THE WESTERN JOURNAL OF MEDICINE THl
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DECEMBER 1992
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Treatment of Postconcussion Syndrome THERE CONTINUES TO BE much controversy regarding the cause and classification of the postconcussion syndrome. It has been thought of as a subset ofthe broader classification of mild head injury where initial Glasgow Coma Scale scores in such patients range between 13 and 15. It has been suggested that the postconcussion syndrome results from injuries in which a patient may have been initially "dazed" to having a brief coma. The syndrome typically consists of some combination of the following that persist after head trauma: headaches, fatigue, dizziness, blurred vision, difficulties in concentration, increased sensitivity to noise and light, irritability and emotional lability, recent memory difficulty, anxiety, and sleep disturbance. Many patients have persistent headaches, memory problems, and dizziness for a year after their injury. Persisting symptoms after a mild head trauma are frequently assumed to be a function of psychological overlay to the injury itself, pending litigation, or the presence of medically undetectable diffuse axonal injury. What makes diagnosis and subsequent rehabilitation difficult in many cases of postconcussion syndrome is the lack of evidence for craniocerebral injury by diagnostic imaging, neurophysiologic measurements, or neurologic examination. Cases of the postconcussion syndrome bear a strong resemblance to those of chronic pain syndromes. In fact, the rates of chronic pain problems in this population are high. For example, chronic headaches occur in 89% and chronic upper extremity syndromes in 51% of those with postconcussion syndrome and are judged to be of a myofascial origin. Furthermore, many of the clinical features of the syndrome are similar to those of chronic pain and other chronic illnesses such as the irritable bowel syndrome and chronic fatigue syndrome. Common features that are shared among all of these syndromes are the frequent lack of diagnostic findings, a strong conviction of illness on the part of the patient, the existence of incentives for maintaining disability behaviors, the coexistence of depressive disorders, a social reinforcement of disability behaviors by significant others in the patient's home environment, and involvement by many health-care professionals. Given these sets of patient problems and behaviors, the treatment of patients with the postconcussion syndrome can be approached in a similar manner to those with chronic pain and chronic illness. Centralizing treatment under one facility or primary care physician lessens the chance of care being fragmented. Early mobilization and physiotherapy for general aerobic conditioning and endurance are recommended. Trials of antidepressant medications combined with behavioral interventions that support physical reactivation, decrease illness behaviors, and lessen the effects of social reinforcement for illness can be useful with these patients. Consulting with a speech pathologist or neuropsychologist can be helpful with cognitive complaints. Finally, aggressive vocational rehabilitation efforts can be implemented early after the injury to reduce lost work productivity and to educate employers regarding the natural history of the syndrome. JAY M. UOMOTO, PhD PETER C. ESSELMAN, MD DIANA D. CARDENAS, MD Seattle, Washington REFERENCES Alves WM: Natural history of post-concussive signs and symptoms. Phys Med Rehabil 1992; 6:21-32
6
665 Berrol S: Terminology of post-concussion syndrome. Phys Med Rehabil 1992; 6:1-8
Binder LM: Persisting symptoms after mild head injury: A review of the postconcussive syndrome. J Clin Exp Neuropsychol 1986; 8:323-346 Cardenas DD, McLean A: Psychophannacologic management of traumatic brain injury. Phys Med Rehabil Clin North Am 1992; 3:272-290 Uomoto JM, Esselman PC: Traumatic brain injury and chronic pain: Differential
types and rates by head injury severity. Arch Phys Med Rehabil 1993, in press
Family Support and Stroke Rehabilitation THE DEVASTATING CONSEQUENCES of stroke affect the family as well as the patient. Relationships are disrupted, and family members take on roles unfamiliar to them. Questions about medical treatments, prognosis and the extent of recovery, financial management, and the new or heightened need for a care giver must all be urgently decided. Family involvement is becoming more important as more stroke patients are being cared for at home after discharge. The degree of a patient's recovery is directly related to the degree of psychological adjustment by care givers. This adjustment is determined more by a family's past ability to cope than by the severity of a patient's deficits at hospital discharge. A family's emotional distress may be expressed as increased hostility and criticism of the patient or with overinvolvement. The patient's adjustment to the disability is impaired as a result, and function deteriorates, compounding the likelihood of a poor recovery. Depression frequently occurs in care givers. The incidence of depression in spouses of stroke patients is about 2½/2 to 31/2 times greater than in controls. Factors leading to depression revolve around the stresses associated with new responsibilities that family member(s) must shoulder. The need for constant supervision and assistance, nursing care, and the assumption of full financial responsibilities for the family can be unmanageable without adequate preparation and support. These responsibilities lead to a constellation of decreased personal time, companionship, and social interactions outside the home. Marital discord and family conflicts grow. The patient's impaired judgment, safety, and insight complicate interactions with the care giver. Approaches to solving problems are often met with resistance and irrational demands by the patient, rather than the acceptance of compromises the family may offer. The health professionals caring for a stroke patient can work together to address the concerns and needs of the family and to facilitate the transition home during this stressful time. Each member of the integrated team plays an essential role in educating the family. Families are most concerned with the neurologic and cognitive deficits present in their family member and the prognosis for future functioning or the extent of disability. These issues can be addressed by the physicians and nursing staff with careful explanations in lay terms of the various aspects surrounding the stroke. Family counseling and education are essential. Individual sessions and family support groups can be led by licensed clinical social workers and neuropsychiatrists. This is an area requiring heightened attention in planning rehabilitation programs. The family also needs information from the case manager or social worker regarding the availability and means for getting financial, psychological, and physical (at-
tendant) care assistance in the community. Referrals for outpatient programs such as adult day health care centers can be essential. These programs provide therapeutic activities, opportunities for social interaction and counseling for the patient, and respite for care givers after discharge.
EPITOMES-PHYSICAL MEDICINE AND REHABILITATION
-666
All team members can provide a supportive and educational role. Defining the family's goals for the patient (and themselves) should be initiated early during the rehabilitation course, when the team's plans and goals for treatment are established. The therapists can instruct the family how to assist the patient in various activities of daily living, transfers, ambulation, and communication. Medication regimens, bowel and bladder management, and skin care can be taught by the nursing staff. It is important for the rehabilitation team to incorporate the family into the care of the stroke patient and the careful planning for the return home for a smoother, less stressful transition and readjustment. The role of a comprehensive rehabilitation program becomes evident to this end. The better adjusted the family is to the consequences of the stroke, the better the physical and emotional recovery the patient will likely make and maintain after discharge. JEFFREY TERAOKA, MD RENEE BURGARD, LCSW Stanford, California REFERENCES Berk SN, Schall RR: Psychosocial factors in stroke rehabilitation, In Goldberg G (Ed): Physical Medicine and Rehabilitation Clinics-Vol 2. Philadelphia, PA, WB Saunders, 1991, pp 547-562 Evans RL, Bishop DS, Matlock A, Stranahan S, Halar EM, Noonan WC: Prestroke family interaction as a predictor of stroke outcome. Arch Phys Med Rehabil 1987; 68:508-512 Evans RL, Bishop DS, Matlock A, Stranahan S, Smith GG, Halar EM: Family interaction and treatment adherence after stroke. Arch Phys Med Rehabil 1987; 68:513-5 17 Malec JF, Richardson JW, Sinaki M, O'Brien MW: Types of affective response to stroke. Arch Phys Med Rehabil 1990; 71:279-284
Focal Dystonia in Musicians DYSTONIA IS A SPECIFIC type of involuntary movement characterized by sustained muscle contractions, often causing twisting and repetitive movements. Although dystonic movements can be seen secondarily in a number of conditions, including inherited disorders, Wilson's disease, drug and heavy metal toxicity, and stroke, adult-onset dystonia is usually idiopathic and often starts and remains localized to a circumscribed body part. Well-known examples of focal dystonia are writer's cramp and blepharospasm, but similar dysfunctions occur in musicians' hands and facial muscles. The incidence of writer's cramp has been estimated to be 3 per 1 million person-years. The incidence of focal dystonia in musicians is not known, but about 10% of musicians seen in arts medicine centers have motor control problems. For the better part of this century, the dystonias were thought of as functional, psychiatric syndromes. This view no longer predominates because objective findings have been shown. Although the diagnosis remains one of exclusion, in musicians symptoms may include weakness, a loss of control, the drooping of fingers, involuntary flexing and extending, difficulty relaxing, difficulty moving fingers off keys, and difficulty with rapid alternating, ascending, or descending patterns. Facial involvement manifests as difficulty with embouchure. Pain is not common. The abnormal movement is usually task specific and requires examining the patients as they play their instruments. Men are affected by a ratio of 2 to 1. A family history of movement disorders such as essential tremor and Parkinson's disease may raise the index of suspicion. There does not appear to be an association between handedness or number of years playing. A history of some earlier injury to the affected area, such as transient
overuse from excessive practicing, is common. The yield is low from workup for an underlying disease, but any suggestion of nerve entrapment should be fully evaluated electrodiagnostically because there have been occasional reports of dystonia resolving following a surgical release. In general, only 5% of cases of dystonia resolve spontaneously. The basal ganglia are thought to be the site ofthe disorder, but no identifiable lesions have been shown on imaging studies-computed tomography, magnetic resonance imaging-in musicians. Recently abnormalities in the normal pattern of reciprocal inhibition between agonist and antagonist muscles have been observed electrophysiologically. Instead of the normal, smoothly coordinated pattern of antagonist relaxation with agonist contraction, a defect in presynaptic inhibition occurs at the spinal level (possibly due to a disruption of descending control from the subcortical areas), resulting in an abnormal cocontraction seen clinically as a cramp or involuntary movement. These findings are not unique to dystonia but do provide objective evidence of central, neurophysiologic disturbance. No single treatment has been consistently successful. Electromyographic biofeedback, manipulative and movement therapies (such as the Alexander technique), stretching and strengthening exercises, relaxation techniques, and laborious retraining of musical technique have been of some benefit in a few cases. Anticholinergics (trihexyphenidyl hydrochloride) have been the most effective medications. Administering botulinum toxin to the abnormally contracting muscle has been effective in reducing the involuntary contraction in several types of dystonia, most notably blepharospasm, torticollis, and spasmodic dysphonia. Results in instrumental musicians have been mixed because of unavoidable weakness and the need for repeated administrations. The success of treatment in musicians depends largely on the playing requirements of each person. A better result can be expected for a section player than a concert soloist. Unfortunately, substantial compromises often must be made in repertoire, tempo, and overall performing availability. Patients should be encouraged to consider other outlets such as teaching, conducting, and composing. The best approach at this time combines physical, pharmacologic, and pedagogic measures.
SCOTT E. BROWN, MD
Loma Linda, California
REFERENCES Brin MF, Fahn S, Moskowitz C, et al: Localized injections of botulinum toxin for the treatment of focal dystonia and hemifacial spasm. Adv Neurol 1988; 50:599-608 Lederman RJ: Focal dystonia in instrumentalists: Clinical features. Med Problems Perforn Art 1991; 6: 132-136 Panizza ME, Hallett M, Nilsson J: Reciprocal inhibition in patients with hand cramps. Neurology 1989; 39:85-89
Venous Thromboembolism in Stroke THE INCIDENCE OF deep venous thrombosis is greatly increased in patients who have survived a stroke. Its risk is higher in patients with the most severe leg weakness, and, in patients at highest risk who do not receive thrombotic prophylaxis, the incidence may be as high as 75%. Although most thrombi have been detected within the first week following a stroke, the risk of deep venous thrombosis continues after the acute phase. Almost a third of patients admitted to a rehabilitation hospital after a recent stroke have deep venous thrombosis that can be detected by impedance plethysmography, despite being unsuspected clinically. Stud-
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DECEMBER 1992
e
157
o
Treatment of Postconcussion Syndrome THERE CONTINUES TO BE much controversy regarding the cause and classification of the postconcussion syndrome. It has been thought of as a subset ofthe broader classification of mild head injury where initial Glasgow Coma Scale scores in such patients range between 13 and 15. It has been suggested that the postconcussion syndrome results from injuries in which a patient may have been initially "dazed" to having a brief coma. The syndrome typically consists of some combination of the following that persist after head trauma: headaches, fatigue, dizziness, blurred vision, difficulties in concentration, increased sensitivity to noise and light, irritability and emotional lability, recent memory difficulty, anxiety, and sleep disturbance. Many patients have persistent headaches, memory problems, and dizziness for a year after their injury. Persisting symptoms after a mild head trauma are frequently assumed to be a function of psychological overlay to the injury itself, pending litigation, or the presence of medically undetectable diffuse axonal injury. What makes diagnosis and subsequent rehabilitation difficult in many cases of postconcussion syndrome is the lack of evidence for craniocerebral injury by diagnostic imaging, neurophysiologic measurements, or neurologic examination. Cases of the postconcussion syndrome bear a strong resemblance to those of chronic pain syndromes. In fact, the rates of chronic pain problems in this population are high. For example, chronic headaches occur in 89% and chronic upper extremity syndromes in 51% of those with postconcussion syndrome and are judged to be of a myofascial origin. Furthermore, many of the clinical features of the syndrome are similar to those of chronic pain and other chronic illnesses such as the irritable bowel syndrome and chronic fatigue syndrome. Common features that are shared among all of these syndromes are the frequent lack of diagnostic findings, a strong conviction of illness on the part of the patient, the existence of incentives for maintaining disability behaviors, the coexistence of depressive disorders, a social reinforcement of disability behaviors by significant others in the patient's home environment, and involvement by many health-care professionals. Given these sets of patient problems and behaviors, the treatment of patients with the postconcussion syndrome can be approached in a similar manner to those with chronic pain and chronic illness. Centralizing treatment under one facility or primary care physician lessens the chance of care being fragmented. Early mobilization and physiotherapy for general aerobic conditioning and endurance are recommended. Trials of antidepressant medications combined with behavioral interventions that support physical reactivation, decrease illness behaviors, and lessen the effects of social reinforcement for illness can be useful with these patients. Consulting with a speech pathologist or neuropsychologist can be helpful with cognitive complaints. Finally, aggressive vocational rehabilitation efforts can be implemented early after the injury to reduce lost work productivity and to educate employers regarding the natural history of the syndrome. JAY M. UOMOTO, PhD PETER C. ESSELMAN, MD DIANA D. CARDENAS, MD Seattle, Washington REFERENCES Alves WM: Natural history of post-concussive signs and symptoms. Phys Med Rehabil 1992; 6:21-32
6
665 Berrol S: Terminology of post-concussion syndrome. Phys Med Rehabil 1992; 6:1-8
Binder LM: Persisting symptoms after mild head injury: A review of the postconcussive syndrome. J Clin Exp Neuropsychol 1986; 8:323-346 Cardenas DD, McLean A: Psychophannacologic management of traumatic brain injury. Phys Med Rehabil Clin North Am 1992; 3:272-290 Uomoto JM, Esselman PC: Traumatic brain injury and chronic pain: Differential
types and rates by head injury severity. Arch Phys Med Rehabil 1993, in press
Family Support and Stroke Rehabilitation THE DEVASTATING CONSEQUENCES of stroke affect the family as well as the patient. Relationships are disrupted, and family members take on roles unfamiliar to them. Questions about medical treatments, prognosis and the extent of recovery, financial management, and the new or heightened need for a care giver must all be urgently decided. Family involvement is becoming more important as more stroke patients are being cared for at home after discharge. The degree of a patient's recovery is directly related to the degree of psychological adjustment by care givers. This adjustment is determined more by a family's past ability to cope than by the severity of a patient's deficits at hospital discharge. A family's emotional distress may be expressed as increased hostility and criticism of the patient or with overinvolvement. The patient's adjustment to the disability is impaired as a result, and function deteriorates, compounding the likelihood of a poor recovery. Depression frequently occurs in care givers. The incidence of depression in spouses of stroke patients is about 2½/2 to 31/2 times greater than in controls. Factors leading to depression revolve around the stresses associated with new responsibilities that family member(s) must shoulder. The need for constant supervision and assistance, nursing care, and the assumption of full financial responsibilities for the family can be unmanageable without adequate preparation and support. These responsibilities lead to a constellation of decreased personal time, companionship, and social interactions outside the home. Marital discord and family conflicts grow. The patient's impaired judgment, safety, and insight complicate interactions with the care giver. Approaches to solving problems are often met with resistance and irrational demands by the patient, rather than the acceptance of compromises the family may offer. The health professionals caring for a stroke patient can work together to address the concerns and needs of the family and to facilitate the transition home during this stressful time. Each member of the integrated team plays an essential role in educating the family. Families are most concerned with the neurologic and cognitive deficits present in their family member and the prognosis for future functioning or the extent of disability. These issues can be addressed by the physicians and nursing staff with careful explanations in lay terms of the various aspects surrounding the stroke. Family counseling and education are essential. Individual sessions and family support groups can be led by licensed clinical social workers and neuropsychiatrists. This is an area requiring heightened attention in planning rehabilitation programs. The family also needs information from the case manager or social worker regarding the availability and means for getting financial, psychological, and physical (at-
tendant) care assistance in the community. Referrals for outpatient programs such as adult day health care centers can be essential. These programs provide therapeutic activities, opportunities for social interaction and counseling for the patient, and respite for care givers after discharge.
EPITOMES-PHYSICAL MEDICINE AND REHABILITATION
-666
All team members can provide a supportive and educational role. Defining the family's goals for the patient (and themselves) should be initiated early during the rehabilitation course, when the team's plans and goals for treatment are established. The therapists can instruct the family how to assist the patient in various activities of daily living, transfers, ambulation, and communication. Medication regimens, bowel and bladder management, and skin care can be taught by the nursing staff. It is important for the rehabilitation team to incorporate the family into the care of the stroke patient and the careful planning for the return home for a smoother, less stressful transition and readjustment. The role of a comprehensive rehabilitation program becomes evident to this end. The better adjusted the family is to the consequences of the stroke, the better the physical and emotional recovery the patient will likely make and maintain after discharge. JEFFREY TERAOKA, MD RENEE BURGARD, LCSW Stanford, California REFERENCES Berk SN, Schall RR: Psychosocial factors in stroke rehabilitation, In Goldberg G (Ed): Physical Medicine and Rehabilitation Clinics-Vol 2. Philadelphia, PA, WB Saunders, 1991, pp 547-562 Evans RL, Bishop DS, Matlock A, Stranahan S, Halar EM, Noonan WC: Prestroke family interaction as a predictor of stroke outcome. Arch Phys Med Rehabil 1987; 68:508-512 Evans RL, Bishop DS, Matlock A, Stranahan S, Smith GG, Halar EM: Family interaction and treatment adherence after stroke. Arch Phys Med Rehabil 1987; 68:513-5 17 Malec JF, Richardson JW, Sinaki M, O'Brien MW: Types of affective response to stroke. Arch Phys Med Rehabil 1990; 71:279-284
Focal Dystonia in Musicians DYSTONIA IS A SPECIFIC type of involuntary movement characterized by sustained muscle contractions, often causing twisting and repetitive movements. Although dystonic movements can be seen secondarily in a number of conditions, including inherited disorders, Wilson's disease, drug and heavy metal toxicity, and stroke, adult-onset dystonia is usually idiopathic and often starts and remains localized to a circumscribed body part. Well-known examples of focal dystonia are writer's cramp and blepharospasm, but similar dysfunctions occur in musicians' hands and facial muscles. The incidence of writer's cramp has been estimated to be 3 per 1 million person-years. The incidence of focal dystonia in musicians is not known, but about 10% of musicians seen in arts medicine centers have motor control problems. For the better part of this century, the dystonias were thought of as functional, psychiatric syndromes. This view no longer predominates because objective findings have been shown. Although the diagnosis remains one of exclusion, in musicians symptoms may include weakness, a loss of control, the drooping of fingers, involuntary flexing and extending, difficulty relaxing, difficulty moving fingers off keys, and difficulty with rapid alternating, ascending, or descending patterns. Facial involvement manifests as difficulty with embouchure. Pain is not common. The abnormal movement is usually task specific and requires examining the patients as they play their instruments. Men are affected by a ratio of 2 to 1. A family history of movement disorders such as essential tremor and Parkinson's disease may raise the index of suspicion. There does not appear to be an association between handedness or number of years playing. A history of some earlier injury to the affected area, such as transient
overuse from excessive practicing, is common. The yield is low from workup for an underlying disease, but any suggestion of nerve entrapment should be fully evaluated electrodiagnostically because there have been occasional reports of dystonia resolving following a surgical release. In general, only 5% of cases of dystonia resolve spontaneously. The basal ganglia are thought to be the site ofthe disorder, but no identifiable lesions have been shown on imaging studies-computed tomography, magnetic resonance imaging-in musicians. Recently abnormalities in the normal pattern of reciprocal inhibition between agonist and antagonist muscles have been observed electrophysiologically. Instead of the normal, smoothly coordinated pattern of antagonist relaxation with agonist contraction, a defect in presynaptic inhibition occurs at the spinal level (possibly due to a disruption of descending control from the subcortical areas), resulting in an abnormal cocontraction seen clinically as a cramp or involuntary movement. These findings are not unique to dystonia but do provide objective evidence of central, neurophysiologic disturbance. No single treatment has been consistently successful. Electromyographic biofeedback, manipulative and movement therapies (such as the Alexander technique), stretching and strengthening exercises, relaxation techniques, and laborious retraining of musical technique have been of some benefit in a few cases. Anticholinergics (trihexyphenidyl hydrochloride) have been the most effective medications. Administering botulinum toxin to the abnormally contracting muscle has been effective in reducing the involuntary contraction in several types of dystonia, most notably blepharospasm, torticollis, and spasmodic dysphonia. Results in instrumental musicians have been mixed because of unavoidable weakness and the need for repeated administrations. The success of treatment in musicians depends largely on the playing requirements of each person. A better result can be expected for a section player than a concert soloist. Unfortunately, substantial compromises often must be made in repertoire, tempo, and overall performing availability. Patients should be encouraged to consider other outlets such as teaching, conducting, and composing. The best approach at this time combines physical, pharmacologic, and pedagogic measures.
SCOTT E. BROWN, MD
Loma Linda, California
REFERENCES Brin MF, Fahn S, Moskowitz C, et al: Localized injections of botulinum toxin for the treatment of focal dystonia and hemifacial spasm. Adv Neurol 1988; 50:599-608 Lederman RJ: Focal dystonia in instrumentalists: Clinical features. Med Problems Perforn Art 1991; 6: 132-136 Panizza ME, Hallett M, Nilsson J: Reciprocal inhibition in patients with hand cramps. Neurology 1989; 39:85-89
Venous Thromboembolism in Stroke THE INCIDENCE OF deep venous thrombosis is greatly increased in patients who have survived a stroke. Its risk is higher in patients with the most severe leg weakness, and, in patients at highest risk who do not receive thrombotic prophylaxis, the incidence may be as high as 75%. Although most thrombi have been detected within the first week following a stroke, the risk of deep venous thrombosis continues after the acute phase. Almost a third of patients admitted to a rehabilitation hospital after a recent stroke have deep venous thrombosis that can be detected by impedance plethysmography, despite being unsuspected clinically. Stud-
