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Objectives Intrathecal baclofen (ITB) is a cost-effective therapy for patients with severe spasticity. The most common complications are catheter-related complications (CRCs) including kinking/occlusion, blockage, migration, fracture, disconnection, and CSF leak. Our objective was to determine the CRC rate in a large cohort of adults with newly implanted ITB pump systems with polymer reinforced silicone catheters. Materials and methods This is a retrospective study of a prospectively maintained database consisting of patients who had undergone implantation of ITB pump systems with Ascenda (Medtronic, Minneapolis) catheters from 2013 to 2020. Over this seven-year period, 141 patients underwent ITB pump system implantations; 126 of which had a minimum of one-year follow-up. Results The 126 patients with a minimum of one year follow-up (average 43 month; range 12-89), had an average age of 51 years (63% male). Severe spasticity was due to spinal cord injury (38%), traumatic brain injury (15%), cerebral palsy (13%), multiple sclerosis (11%), stroke (10%), and other (13%). Nine (7.1%) CRCs occurred in 7 (5.6%) patients (median 6 mo. post-implant): 5 intrathecal catheter occlusions (range 3-52 months post-implant), two fractures in one patient (6 months), one disconnection at the catheter pump interface (2 months), and one due to kinking at 84 months No migrations occurred. Conclusions Reported CRCs have been high for ITB pump systems. Ours is the first large cohort, long-term study of CRCs related to reinforced catheters; additionally, our low CRC rate compares favorably to previously published data. Thus, implantation of reinforced catheters may be associated with a low CRC rate.

The COVID-19 global pandemic has resulted in significant changes to delivery of care in the field of physiatry. Most prominently, in-person visits have fast tracked to virtual visits. As we are forced to quickly adopt this new technology for our doctor-patient interactions, many questions remain with regard to structuring telemedicine visits for optimal outcomes. Little has been written on virtual evaluations of patients with spasticity. The intent of this article was to provide a framework for conducting a virtual spasticity assessment via telemedicine. We will provide tips on how to conduct a person-centered virtual examination assessment and how to document goals related to the virtual assessment.

Entrustable professional activities have emerged as a means for the evaluation of resident competency that is expressed in terms of the assessed need for supervision. Recently, 19 physical medicine and rehabilitation-specific entrustable professional activities were published (Am J Phys Med Rehabil. 2017;96:762-764). The electrodiagnostic entrustable professional activity and six new electrodiagnostic entrustable professional activities subcategories (observable practice activities) were piloted as an entrustable professional activities/observable practice activities set within five residency programs. Survey-based (quantitative) and open-ended (qualitative) feedback was collected from participants. Participating attendings found this method feasible and generally reported satisfaction with the entrustable professional activities/observable practice activities as a means of providing feedback to residents. Residents were less clear on the added value of this approach. Qualitative data supported the need for adjustments to the entrustment scale to allow for more gradations within supervisory levels, a standardized orientation of residents to the use of observable practice activities and an increased quantity of assessments for each observable practice activities category to allow for demonstration of resident progress toward independence. Use of the electrodiagnostic entrustable professional activity/observable practice activities set shows promise as a means for observational competency assessment in the outpatient setting. However, feedback acquired through this pilot study suggests changes that could be made to improve future implementation.

This consensus paper is derived from a meeting of an international group of 19 neurological rehabilitation specialists with a combined experience of more than 250 years (range 4-25 years; average 14.1 years) in treating post-stroke spasticity with botulinum toxin A. The group undertook critical assessments of some recurring practical challenges, not yet addressed in guidelines, through an extensive literature search. They then discussed the results in the light of their individual clinical experience and developed consensus statements to present to the wider community who treat such patients. The analysis provides a comprehensive overview of treatment with botulinum toxin A, including the use of adjunctive therapies, within a multidisciplinary context, and is aimed at practicing clinicians who treat patients with post-stroke spasticity and require further practical guidance on the use of botulinum toxin A. This paper does not replicate information published elsewhere, but, instead, aims to provide practical advice to help optimize the use of botulinum toxin A and maximize clinical outcomes. The recommendations for each topic are summarized in a series of statements. Where published high-quality evidence exists, the recommendations reflect this; however, where evidence is not yet conclusive, the group members issued statements and, in some cases, made recommendations based on their clinical experience.

The COVID-19 global pandemic has resulted in significant changes to delivery of care in the field of physiatry. Most prominently, in-person visits have fast tracked to virtual visits. As we are forced to quickly adopt this new technology for our doctor-patient interactions, many questions remain with regard to structuring telemedicine visits for optimal outcomes. Little has been written on virtual evaluations of patients with spasticity. The intent of this article was to provide a framework for conducting a virtual spasticity assessment via telemedicine. We will provide tips on how to conduct a person-centered virtual examination assessment and how to document goals related to the virtual assessment.

BackgroundMedical professionals remain conflicted about the best rehabilitation protocol a patient should perform after rotator cuff repair surgery. Exercises deemed passive may be activating the shoulder muscles to a moderate level, thus putting the surgical repair construct at risk for re-injury. The purpose of this study was to measure the activation of the rotator cuff and surrounding musculature during exercises used in physical therapy following rotator cuff repair surgery using electromyography (EMG).MethodsMuscle activation was recorded in fourteen participants performing sixteen exercises. Four fine wire electrodes (supraspinatus, infraspinatus, subscapularis, teres minor) and six surface electrodes (upper and middle division of the trapezius, anterior, medial and posterior head of the deltoid, biceps brachii) were utilized. EMG activity values for each muscle were normalized to the maximum voluntary isometric contraction and activation levels were assessed.ResultsTwelve of the sixteen exercises tested were moderately active in the subscapularis muscle. The results show the subscapularis muscle was activated in all three planes of motion.DiscussionMost exercises were found to have low activation levels for the supraspinatus, infraspinatus and teres minor muscles. While the exercises examined in this study appear to be safe for the more commonly repaired supraspinatus, caution should be used when administering exercises to individuals with repairs involving the subscapularis.

Objective To determine the prevalence of prostate cancer in patients with chronic spinal cord injury (SCI), with regard to the duration, level, and severity of injury. Design Retrospective chart review study. Setting Inpatient and outpatient Veterans Affairs spinal cord unit. Participants The electronic medical records of 350 veterans with chronic SCI and 344 veterans without SCI as a control group were reviewed. Main Outcome Measure Prevalence of prostate cancer in patients with chronic SCI with regard to the duration, level, and severity of injury. Results Of 350 veterans with chronic SCI, 7 individuals (2%) had prostate cancer. In comparison, of 344 age-matched veterans without SCI, 18 (5.2%) had prostate cancer. In SCI group with prostate cancer, 2 patients had motor complete injury (American Spinal Cord Injury Association Impairment Scale [AIS] A and B), and 5 patients had motor incomplete injury (AIS C, D, and E). Patients with SCI and with prostate cancer were slightly older (mean [SD] age, 72.14 ± 8.25 years) than the control group (mean [SD] age, 69.83 ± 8.79 years) with cancer. Conclusion Findings from this study indicate a lower prevalence of prostate cancer among veterans with chronic SCI in comparison with age-matched veterans without SCI. Given the small number of patients with SCI and with prostate cancer in this study, we did not find any statistically significant correlation between the prevalence of prostate cancer and the level, duration, and severity of injury.

Stroke is one of the leading causes of adult disability in the United States, with a reported prevalence of 6.4 million people. Spasticity is one of the clinical features of the upper motor neuron syndrome seen after a stroke. The prevalence of spasticity after a stroke ranges from 17% to 42.6%, and an average of two-thirds of people with spasticity have upper and lower extremity involvement. Oral medications and botulinum neurotoxin injections are current treatments for problematic spasticity. However, these treatments are often limited by side effects or dose ceilings. Intrathecal baclofen (ITB) is a proven method for the management of disabling spasticity from multiple etiologies. Studies have demonstrated improved mobility, activities of daily living, and quality of life in spastic poststroke patients. Despite the benefits of ITB, fewer than 1% of stroke patients with severe disabling spasticity are being treated with ITB. This article will review the prevalence of severe poststroke spasticity and the rate of ITB use and will discuss reasons for its limited use in stroke survivors.