests that pain reproduction during discography is more closely correlated with peak dynamic pressure than with static postinjection pressure. Although there can be a significant difference between dynamic and static pressures, to date most discographic evaluations use static pressure recorded postinjection (which is stable and easily measured). The use of readings taken after injection, rather than readings of maximum dynamic peak pressure recorded during injection, appear to increase false positives in lumbar discography. High-speed intradiscal injections also appear to have potentially confounding effects that may increase the rate of false-positive responses during lumbar discography. To date there has been no study for the evaluation of peak dynamic intradiscal pressures or for differentiating dynamic from static pressures in the nucleus pulposus (NP) in response to various speeds of intradiscal injection. Purpose: The goal of this study was to obtain additional data on potential confounding factors that could affect discographic results by assessment of pressures within the NP during discography at various injection speeds. The purpose of data collection was to more precisely evaluate pressure differences between dynamic and static pressure within the NP, evident during discography. Study design: In vitro laboratory study. Samples: A total of 82 trials were performed on intervening discs of 82 porcine cadaver lumbar spines. Methods: Dynamic and static intradiscal pressures were measured with manometry, using two pressure sensors simultaneously during intradiscal injection of contrast media at various speeds. The tip of a 25-gauge needle was placed in the center of the NP and connected with a pressure manometer, which recorded the pressure and therefore the speed of injection. A second pressure reading was obtained using a sensor tip connected to a transducer; the sensor tip was located separately in the same NP tissue. The needle and transducer locations were confirmed by fluoroscopy. Outcome measures: At low controlled injection speeds (below 0.08 mL/s), the mean peak pressure difference in the NP was 4.06 (±1.52) psi. With high-speed injections of 0.08 mL/s or greater, the mean increased abruptly up to 14.52 (±4.11) psi (p<.05). The data indicate that injections applied slowly resulted in smaller differences in pressure within the NP, registered by both manometry and the needle sensor tip. Additional samples were taken using both devices to confirm this threshold level. Results: With low injection speeds, especially those below 0.08 mL/s, differences between dynamic and static pressures on both pressure sensors were minor. These differences increased as injection speed became faster. However, at fast injection speeds of 0.08 mL/s and above, those differences were significantly higher. Conclusion: Dynamic and static intradiscal pressures are of similar value when measured by manometer and by needle sensor at slow injection speeds during discography. However, the pressure differences appeared to rapidly increase in response to incremental increases in injection speed. The data from these 82 samples suggest that uncontrolled high speeds of intradiscal injections are a potential confounding factor, which may increase false-positive responses during lumbar discography. [Copyright &y& Elsevier]