Archives of PMR, September 2013

1699 Treat the patient and not the X-Ray, was what we were told during our orthopedics clinical training. Not quite that in this systematic review on Shock Wave Therapy for Calcific tendinitis of shoulder. Results seem to favor SWT in improving, you-know-what, radiological signs; disappointing that there are no forest-plots of changes in pain/functional outcomes.  “It would be of interest to determine whether and, if so, to what degree there exists a correlation between decreased pain and functional recovery, on the one hand, and the resorption of calcific deposits”. To me, pain and functional recovery should be the primary outcomes that matter.

1753 Rick Hanson Institute in Canada is not just about an illustrious founder. Going by their twitter feed, there is some good work being done for the public cause. This community follow-up questionnaire for their SCI registry, though, like many such check-box tools, with more than 150 items, is too extensive to try out in an active clinical practice.

Archives of PMR, October 2013

Topical focus: Research on Disorders of Consciousness (DOC)

“It was not uncommon to find patients in a vegetative state undergoing several hours of daily therapy for many months after injury regardless of the neurologic progress achieved.” Sounds familiar?? Read on.

You might want to quickly flip through the issue for a couple of interesting articles, starting with the opening special communication that rightly touches upon many related ethical and clinical dilemmas. The American authors note that most persons with DOC do not received structured rehabilitation in the US (what does Obamacare say about this?). They propose a system, where “…all patients with DOC receive an early period of expert assessment and management that focuses on accurate diagnosis, tracking of functional change with sensitive objective measures, medical management to stabilize and resolve complications, and caregiver education and prognostic planning. Those who make substantial functional progress within such a system would be transitioned to more active rehabilitation and those who fail to make progress would be triaged to nursing facilities or family homes, but with well-developed rehabilitation plans in place, periodic monitoring of change planned for, and a consultation link available to address new and unanticipated changes”. Glad we are already doing something similar, not to “all patients with DOC”, but to whoever manages to wade through the convoluted admission process that’s unavoidable due to many factors, primarily the disparity between high case loads and bed availability.

1855 Functional outcomes in traumatic disorders of consciousness: 5 year outcomes, is a retrospective chart review study from the TBI model systems, USA. They looked at functional outcomes at discharge, 1 year, 2 years and 5 years among persons with absent command-following at admission to rehabilitation (Minimally conscious state/Locked-in syndrome not accounted for!). With data losses at multiple levels, records of just 108 individuals make the cut. 1988 to 2009, from 16 sites across the US, that’s paltry numbers. Such reports from hospital-based databases just cannot compete with the likes of the robust, all-inclusive Scandinavian population databases. Still, there are a few stats that might be of clinical value. Persons who start showing command-following abilities by the time of discharge continue to show improvements in physical independence, not in cognitive independence, till 5 years. In contrast, those who start showing responses after discharge max out on all improvements by 2 years; “In other words, the early recovery group tended to have a larger gap between physical and cognitive independence, whereas the late recovery group tended to be more similarly impaired across domains”.

1891 It’s festive season all around, and let’s wind-up with some fantasy stuff. Can mental imagery fMRI predict recovery in patients with disorders of consciousness? Yes, say the German authors, who found in this observational study that all 5 patients in vegetative state who showed significant activity in the region of interest on fMRI progressed to at least minimally conscious state at the end of the observation period. And none of the 5 non-responders improved from vegetative state. That works out to a fantastic 100% sensitivity and 100% specificity! The authors propose a new term for the responders- “functional minimally conscious state” till the time they progress to clinically apparent minimally conscious state. The findings beg to be replicated. A potential thesis topic if funding can be arranged.

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Response to this blog has been expectedly underwhelming. Yet, I intend to continue as long as all the reading that goes into the writing amuses me. An African proverb from my twitter feed read “If you want to go fast, go alone. If you want to go far, go together”. Let’s go far. New Year greetings to all!