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Objectives Hyper-Acute Rehabilitation Units (HA-RUs) provide multidisciplinary rehabilitation to patients with acute neurological injuries. This includes managing patients with tracheostomies. This is the first study of its kind to examine clinical outcomes in patients with brain injury and tracheostomy managed in a HARU. Methods Retrospective analysis of clinical outcomes in tracheostomy patients admitted to a HARU over a 2-year period. Results A total of 208 patients were admitted to the HARU, of whom 99 (60 males and 39 females) had a tracheostomy either at admission or during their stay in the HARU. Mean Glasgow Coma Scale score at admission was 11 (range 5-15) and at discharge was 13 (range 8-15). Mean Functional Independence Measure and Functional Assessment Measure (FIM+FAM) score improved from 52 at admission to 95 at discharge. Mean FIM+FAM cognitive admission cognitive sub-score improved from 23 to 42, and mean motor sub-score from 29 to 42. Changes in scores were deemed to be clinically significant as per thresholds reported in the literature. Of the total patients in this study, 79% were successfully decannulated and 21% needed long-term tracheostomy. Conclusion Patients with tracheostomy following brain injury can be appropriately managed in a HARU and show clinically significant improvement in functional outcomes. LAY ABSTRACT A Hyper-Acute Rehabilitation Unit (HARU) provides rehabilitation to patients with sudden neurological injury, such as traumatic brain injury or stroke. In order to maintain a safe airway some of these patients have an artificial tube inserted into the trachea through an opening in the neck. This procedure is called a tracheostomy.This study analysed outcomes in tracheostomy patients admitted to a HARU over a 2-year period. A total of 208 patients were admitted to the unit, of whom 99 had a brain injury and had had a tracheostomy, either at admission or during their stay in the HARU. Functional activity, measured using Functional Independence Measure and Functional Assessment Measure (FIM+FAM) scales, showed significant improvement in both physical and mental ability in these patients. The tracheostomy tubes were removed successfully in 79% of patients as they became more independent and able to maintain their airway. However, long-term tracheostomy was needed in 21% of patients. This study shows that patients who have a tracheostomy following an acute neurological injury can be managed appropriately in a HARU and improve in functional ability.

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.