Abstract
Rehabilitative Approach to Patient Needing Intrathecal Baclofen Therapy for Severe Spasticity
Mario Loffredo
Amana Healthcare Medical & Rehabilitation Hospital
Objective. Describe the multidisciplinary approach to treatment of patients with severe spasticity in a postacute rehabilitation setting, considering both a quantitative model as well as the functional impacts. Methods. Overview of spasticity and sequelae in patients post–neurological diseases/injuries such as spinal cord injury, stroke, and brain injury. Describe processes for completing a multidisciplinary assessment, including physical medicine and rehabilitation, physiotherapy, occupational therapy, speech language therapy, and rehabilitation nursing. Discuss ways to use the assessment results to implement an effective multidisciplinary treatment plan. Describe use of intrathecal baclofen in treatment of severe spasticity.
Swallowing and the Impact of Stroke
Apoorva Pauranik
MGM Medical College & M.Y. Hospital
Stroke is the most common cause of dysphagia in the elderly. The literature suggests that swallowing difficulties can affect 22% to 64% of the acute stroke population. Nearly half of all stroke patients aspirate early after the event. As many as 35% of the deaths that occur after an acute stroke are caused by pneumonia. Dysphagia following stroke is associated with many complications like aspiration pneumonia, malnutrition, dehydration, debilitation, fatigue, diminished quality of life, and increased length of stay in hospital. Given the high number of cases annually, and associated mortality, it is critical to identify the stroke patients that are at greatest risk for developing pulmonary complications. Prompt identification and treatment of dysphagia can have a positive impact on morbidity and mortality in the stroke population. As a result, it is critical to address dysphagia in the acute care setting. Dysphagia screening is one of JCAHO’s core performance measures for Primary Stroke Centers. To date, no swallowing screening tool has been universally accepted or recommended. Most of the swallowing screening tools have been developed for the stroke population. All, however, evaluate: level of alertness; presence of a communication deficit (dysarthria/aphasia); symmetry of face, tongue, and lips; presence of voluntary cough; ability to swallow own secretions (no drooling). The good news is that nearly half of the patients recover to their premorbid swallowing status within a week of the event. Up to 87% resume normal oral intake by 6 months after the event. In a recent systematic review, 15 articles were analyzed covering broad range of treatments that included texture-modified diets, general dysphagia therapy programs, nonoral (enteral) feeding, medications, and physical and olfactory stimulation. Across the studies there was heterogeneity of the treatments evaluated and the outcomes assessed that precluded the use of pooled analyses. Descriptively, these findings present emerging evidence that nasogastric tube feeding is not associated with a higher risk of death compared to percutaneous feeding tubes; and general dysphagia therapy programs are associated with a reduced risk of pneumonia in the acute stage of stroke.
Measures of Outcomes in Chronic Neurological Disability
Robyn Tate
Sydney Medical School
The importance of assessment in neurorehabilitation cannot be underestimated. Without assessment, we cannot accurately evaluate function in our patients and we cannot reliably determine whether change (improvement or deterioration) has occurred. It is therefore critical that clinicians and researchers know what assessment tools are available and how good they are. Advances in the clinical application of the International Classification of Function, Disability and Health (ICF; World Health Organization, 2001) have been facilitated by the development of Core Sets. These are available for a range of neurological groups, including stroke, traumatic brain injury and multiple sclerosis. Because Core Sets are specific to different health conditions, they provide a good guide regarding the areas of function that are important to evaluate in different conditions. The ICF Core Set for traumatic brain injury, for example, contains 139 categories in the Comprehensive Core Set and 23 categories in the Brief Core Set. The large number of categories in the comprehensive core set reflects the wide variety of body function impairments seen after traumatic brain injury, along with the diversity of outcomes in activity and participation domains. Instruments to measure function and outcome in neurological conditions are diverse and vast in number. In the area of traumatic brain injury alone, the systematic review of Tate, Godbee, and Sigmundsdottir (2013) identified 728 unique instruments reported in the literature in the past 10 years. In our systematic review, of the 693 instruments that evaluated concepts covered by the ICF, two-thirds (n = 466) were (mainly) performance-based measures of body functions, and they linked to most of the 37 body function categories contained in the ICF comprehensive Core Set. By contrast, instruments addressing activities/participation (n = 109) and environmental factors (n = 22) identified in our review did not cover all categories contained in the ICF comprehensive core set. This presentation describes the way in which the ICF Core Sets can be used to identify the areas of function that need to be addressed in different neurological conditions and uses the example of traumatic brain injury to examine the scope of measuring instruments that are available and useful for clinical practice and research.
Management of Neuropathic Bladder in Children
Alan Dickson
Royal Manchester Children’s Hospital
The majority of neuropathic bladder disease in children is secondary to neural tube defects, particularly open myelomeningocele. The clinical effects of neuropathic bladder in children are incontinence, urinary tract infection, and most important, kidney damage. Kidney damage may occur in the first year of life. The management of neuropathic bladder begins therefore in most children after birth. Intermittent clean intermittent catheterization is instituted along with anticholinergic therapy. Bladder and renal surveillance commences in the first year of life. This includes at least annual ultrasound, urodynamics, and DMSA (dimercaptosuccinic acid) scans as indicated. Most children with neuropathic bladder will require management of detrusor dysfunction, sphincter incompetence, and urinary infection. Bowel management for constipation and soiling is an integral part of bladder management as well. The mode of management for each child is patient specific as they grow up dependent on their needs and disability level. The use of pharmacological agents and surgical procedures will be discussed. Learning Points: 1. Clinical effects of neuropathic bladder in children; 2. Assessment of neuropathic bladder in children; 3. Medical and surgical management of neuropathic bladder in children.
Telerehabilitation: Does It Work in Neurorehabilitation?
Paolo Tonin
Hospital San Camillo
Learning Objectives. (1) To supply neurologists, PRM (physical and rehabilitation medicine) specialists, motor therapists, and speech therapists with up-to-date information on clinical opportunities offered by telerehabilitation. (2) To underline the specific difficulties that emerged from recent experiences on telerehabilitation. (3) To suggest the future directions of telerehabilitation.
The Management of Spasticity
Nirmal Surya
Surya Neuro Center
Spasticity is a common and disabling symptom, particularly after stroke or traumatic brain injury but also in the context of neurodegenerative diseases, such as multiple sclerosis. The treatment is always multidisciplinary. Spasticity is a dynamic phenomenon that will vary according to medication, time of day, seating, positioning, etc. Thus, often a prolonged period of observation is required to determine trigger factors and plan an adequate treatment strategy. Often spasticity will not need treatment. If treatment is needed, then the first line is often antispastic medication. Baclofen is probably still the safest and most effective agent and doses could vary from 20 to 120 mg per day. Other alternatives are dantrium or tizanidine, of which tizanidine is used more frequently in doses of 12 to 14 mg per day. Dantrolene can cause muscle weakness and is less popular. Other agents are less useful but there is emerging evidence of the usefulness of cannabis as an antispastic agent. Old drug diazepam could be useful in spasticity as it is very cheap. All the drugs cause sedation in optimal doses and that is the point which limits the uses in higher doses. Most spasticity is focal in origin and thus may benefit from focal treatment. The focal treatment of choice is now botulinum toxin. This is a very effective and safe antispastic agent, which is easy to administer and virtually free of side effects. However, its main disadvantage, particularly in the developing world, is expense and the fact that the treatment needs to be repeated at roughly 3 monthly intervals. An alternative focal treatment to botulinum is phenol nerve blocks, which are more difficult and cumbersome to administer but nevertheless this treatment is much cheaper. The phenol block also gives rise to permanent changes and hence needs to be given carefully. Use of intrathecal baclofen, which is also an effective antispastic agent but obviously requires surgical intervention, is a good option for severe spasticity, particularly in para or quadriparesis. It’s not free of operative and postoperative complications. Other surgical techniques can be used, such as selective dorsal rhizotomy. Overall, there are now a number of modern techniques that can alleviate the troublesome and often painful symptom of spasticity but the assessment and treatment should always remain multidisciplinary. Proper management could change the life of person with disability; selection of appropriate mode of anti spastic treatment is the challenge for rehab specialists.
Cerebral Palsy: Rehabilitation Needs of a Growing Child
Martin Staudt
Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children & Adolescents
Children with early brain damage resulting in cerebral palsy must be expected to experience difficulties not only in motor development but also concerning other aspects of development (eg, sensory, visual, cognitive, or language development). These can eventually result in long-term restrictions in body functions, activities, and participation. Because of developmental neuroplasticity, children with cerebral palsy have a—sometimes considerable—potential to minimize these restrictions. The aim of all medical and rehabilitative efforts must therefore be to optimize the developmental potential of these children. This can only be achieved with a multidisciplinary, “comprehensive” approach looking regularly and in an age-specific manner at all aspects of development and participation throughout childhood and adolescence. In the first phase, a firm diagnosis of cerebral palsy must be established (by excluding cerebral palsy “mimics” like neurotransmitter disorders or neurodegenerative diseases), and for this, magnetic resonance imaging (MRI) is a crucial investigation. MRI also helps in establishing an early prognosis, and adds to clarify the etiology of the lesion and its “timing.” This information must then be communicated with the parents. Functional therapies like physiotherapy (focusing on motor development) and occupational therapy (focusing on age-appropriate activities and participation) should start early, and be performed either continuously or as intensive “blocks” of therapies in specialized centers. In severe cases, swallowing therapy should be performed, and sometimes, a safe way of tube feeding must be established. In less severe cases, speech therapies can facilitate the development of communicative skills, ranging from speech therapy to computer-aided assisted communication devices. Rehabilitation must often be accompanied by pharmacological agents like Botulinum toxin injections, systemic antispastic medication or drugs acting against dyskinesias. Complications like hydrocephalus, epilepsy, hip dislocations, scoliosis or joint contractures must be identified and treated early, because these can severely reduce the efficacy of all therapeutic efforts. For all these medical and therapeutic efforts, it is of utmost importance that they are performed regularly, throughout childhood and adolescence, since with ongoing development and with a growing musculoskeletal system, an optimal therapeutic approach at one time is often far from optimal a year later, or early signs of complications can become visible.
Neurological Disabilities in Children in the Middle East
Mario Patricolo
Al Noor Hospital
The impact of neurological disabilities on the life of newborns, children, and young adults is enormous. The disabilities spectrum varies largely and has multifactorial etiopathogenesis, with the most frequent cases being due to perinatal issues (asphyxia, oligohydraminios, maternal infections, etc), or congenital anomalies of the central nervous system as well as metabolic disorders. In the Middle East, the numbers of detected cases and their incidence are higher than in the Western countries, as a consequence of several etiopathogenetic, cultural, and religious reasons. For example, not all families are inclined to expose severe health conditions of one of their offspring, may not use preventive measures during pregnancy (eg, folic acid) due to lack of awareness, or may have a higher risk of congenital anomalies as a consequence of a more frequent occurrence of consanguineous marriages. Moreover, voluntary interruption of pregnancy does not occur in the majority, if not all, the Middle Eastern countries. This results in an increased number of live births of children with congenital anomalies or conditions. Cerebral palsy, limb deformities, neurogenic bladder, neurogenic bowel, metabolic diseases, and so on, are only some of the identified conditions in our practice. Several aspects of postnatal and long-term follow up also differ from the clinical approach and patient-physician relationship, from the known equivalent situation of the Western countries (adherence to chronic medical treatment, attendance to follow-up appointment, and acceptance of invasive investigation), reluctance toward invasive home care procedures such as clean intermittent catheterization, antegrade colonic enema, or transrectal washouts. In this lecture, a list of most frequently identified neonatal or pediatric disabilities and the approach utilized to successfully overcome cultural, financial and religious differences, as well as the difference or lack of available resources, will be described and discussed interactively with the audience. Particular focus will be put on the complex management of bladder and bowel issues in children and young adults with disabilities. Take home messages will be provided to facilitate the day-to-day care of disabled children in our clinics and hospitals in the Middle East.
Robot Therapy and tDCS for Recovery of Movement in Stroke Patients
Caterina Pistarini
IRCCS Salvatore Maugeri Foundation, Pavia Institute
Robot therapy (RT) is based on the motor learning phenomenon (MLP) resulting from repetitive, task-oriented, and attention-demanding activities. Different neuromodulation techniques are based on the use of physical agents (electrical fields, magnetic field, etc) with the purpose to modulate central nervous system activities with a recovery attempt, generally for normalizing dysfunctional structures, implementing activity of injured areas, decreasing activity of areas, inhibiting injured ones, promoting neural repair and neuroplasticity. Aim. We present a study on the use of RT combined with transcranial direct current stimulation (tDCS) during rehabilitation protocols for the recovery of upper limb impairment in subacute stroke patients in order to evaluate its efficacy. Methods. We enrolled consequently stroke patients in the Neurorehabilitation Unit of S. Maugeri Institute of Pavia, Italy. Inclusion criteria were the following >18 years old and < 80 years old; ischemic stroke <3 months. Exclusion criteria were seizure, drug therapies changes, skull fractures, and others devices. The assessment included Fugl-Meyer Upper Extremities, Motor Power Score, Functional Independence Measure, through movement efficacy, movement accuracy, movement efficiency, movement smoothness. Timing of assessment: T0 (pre-tDCS); T1 (end of third week). Results. All patients performed (total period of 3 weeks, 5 times a week) standard daily motor rehabilitation plus 45 minutes of RT with randomly stimulation by tDCS/sham. Six patients underwent tDCS stimulation, 6 received sham. Our results indicated that RT and tDCS are safe and useful treatment techniques in both subacute and chronic phase of stroke; in particular, they improve dexterity, range of motion, smoothness, and functioning of upper limbs. Conclusions. Although the data collected are still few, it may show a trending improvement in patients undergoing robot rehabilitation in conjunction with tDCS that seems to have a greater impact on final motor outcome. Motricity index, range of movement, and RT assessment was performed.
Respiratory Care in Neuromuscular Disease
Imtiaz Khurshid
Linde Sleep & Respiratory Care Center
Respiratory muscles including diaphragm constitute the ventilatory pump on which the act of breathing depends. In most neuromuscular disorders, there is simultaneous respiratory muscle weakness of similar or even greater extent than to other skeletal muscles. Causes of neuromuscular weakness: cerebral cortex—stroke, seizure disorders, degeneration, neoplasm; brainstem/basal ganglia—stroke, postpolio syndrome, progressive bulbar palsy, Parkinson’s disease, multiple sclerosis; spinal cord—trauma, demyelinating disease, disk compression, multiple sclerosis; anterior horn cells—motor neuron disease, postpolio syndrome, amyotrophic lateral; neuromuscular junction myasthenia gravis, Lambert-Eaton syndrome, drugs (steroids, AChE sclerosis, spinal muscular atrophy, primary lateral sclerosis inhibitors); myopathies muscular dystrophies, glycogen storage disease, polymyositis, dernatomyositis, other myopathies. Major respirator problems in patients with neuromuscular disease: pneumonia—aspiration; diurnal ventilation failure; sleep disordered breathing. Aspiration pneumonia—Caused by oropharyngeal muscle weakness, gastric reflux, and cough insufficiency. Aspiration risk factors: Head-end elevation <30°, use of sedatives/opioids, low Glasgow Coma Scale score, that is, <9, gastric residual volume (>200 cm3), gastroesophageal reflux/vomiting. Diurnal ventilatory failure: Respiratory symptoms are often initially absent or minimal because of the large reserve of the respiratory system. Respiratory muscle involvement may also be masked because patients with skeletal muscle weakness spontaneously decrease their overall activity level, thereby reducing the daily physiologic challenge faced by the respiratory system. For all these reasons, it is not unusual for respiratory muscle weakness to go undetected until overt respiratory failure is precipitated by an acute episode of pulmonary aspiration or infection. Evaluation. Symptoms and signs—unexplained dyspnea on exertion, orthopnea, recurrent cough, choking; objective tests; nocturnal pulse oximetry; forced vital capacity (FVC); sniff nasal inspiratory pressure (SNIP); arterial blood gases. Treatment. Noninvasive positive pressure ventilation (NIPPV)—indications: acute respiratory failure secondary to chest infection, perioperative support/peg tube placement, hypercapnic chronic respiratory failure, sleep-disordered breathing, during pregnancy, palliate symptoms. Long-term ventilation—tracheostomy care (TRACHE): tape—keep tube position secured; resuscitation—know the resuscitation process; airway clear—use correct suction technique; care of the site—care of stoma and neck; humidity—essential to keep tube clear; emergency kit—have the kit ready. Obstructive sleep apnea (OSA) in patients with neuromuscular disorders: Higher incidence of OSA in patients with neuromuscular disease; need high index of suspicion for OSA in these patients; polysomnography (PSG) is the test of choice for diagnosis of OSA; NIPPV (CPAP/bilevel) is recommended if PSG is positive for OSA.
Electronic Assistive Technologies: A View From the Developing World
Aejaz Zahid
Mada–Qatar Assistive Technology Center
According to the World Health Organization, it is estimated that around 80% of the disabled population of the world live in developing countries. Electronic assistive technologies, on the other hand, are frequently produced in industrialized nations, where the cost of labor is relatively high and the markets are relatively small, making these technologies prohibitively expensive for the developing world. However, even if costs were compensated for, numerous other challenges relating to for example, infrastructure, professional training and technical support, and so on exist, which compound the issues that make it more and more difficult for persons with disabilities in developing countries to have access to the assistive technology they need to fulfill their goals. This presentation will highlight some of these challenges and discuss potential solutions through case studies on new assistive technology services that have been established in countries where previously no such services existed.
Effect of Cognitive Impairments on Ipsilateral Hand Performance Following Acute Stroke
Tarun Ramachandran
Hamad Medical Corporation
Objective. In this correlation study, relationship between cognitive impairments and ipsilateral hand performance in function activities after acute stroke was investigated. Method. Ten subjects were assessed following acute stroke on LOTCA (Loewenstein Occupational Therapy Cognitive Assessment) for cognitive abilities. Ipsilateral hand performance in functional activities was assessed in dressing; bean spoon test and manipulation of lock were done to see the ipsilateral hand performance after stroke. Result. A Spearman’s correlation showed significant correlation of r = 0.79, P = .01 between total LOTCA scores and ipsilateral hand performance. A significant correlation of r = 0.72, P = .01 was seen between cognitive impairments and bean-spoon test. A significant correlation of r = 0.78, P = .01 was seen between cognitive impairments and lock manipulation. No significant correlation was seen with dressing. Conclusion. From the study it can be concluded that cognitive impairments influence ipsilateral hand performance in functional activities following acute stroke.
The Berg Balance Scale Is a Predictor of Functional Outcome and Length of Stay in Stroke Rehabilitation
Amjad Annethattil
Hamad Medical Corporation
Background and Objectives. The Berg Balance Scale (BBS) is a 56-point scale measuring balance developed by Katherine Berg (Berg et al, 1989). It has been shown to have strong internal consistency and high interrater and intrarater reliability in patients with stroke (Blum et al 2008). The objectives of this study are (1) to evaluate the clinical use of BBS in predicting functional outcome in stroke rehabilitation; (2) to evaluate the relationship of admission BBS and admission Functional independent measure motor (FIMM) with length of stay (LOSr) in rehabilitation unit. Method and Measurements. Design, prospective study setting; rehabilitation unit, Rumanian Hospital, Doha, Qatar; subjects, 61 males diagnosed with stroke. Period of study from January 2014 to June 2014. Measurement tools: BBS, FIMM, LOS, Motor Assessment Scale (MAS), 10-meter walk test. Result. Admission BBS score had a significant positive correlation with admission FIMM, MAS, and 10-meter walk test (r = 0.640; P = .000; r = 0.581, P = .000; and r = 0.419, P = .000). Discharge BBS showed a significant positive correlation with discharge FIMM (r = 0.769, P = .000), MAS (r = 0.813, P = .000), and 10-meter walk test (r = 0.272, P = .034). Admission FIMM had a significant negative correlation with LOS (r = −0.360, P = .004). Admission BBS score also showed negative correlation with LOS, which was statistically not significant (r = −0.265 and P = .039). Conclusion. Predictive value of BBS was proven for functional outcome on discharge but not for LOS. Our findings suggest that admission and discharge BBS are clinical indicators of rehabilitation outcome and admission FIMM was significant indicator to predict LOS in rehabilitation of stroke patients.
The Outcome of Severe Traumatic Brain Injury in Children in Qatar: Six-Year Study
Azhar Khattab
Hamad Medical Corporation
Introduction. Traumatic brain injuries (TBIs) remain one of the main public health problems in developing and developed countries. TBIs may produce severe illness resulting in significant morbidity, mortality, and economic loss and, in developed countries, they are an important cause of long-term disability. Aim. The aim of this study is to quantify the burden of severe TBI among young children in Qatar and to examine trends in the distribution of these injuries by gender, age, severity, mechanism, and to organize public health strategies to prevent TBIs. Methodology. This is a retrospective study that included subset of 65 children suffering from severe traumatic brain injury (12 of them died within the first month of admission) during the period between January 2007 and December 2013, among children aged <14 years. The study was conducted at the Children Rehabilitation Unit, Paediatric Department, Hamad General Hospital. Severity of TBI was assessed by Glasgow Coma Scale (GCS), severe TBI where Glasgow Coma Scale was ≤83. The TBI cases were obtained from the medical records and information collected included child’s age at the time of injury, gender, nationality, date of admission, date of discharge, and outcome. The study was approved by the Hamad Medical Corporation, Research Ethics Committee. Results. The predominant gender was males (73.8%), Qatari form 50.8% and the highest frequency was among children 6 to 10 years old. In our study, predominant mechanisms of injury were road traffic accidents (84.6%), then falls (10.8%). The results revealed that only 18.2% of TBI children had good recovery and 21.5% left with mild disability, 27.7% of hospitalized patients discharged home with severe disability, and 13.8% were still in hospital under vegetative state. Among our patients 43.1% had spasticity, 33.8% experienced posttraumatic epilepsy, 24.6% had communication disorder, 26.2% had poor cognition 24.6% had hemiplegia, 18.5% had abnormal behavior and the mortality rate was 18.5%. Conclusion. Traumatic brain injury is an important cause of death and disability in children in Qatar and in Arabian Gulf Countries as well. The evidence on effectiveness of child restraint systems, seat belts, and air bags in automobiles is very promising. Special efforts should be made to further reduce the motor vehicle accidents involving young people and welfare programs are needed to limit the risk of TBIs.
Fenestrated Tracheostomy Tube Followed by Speaking Valve Trials: A Step in the Decannulation Protocol
Nuzha Ishak and Sona Ayanikalath
Provita International Medical Center
The paper describes 2 patients with tracheostomies who were difficult to decannulate but were eventually decannulated after using a fenestrated tracheostomy tube followed by speaking valve trials. Both patients had a history of a cerebrovascular accident and were trachesotmized with Shiley size 6 cuffed tracheostomy tubes. They tolerated cuff deflation but not the speaking valve trials. When the standard tracheostomy tube was replaced by a fenestrated tracheostomy tube, the speaking valve was better tolerated and each patient was eventually decannulated. The fenestrated tube allowed the patients to get used to airflow through the oral cavity and to control breath holding. The use of a fenestrated tube is usually used to improve daily activities like coughing out secretions and use of verbal communication. The effectiveness of both these functions is enhanced with the use of a speaking valve. The use of a fenestrated tracheostomy tube as a step in the decannulation protocol might be worth trying in patients who are difficult to decannulate.
Spinal Cord Injuries in UAE: Retrospective, Demographic, and Overview Study of Patients Admitted and Managed in Neuro-Spinal Hospital, Dubai During Past 12 Years
Kaydar M. Al-Chalabi
Neuro-Spinal Hospital
Study Design. Retrospective demographic statistical analysis and overview of the concept of comprehensive management and rehabilitation in UAE. Settings. Neuro-Spinal Hospital, Dubai, UAE. Objectives. (1) Demographic statistical analysis of 232 patients (age, gender, nationality, etiology/nationality: UAE locals, Expats: Arabs and non-Arabs, levels and types of injuries, surgical and conservative management). (2) Overview of quality, concepts, status of comprehensive care, management, and rehabilitation in UAE. Patients. The number of spinal cord injured patients admitted in Neuro-Spinal Hospital during the period February 2003 until December 2014 was 232: UAE locals were 114 (49%), expats 118 (51%); males 176 (76%), females 56 (24%); tetraplegia 66 (28%), paraplegia 166 (71.5%). Age: 153 (66%) are younger than 40 years. Etiology: road traffic accidents 135 (58%), fall from heights 44 (19%), sport injuries 23 (10%), diseases 20 (8.5%). Surgical procedures (fixation, decompression laminectomy, excision, baclofen pumps, spinal cord stimulation, sacral roots stimulations, etc) were done on 140 patients (60%) while the rest were admitted for conservative treatment. These figures are as per total number of the group; however, for demographic purposes, they were subdivided into 3 main subgroups: UAE locals, Arab expats, and non-Arab expats, just to show the variations between them with regard to etiology, age, gender, and level and types of injuries. For example, RTAs among locals were 71%, while Arab expats 47% and 44% in non-Arab expats, and accordingly there are differences in the other variables. UAE is a country with multiple nationalities and according to 2013 population census 88.5% are expats while locals constitute only 11.5%. On the other hand, in UAE there are huge construction works, all kinds of sport activities, and high-speed modern vehicles. In each kind of work, the domain is from certain countries and each of them has different interests, hobbies as per their culture, habits, religion, traditions, and so on. Concept and status of spinal cord injury (SCI) management and rehabilitation in UAE differs from other countries where there are holistic SCI centers; such centers are not available, and for that reason it is very difficult to obtain national data or registry of such cases or incidence. Adding to that, patients usually receive their acute treatment and then disappear (return home), being unable to cover treatment costs and no insurance covers that for good. The government used to send the local people abroad to continue their treatment and rehabilitation after the initial acute management. We only see them afterward if there is a complication or for certain procedures. Conclusions. In spite of all modern life facilities, services, and high standard of health care whether governmental or private which are afforded by local emirates or federal governments for all people, locals or residents, the concept of SCI comprehensive care, management, and rehabilitation is still not coping with the international standards. No national data about incidence, impact, and awareness of such issue can be obtained or retrieved and there is no SCI center per se either in the capital, Abu Dhabi, or in the other emirates.
Occupational Therapy’s Role in Neurological Rehabilitation
Mahomoud Alshaikh
National Program for Children Developmental and Behavioral Disorders in Maternity and Children Hospital
Purpose. To increase the awareness in Arabic countries about occupational therapy’s role in rehabilitation of neurological disorders by focusing on services that occupational therapists offer for people with neurological disorders.
The First Stroke Unit With Dedicated Rehabilitation Team in UAE: Seven Years’ Experience
Ali Hassan
Al Ain Hospital
Introduction. Organized stroke inpatient care in a multidisciplinary setting (stroke unit) has a positive impact on reduction of mortality, dependency, and improves outcome of stroke patients. Al Ain is the second largest city in the Emirate of Abu Dhabi, with a population of 568 229. Al Ain Hospital has the first and only stroke unit in Al Ain and Abu Dhabi since 2007. The Stroke Unit rehabilitation team includes neurologists, physiotherapists, occupational therapists, speech and language pathologists, clinical neuropsychologists, case managers, dieticians, and nurses, with rehabilitation areas adjacent to the stroke unit. Aims. We aim to elaborate on our experience so other centers can take a head start from us for opening further stroke facilities in the region. Methods. We looked at the Stroke Unit database over the past 7 years and observed patient characteristics, stroke subtypes, risk factors, and outcomes. Results. We admitted 2152 patients, of various ethnic origins, until end of October 2014. There were 27% Emirati/Omani, 22% Arabs, 48% Asians, and 3% patients of other nationalities. I all, 75.6% were male, and 39% were <50 years old. Ischemic stroke patients were the most common type seen (61%), followed by hemorrhagic stroke (14%); and transient ischemic attacks accounted for 13% of patients. Stroke mimics were 13%. Overall, 77.53% were discharged with modified Rankin Scale (mRS) score of ≤2, mortality was 3.5%. A total of 57% were hypertensive, 38% diabetes mellitus, 19% smoking, 19% hyperlipidemia, and 16 % with cardiac diseases. For the rehabilitation, we have a planned weekly multidisciplinary team meeting. All patients admitted to stroke unit are referred to the rehabilitation team. Patients are usually seen within 24 hours after admission. Initial evaluation is conducted by the entire rehabilitation team to assess the treatment needs of the patients. All members of the multidisciplinary team should take all assessments and recommendations from other therapists into consideration/account when planning and delivering treatment, so as to provide optimal care. Multidisciplinary assessment will cover the following aspects: dysphagia, motor function, sensation, tone, vision, cognition and perception, communication, mood, mobility and balance, upper limb activity, activities of daily living, respiratory function, equipment needs, and education requirements. We had a KPI for each patient, including referral to the rehabilitation team. Conclusion. Stroke unit is essential for every hospital in this region and a dedicated team should look after these patients to improve morbidity and mortality. Hypertension was the most common risk factor. Patient outcome was excellent. Intravenous thrombolytic therapy was successfully implemented. Rehabilitation team with multisubspecialists is a very important part of the stroke team and is a gold standard for improving the outcome of the patients.
Factors Influencing Early Arrival of Acute Stroke Patients to Emergency Department in Saudi Arabia
Fatimah Alibrahim
Physical Medicine and Rehabilitation Department, King Abdulaziz Medical City
Background. Tissue plasminogen activator (t-PA) within 4.5 hours of onset is effective in acute ischemic stroke. However, small proportion of patient received such therapy mainly due to delayed presentation to emergency department (ED). This study aimed to examine the extent of and factors associated with prehospital delays after acute stroke in Riyadh, Saudi Arabia. Methods. We conducted a cross sectional survey at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia from November, 2012 to April, 2013. A convenient sample of consecutive acute stroke patients admitted through ED was selected. A self-administered questionnaire by patient (or relative, if communication was impaired) was used to explore the reasons of delayed arrival to the hospital. The study was approved by the local institutional review board. Results. Of the 229 patients enrolled, 68% were men and the mean age was 60.4 ± 15.6 years. Stroke risk factors were diabetes (61%), hypertension (71%), dyslipidemia (35.8%), cigarette smoking (28.4%), previous stroke (20.5%), physical inactivity (69.6%), heart diseases (25.3%), and family history of stroke (15.7%). Nearly 12% had some form of disability (motor, visual, language, or other) prior to stroke. The acute stroke symptoms and signs were mainly motor weakness (77.3%), speech difficulty (63.7%), dizziness (35.8%), altered level of consciousness (22.7%), visual problem (17.9%), headache (15.7%), and vomiting (21%). The median hospital arrival time was 4 hours and 54.6% arrived late (3.5 hours from symptoms onset). In bivariate and multivariate analysis, living within the city of Riyadh, non-Saudi nationality, using ambulance, knowledge of stroke signs, knowing the Red Crescent number and having companion were predictors for early arrival. The most common reasons for late arrival were lack of stroke recognition (41%) and difficulty accessing care (19.4%) while others did not have a clear reason for delay. Conclusion. More than half of stroke patients might miss the golden hours for thrombolysis due to delayed presentation to ED. Reasons include lack of knowledge, underuse of ambulance, and difficult access to care. Urgent community-based intervention is recommended.
Effectiveness of Virtual Reality in Frontalis Muscle Retraining Following Facial Palsy: A Pilot Analysis
Ajimsha Sharafudeen
Hamad Medical Corporation
The loss of facial expression via facial paralysis is a devastating condition, both functionally and aesthetically. However, given the lifelong plasticity of the brain, one could assume that recovery could be facilitated by the harnessing of mechanisms underlying neuronal reorganization. Currently, it is not clear how this reorganization can be mobilized. Novel technology-based neurorehabilitation techniques hold promise to address this issue. In this paper, an immersive Virtual reality (VR)–based system is presented that is based on a number of hypotheses related to the neural structures targeted for recovery/reorganization, the structure of training system, and the role of individualization. The purpose of this paper is to examine the effects of an immersive type VR intervention on activation of facial upper quadrant muscles following facial palsy in comparison with a control program. The key components of an immersive VR–based system and its effectiveness on facial palsy rehabilitation have been described in the form of experimental findings. Experimental trial was performed on 3 individuals with facial upper quadrant muscles weakness due to facial palsy in a crossover study methodology with and without VR. Electromyography (EMG) patterns from the facial upper quadrant muscles were recorded and analyzed for results. This trial has plotted a positive relationship between VR and facial upper quadrant muscles activation following a neurological impetus. The results reported here also show a consistent transfer of movement kinematics between physical and virtual tasks. EMG analysis has shown progressing improvement in the muscle activation in response to the challenging and impulsive activities in the virtual environment provided by the immersive VR device.
Cultural Influences on Stroke Physical Therapy in Qatar: An Exploratory Analysis
Ajimsha Sharafudeen
Hamad Medical Corporation
Purpose. The aim of this study was to investigate the perceptions of physiotherapy professionals who treat stroke patients regarding cultural influences on the experience of stroke rehabilitation in the state of Qatar. Physiotherapy professionals interviewed were from a variety of cultural backgrounds thus providing an opportunity to investigate how they perceived the influence of culture on stroke recovery and physiotherapy in Qatar. Method. A descriptive qualitative exploratory research approach was used for the study. Semistructured interviews were carried out with 23 physiotherapy professionals with current/recent stroke physiotherapy experience meeting the inclusion criteria from the Department of Physiotherapy, Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar, followed by thematic analysis of the verbatim transcripts. Results. The physiotherapy professionals identified several features of the Qatari culture that they believed affected the experiences of stroke patients. These were religious beliefs, family involvement, lack of awareness regarding expected outcomes and use of physiotherapy, limited education and public information about stroke, prevailing negative attitudes toward stroke, depression and loss of hope, social stigma and the public invisibility of disabled people, difficulties in identifying meaningful goals for physiotherapy, lack of patient and family centeredness, and an acceptance of dependency linked with the widespread presence of maids and other paid assistants in most Qatari homes. The key features identified for non-Qatari populations are insecurity, financial burden, social isolation, and emotional isolation. The anxiety of the future, lack of family support, fear of unemployment and repatriation worsens the scenario for those staying in group accommodations. Majority of the non-Qatari population wants a complete recovery and participates heavily in physiotherapy practice in order to resume back to their jobs as early as possible. Conclusion. To offer culturally sensitive care, these issues should be taken into account during the provision of physiotherapy for Qatari stroke patients in their home country and elsewhere. Implications for Rehabilitation. Physiotherapy professionals need to tailor therapy to the patient’s and family’s model of rehabilitation, which may vary with their cultural background. Physiotherapy professionals may need to be mindful that the presence of house maids and privately hired nursing staff may decrease the motivation of people to engage in physiotherapy after stroke. Cultural variations in degree of family involvement, prevailing negative attitudes toward stroke, and acceptance of dependency should be taken into consideration by stroke physiotherapy professionals.
Conservative Treatment of Spastic Contractures: Overview of Scientific Literature
Suad Trebinjac
Rashid Hospital
Contractures are defined as a fixed resistance to passive stretching of a joint due to shortening or wasting (atrophy) of muscle fibers, tendons, or the development of scar tissue (fibrosis) of the joints. They are very common in neurological disorders. Incidence of contractures in craniocerebral trauma patients is around 84%. Deleterious consequences of nontreated contractures are witnessed in clinical practice. They are in the domain of physical functioning, hygiene maintenance, development of secondary complications (eg, pressure source), low self-esteem, and so on. Conservative treatment of spastic contractures include stretching of the tendons and muscles, range of motion exercise, splinting, serial casting, management of spasticity (botulinum toxin), and electrical stimulation. Selected scientific literature, including controlled randomized studies and clinical trials investigating efficacy of stretching, splinting, and serial casting will be presented. Importance of prevention of development of contractures as a most efficient strategy will be particularly highlighted.
Sit-to-Stand Activity Analysis in an Elderly Population: Role of Length of Thigh Supports and Knee Angles and Biomechanical Implications for Neurological Rehabilitation
Ramprasad Muthukrishnan
Gulf Medical University
Introduction: “Sit to stand” is one of the most commonly executed functional activities and vital prerequisite for an upright mobility and gait rehabilitation. This study was focused to find the effect of different thigh supports and different knee angles during sit-to stand (STS) activity in an elderly population. Materials and Methods. Fifteen elderly subjects between the age of 50 and 70 years participated in the study. The STS activity was performed in 25%, 55%, and 85% of thigh support with 80° and 90° knee angles. Electromyography (EMG) activity of tibialis anterior (TA) and ground reaction force (GRF) using force-plate were recorded. Results. Analysis of variance with repeated-measures statistic was used and from the significant results following inferences were drawn: (a) Higher TA activation was observed with higher knee angles and lowest thigh support, that is, 90° angle with 25% thigh support (P < .05). TA activity significantly reduces as increase in thigh supports progressed into 55% and 85%. (b) GRF generation was significantly influenced by different thigh supports and different knee angles. GRF shows peak values during the application of 85% of the thigh supports and reduces as the thigh support decreases (P < .05). Conclusion. During STS, initially 25% of thigh support can be used with 80° and 90° knee angles as this position reduces loading and facilitates TA activity. Further STS progression can be made by using 55% and 85% of thigh supports with 80° and 90° knee angles. These biomechanical progressions can be applied in posture and gait rehabilitation particularly on stroke patients where targeting TA can facilitate lower extremity motor recovery.
Leisure and Its Importance in Neurological Rehabilitation: A Case Study
Rinta Peter Yuvaraj
Berlin Medical and Neurological Rehabilitation
Introduction. Despite leisure’s central position within occupational therapy models of practice, theoretical development from within occupational therapy remains limited. Historically, occupational therapy has viewed leisure as an occupational performance area, quantifiable and discretionary time, and as activity used to achieve clients’ targeted outcomes. The author has used gardening as a purposeful leisure activity and designed an equipment to improve the quality of life and the motivation of my patient, Mr X. Mr X had a road traffic accident following which he has an incomplete spinal cord injury at C3, C4, and C5 levels, and his functional abilities are limited. He had come to a plateau with his treatment. On assessment, it was found that he had keen interest in gardening. So this interest was tapped to improve my patient’s motivation and general outlook to life. The equipment is made from scrap materials from a fabrication and engineering unit based in UAE. Trial and error method was used. Conclusion. This innovative idea helped Mr X improve his mood. His general outlook has become positive. This has made him challenge his physical abilities to participate in more adventurous leisure activities.
Innovative Robotic Solutions for Neurological Disabilities
Paolo Badano
Genny Mobility SA
The speech will cover the following topics: historical evolution of technical solutions for neurological patients, impact of recent acceleration of technological advancement for neurological patients, social cost of current trends due to obsolescence of technical solutions, importance of good design for the integration of neurological patients, and a practical case—the role of self-balancing wheelchairs in neurological hospitals in Europe.
Botulinum Toxin in Pediatric Patients With Cerebral Palsy: Timing and Dosage
Visal Kantaratanakul
Samitivej Hospital Group
Botulinum toxin has proved to be useful in treatment of spasticity in children with cerebral palsy. The benefit was also demonstrated in both ambulatory and nonambulatory patients. According to WeMove, the dose is lower for Asian individuals than it is for those on the other side of the continent. This study aimed to evaluate the effects of low dose of botulinum toxin A (BTX-A) and timing of first treatment on spasticity and outcomes of training. This prospective study enrolled 28 Middle Eastern pediatric cerebral palsy (CP) patients (23 boys, 5 girls; mean age, 3.7 years) who were defined as ambulatory but still could not ambulate. Subjects were evaluated in baseline ross Motor Function Classification System (GMFCS; levels III and IV), Ashworth scale (II-IV), manual muscle strength (grade II-III), and both sides Goal Attaining Scaling (parent and therapist GAS). The average dose of injected BTX-A was 75 units (<7 units per kg body weight) and the average total amount of BTX-A injected at a single visit ranged from 50 to 100 U. Timing of first dose of injection was 98 days after starting of physical training. The results were compared with 12 Middle Eastern pediatric CP patients who could not get the BTX-A injection due to financial or denial reasons. The results revealed that study group demonstrated the changing of Ashworth Scale and GMFCS better than the control group significantly. GAS also favored the study group. The low dosage, low dilution and proper selection of injection time after vigorous training gains the same result as high dose from previous studies. This approach also could reduce the site and frequency of injection, including the antibody formation. Our study demonstrated that with very low dose, low dilution BTX-A injection and proper selective timing after vigorous training revealed the same results as convention dose and early BTX-A injection.
Rapael Smart Rehab Solution: Interactive Stroke Rehabilitation Device and Software
Seungyong Hong
Rapael
According to Ontario Stroke Rehabilitation Consensus Panel 2007, “Stroke rehabilitation is a progressive, dynamic, goal-oriented process aimed at enabling a person with an impairment to reach his or her optimal physical, cognitive, emotional, communicative and/or social functional level.” Task-oriented training has been widely accepted as the most effective approach to motor rehabilitation of upper extremity function after stroke with 3 specific principles: skill acquisition of functional tasks, active participation training, and individualized adaptive training. While these principles have been successfully addressed in the design of effective robotic rehabilitation systems, nowadays new emerging technologies have been consistently introduced and have more weapons to address these principles than the robotic systems. RAPAEL Smart Rehab Solution is the smart interactive rehabilitation system that can seamlessly realize the principles with the help of these technologies: heterogeneous devices that integrate multiple kinds of sensors and interfaces, behavior-changing software such as games and digital coaching, hyper connection technology, and big data–based analytics. RAPAEL Smart Rehab Solution is designed to induce neuroplasticity for hand function of patient with brain damage. In order to enhance rehabilitation of patients whose extremities are affected by lesions in the central nervous system (eg, stroke), they should practice task-oriented and task-specific tasks repetitively. However, the repetitive rehabilitation process easily decreases patients’ motivation and makes it hard to maintain optimal challenging difficulty and to induce neuroplasticity. RAPAEL Smart Rehab Solution applies the “learning schedule algorithm” to game-like exercises so that patients can remain motivated and can find the exercises gradually challenging. The learning schedule algorithm is designed to enhance learning multiple functional tasks by proposing an optimal task in proper challenging difficulty. Based on patient’s data such as training progress, prescription, personal interest, motor function scores, and so on, it computationally selects which game to play at which level of difficulty. In RAPAEL solution, a novel UI/UX (user interface/user experience) for task difficulty modulation process makes patients to understand how exercise progresses in real time. Hence, therapists no longer have to manually adjust the task’s level of difficulty in order to motivate patients. Moreover, objective evaluation of exercises and user-friendly reports on progress allow effective and efficient rehabilitation process management. According to the pilot clinical trial performed at Korea National Rehabilitation Center in 2014, it was also statistically proven that RAPAEL Smart Rehab Solution accelerates post-stroke patients’ neuroplasticity over conventional occupational therapies.