Faculty Bibliography

Healthy individuals appear to use both vector-coded reach plans that encode movements in terms of their desired direction and extent, and target-coded reach plans that encode the desired endpoint position of the effector. We examined whether these vector and target reach-planning codes are differentially affected after stroke. Participants with stroke and healthy controls made blocks of reaches that were grouped by target location (providing target-specific practice) and by movement vector (providing vector-specific practice). Reach accuracy was impaired in the more affected arm after stroke, but not distinguishable for target- versus vector-grouped reaches. Reach velocity and acceleration were not only impaired in both the less and more affected arms poststroke, but also not distinguishable for target- versus vector-grouped reaches. As previously reported in controls, target-grouped reaches yielded isotropic (circular) error distributions and vector-grouped reaches yielded error distributions elongated in the direction of the reach. In stroke, the pattern of variability was similar. However, the more affected arm showed less elongated error ellipses for vector-grouped reaches compared to the less affected arm, particularly in individuals with right-hemispheric stroke. The results suggest greater impairment to the vector-coded movement-planning system after stroke, and have implications for the development of personalized approaches to poststroke rehabilitation: Motor learning may be enhanced by practice that uses the preserved code or, conversely, by retraining the more impaired code to restore function.

Patients or Programs: An 82-year-old woman with supraventricular tachycardia managed with carotid sinus massage. Program Description: The patient is an 82-year-old woman with medical history of hypertension, coronary artery disease, abdominal aortic aneurysm, and carotid artery stenosis after right carotid artery endarterectomy and who developed supraventricular tachycardia and presented to her outpatient clinic. Carotid sinus massage was implemented with termination of the arrhythmia. The patient subsequently began to complain of weakness in her left upper and lower extremity. The patient was transferred to an emergency department where examination revealed dysarthria, left lower facial palsy, and left hemiparesis. Setting: Acute rehabilitation hospital. Results: Magnetic resonance imaging revealed multiple rightsided acute infarctions of embolic etiology and subtle atherosclerosis of the right common carotid artery. The patient was stabilized on the neurology service and subsequently was admitted to a rehabilitation program where her dysarthria resolved and she regained strength in her left upper extremity. The patient was discharged with a mild residual weakness of her left hand, and functionally she was ambulating 300 ft with modified independence. Discussion: There have been few case reports that note neurologic complications after carotid sinus massage. Two large prospective studies that review complications after carotid sinus massage report neurologic rates from 0.1%-0.17%. To our knowledge, this is the first reported case of an embolic stroke after carotid sinus massage on a surgically treated carotid artery. In a background that included prior carotid artery endarterectomy and lack of bruits on carotid auscultation, there remains sufficient risk to embolize atherosclerotic disease and the potential exists for iatrogenic cerebral infarction. Conclusions: Physicians should only use vagal maneuvers in patients whose comorbidities permit. In an elderly population, especially those who have undergone carotid artery endarterectomies or other surgical procedures that indicate the severity of their atherosclerosis, carotid sinus massage should be implemented sparingly to terminate supraventricular tachycardia

OBJECTIVE: This study explores the link between neurologic deficit as measured by the National Institutes of Health Stroke Scale (NIHSS), and its relationship to length of stay (LOS) and discharge destination. DESIGN: A retrospective chart review was completed of 54 patients admitted for rehabilitation after experiencing a cerebrovascular accident. SETTING: The study was completed in an acute inpatient rehabilitation stroke unit in a large urban tertiary care medical center. PARTICIPANTS: Patients were included in this analysis if their record contained an NIHSS score on both admission and discharge, if they had neuroimaging documentation of an acute hemorrhagic or ischemic stroke, and if they were not transferred away from the rehabilitation unit during their stay. Of 54 cases reviewed, 47 were ultimately included. MAIN OUTCOME MEASUREMENTS: Independent variables included were NIHSS admission and discharge scores, change in score from admission to discharge, discharge destination, age, gender, type of stroke, and use of tissue plasminogen activator. These were examined against the dependent variable, LOS. RESULTS: Greater admission NIHSS scores predicted longer hospital stays. Mean admission and discharge scores were significantly greater for patients discharged to subacute facilities, and LOS was also longer for these patients compared with those discharged to the community. Surprisingly, age was inversely related to LOS, admission score, and discharge score. CONCLUSION: Stroke remains one of the most common reasons for admission to acute care hospitals. The authors know of no studies that have examined the rehabilitation aspect of care incorporating the NIHSS in this manner. This study draws a connection between neurologic impairment by using the NIHSS and LOS and discharge destination in an acute inpatient rehabilitation stroke unit. In the future, multidisciplinary rehabilitation teams may consider using this measure to predict LOS and disposition at discharge from inpatient rehabilitation

This self-directed learning module highlights the physician's role in the diagnosis and treatment of neuromuscular disorders in pediatric populations. It is part of the chapter on neuromuscular rehabilitation and electrodiagnosis in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses both clinical and electrodiagnostic features of common neuromuscular disorders in pediatric populations. The diagnostic value of somatosensory evoked potential is reviewed in a case of traumatic spinal cord injury without radiographic abnormality. Therapeutic interventions of progressive muscular dystrophy are discussed, as well as the differential diagnosis of floppy infant syndrome, the most common pediatric electrodiagnostic referral. OVERALL ARTICLE OBJECTIVES: (a) To become familiar with electrodiagnosis and rehabilitation for common neuromuscular disorders in the pediatric population, (b) to undrstand electrodiagnostic findings of Guillain-Barre syndrome corresponding to pathophysiology, (c) to become familiar with somatosensory evoked potentials, and (d) to be able to make differential diagnosis of floppy infant syndrome based on clinical findings as well as electrodiagnosis

This self-directed learning module highlights formation of a differential diagnosis as well as electrodiagnostic evaluation for those patients who present with the common complaint of weakness. It is part of the chapter on neuromuscular rehabilitation and electrodiagnosis in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the common symptoms and typical clinical findings that allow the clinician to narrow the differential diagnosis. This is followed by the diagnostic evaluation, with emphasis on the technical aspects and interpretation of electrodiagnostic studies. OVERALL ARTICLE OBJECTIVE: To summarize the clinical presentation and electrodiagnostic findings in persons with disorders of muscle or disorders of the neuromuscular junction

This self-directed learning module highlights peripheral neuropathies. It is part of the chapter on neuromuscular rehabilitation and electrodiagnosis in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on diagnostic criteria and classifications of peripheral neuropathy, including diabetic, alcoholic, carcinomatous, human immunodeficiency virus-associated, and critical illness polyneuropathies. Treatment options are reviewed. The causes for difficult to obtain nerve conduction studies are highlighted. OVERALL ARTICLE OBJECTIVE: To summarize the diagnosis, classification, and treatment of peripheral neuropathies