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BACKGROUND:Rehabilitation following severe Traumatic Brain Injury (TBI) often involves the use of temporary tracheostomies. Tracheostomy weaning is influenced by physiological parameters, which are abnormal in the concomitant complication of Paroxysmal Sympathetic Hyperactivity (PSH). OBJECTIVE:To investigate the association between PSH and tracheostomy weaning in severe TBI. METHODS:This was a retrospective cohort study of consecutive patients with TBI and tracheostomy admitted to a Hyper-Acute Neurorehabilitation Unit over a 34-month period. Duration of tracheostomy wean and influencing characteristics were statistically compared between those with and without PSH. RESULTS:Fifty-one patients admitted with TBI required a tracheostomy. Of these, 10 patients were also diagnosed with PSH. The mean tracheostomy wean in the PSH group was longer compared to the non-PSH group (72.3, SD 61.0 versus 30.0 days, SD 16.2). This difference was statistically significant (p = 0.007, using Mann Whitney U test). The PSH group had more respiratory and oral secretions, but this was not statistically significant (p = 0.16 and 0.29). CONCLUSIONS:This is the first study to demonstrate that PSH is associated with prolonged tracheostomy weaning in severe TBI. Awareness of this association should enable those planning rehabilitation to set realistic goals for a patient’s tracheostomy weaning programme.

To analyse whether the outcome of tracheostomy weaning is influenced by the site of injury in acquired brain injury.A retrospective case review of all the consecutive admissions to an acute neurorehabilitation unit in a 2-year period was performed. Patients with a diagnosis of acquired brain injury and tracheostomy in situ were included in this study.One hundred and six patients were included in the analysis. They were considered in two groups based on the site of brain injury: Group S, those with supratentorial brain injury only; and Group I, those with any injury with infratentorial involvement. Fifty-one (82%) patients in Group S were successfully weaned from the tracheostomy, compared to only 27 (61%) of patients in Group I. In other words, the proportion of unsuccessful weans (long-term tracheostomy) was 11 (18%) in Group S compared to 17 (39%) in Group I. The statistical significance of successful weans between the groups was p = 0.01 (Chi-square test). The common reasons for unsuccessful weaning were excessive secretion load and recurrent aspiration pneumonia.Patients with isolated supratentorial brain injury have a statistically significant higher chance of successful decannulation when compared to those patients with any infratentorial brain injury involvement.

This article provides an overview of the assessment and management of spasticity in multiple sclerosis (MS) patients from a practical clinical perspective. Spasticity is a significant factor contributing to pain and disability in patients who have MS. It can cause impaired function, painful spasms, deformity, and adversely affect the provision of care. The assessment and management of spasticity requires expertise, and the involvement of a multidisciplinary team. Treatment is primarily physical, and supplemented by pharmacological treatments, which can be systemic or focal. Management strategies should be goal directed, and targeted to the needs of the individual. The range of treatments commonly used, and the rationale for choosing specific treatments, is described in this article.

A 73-year-old diabetic presented with septic arthritis of the knee; Pseudomonas aeruginosa was isolated. She was successfully treated with a combination of parenteral and intra-articular ceftazidime, after failure to eradicate the organism with adequate serum levels of gentamicin and full doses of azlocillin.