Cases reported "Quadriplegia"

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1/36. Repetitive sensorimotor training for arm and hand in a patient with locked-in syndrome.

    The locked-in syndrome is characterized by quadriplegia, preserved consciousness and inability to respond to the outside world. In recent years, the repetitive execution of identical movements has been demonstrated to be crucial for the recovery of arm and hand function in stroke patients. The present study aimed at investigating the efficiency of repetitive training in a patient suffering from locked-in syndrome due to an occlusion of the basilar artery. Seven months after the brainstem lesion and after a 15-week period of standard inpatient therapy, the repetitive training was applied to the (most affected) right upper extremity in addition to usual therapy. After 42 weeks of the repetitive training for the right arm, it was applied to the left arm. The ranges of active motion as well as functional motor capacity and muscle tone were regularly assessed. During those phases when the repetitive sensorimotor training was applied to the right or left arm, the ranges of active motion, muscle strength and functional motor capacity of the trained arm increased significantly accompanied by a continuous normalization of muscle tone in the flexor muscle groups. Since the prominent functional improvements of the right and left arms were observed during those phases when the repetitive training was applied, these effects were likely to be due to the training rather than to the standard rehabilitation program or extraneous influences. The repetitive sensorimotor training, therefore, appears to be appropriate to improve motor function of the arm and hand and to accelerate the time course of recovery even in patients with almost complete central paralysis of both arms.
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2/36. Forced oscillation technique to detect and monitor tracheal stenosis in a tetraplegic patient.

    STUDY DESIGN: A case report. Objectives: To demonstrate forced oscillation technique's (FOT) utility in a tetraplegic patient with tracheostenosis. SETTING: A rehabilitation Hospital, Brasilia, brazil. methods: Serial evaluations of spirometry, bronchoscopy and forced oscillation assessment. RESULTS: A 16-year-old male with C7 spinal cord injury, initially required mechanical ventilation and subsequent tracheostomy over a period of 4 weeks. Five months after the accident the onset of tracheostenosis was diagnosed. Flow-volume data were compatible with a fixed tracheal stenosis. FOT showed an obstructed pattern, manifested by high levels of resonance frequency and impedance. The FOT pattern returned to normal after dilatation. The FOT abnormalities recurred with two subsequent broncoscopicaly confirmed episodes of tracheal restenosis without parallel changes in spirometric parameters. CONCLUSION: This case suggests a role for FOT in the non invasive detection and follow up of tracheal stenosis. FOT may be particularly useful in tetraplegic patients, in whom the restriction from muscle weakness may make interpretation of forced expiratory flow-volume data problematic.
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3/36. Glossopharyngeal and neck accessory muscle breathing in a young adult with C2 complete tetraplegia resulting in ventilator dependency.

    BACKGROUND AND PURPOSE: This case report describes the use of glossopharyngeal breathing (GPB) and neck accessory muscle breathing (NAMB) in the treatment of an individual who was dependent on a ventilator secondary to a spinal cord injury. CASE DESCRIPTION: The patient was a 19-year-old man with C2 complete tetraplegia. He received a 5-week inpatient program of GPB training 3 to 4 times per week. A 4-week NAMB training program followed. OUTCOME: Following GPB training, forced vital capacity increased 35-fold, time off the ventilator improved from 0 to 30 minutes, and a nonfunctional cough became a weak functional cough. After NAMB training, the patient was able to be off the ventilator for 2 minutes. DISCUSSION: Increased ventilatory capability has the potential to affect patients' quality of life by improving cough function and decreasing dependence on a ventilator in the event of accidental disconnection.
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4/36. phrenic nerve pacing in a tetraplegic patient via intramuscular diaphragm electrodes.

    In patients with ventilator-dependent tetraplegia, phrenic nerve pacing (PNP) provides significant clinical advantages compared with mechanical ventilation. This technique however generally requires a thoracotomy with its associated risks and in-patient hospital stay and carries some risk of phrenic nerve injury. We have developed a method by which the phrenic nerves can be activated via intramuscular diaphragm electrodes. In one patient with ventilator-dependent tetraplegia, two intramuscular diaphragm electrodes were implanted into each hemidiaphragm near the phrenic nerve motor points via laparoscopic surgery. The motor points were identified employing a previously devised mapping technique. Because inspired volumes were suboptimal on the right, a second laparoscopic procedure was necessary to position electrodes near the anterior and posterior branches of the right phrenic nerve. During bilateral stimulation, inspired volume was 580 ml. After a reconditioning program of progressively increasing diaphragm pacing, maximum inspired volumes on the left and right hemidiaphragms increased significantly. Maximum combined bilateral stimulation was 1120 ml. Importantly, the patient has been able to comfortably tolerate full-time pacing. If confirmed in additional patients, PNP with intramuscular diaphragm electrodes via laparoscopic surgery may provide a less invasive and less costly alternative to conventional PNP.
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5/36. Breathlessness associated with abdominal spastic contraction in a patient with C4 tetraplegia: a case report.

    A tetraplegic patient with C4 cervical cord injury reported breathlessness during episodes of spastic contraction of the abdominal muscles. To determine the mechanism, we performed electrophysiologic testing of the phrenic nerves. We measured abdominal pressure, esophageal pressure, and transdiaphragmatic pressure (Pdi) during a maximal inspiratory effort (Pdi max), a maximal sniff maneuver (sniff Pdi) during resting breathing, and during the episodes of breathlessness. Electrophysiologic testing of the phrenic nerves showed axonal neuropathy on the left. Sniff Pdi and Pdi max were 38cmH(2)O and 42cmH(2)O, respectively. Transient spastic contractions of abdominal muscles were associated with an increase in abdominal pressure greater than 30cmH(2)O, with a decrease in abdominal volume; this rise in abdominal pressure was transmitted to the esophageal pressure. Inspiration became effective only when esophageal pressure fell below the resting baseline value. Achieving this decrease required an increase in inspiratory effort, characterized by swings in esophageal pressure and Pdi of 30cmH(2)O and 40cmH(2)O (approximately 100% of Pdi max), respectively. During these periods, minute ventilation was markedly reduced. This is the first report that spastic abdominal muscle contractions can impose a significant load on the diaphragm, uncovering moderate diaphragmatic weakness. This has important clinical implications; abolition of the spastic abdominal muscle contraction in this patient completely resolved her intermittent respiratory symptoms.
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6/36. An unusual cause of autonomic dysreflexia: pheochromocytoma in an individual with tetraplegia.

    BACKGROUND: autonomic dysreflexia (AD) is a frequent, serious acute syndrome that occurs in patients with spinal cord lesions at level T6 and above. The syndrome is caused by massive sympathetic discharge that is triggered by a noxious stimulus below the level of the spinal cord lesion. Pheochromocytomas are rare tumors that present with symptoms similar to AD. methods: Case Report. FINDINGS: A 50-year-old man with C7 American Spinal Injury association scale A tetraplegia presented with episodes of severe headaches and paroxysmal hypertension. He was diagnosed with AD. Despite resolving bladder and bowel problems, he continued to have hypertensive episodes. A CT scan of the abdomen revealed a heterogeneous left adrenal mass. Further workup revealed significantly elevated serum and 24-hour urinary catecholamines. clonidine failed to fully suppress the markedly elevated concentrations of serum catecholamines. These biochemical findings were consistent with the diagnosis of pheochromocytoma. Prior to surgery, the patient was treated with alpha-receptor blockers and volume expansion with intravenous fluids. A left adrenalectomy was performed. The surgical specimen revealed that the adrenal gland was expanded by a spherical mass. The pathologic report was benign pheochromocytoma of the left adrenal gland. CONCLUSION: Clinical symptoms and hypertensive episodes resolved following adrenalectomy. To our knowledge, this is the first reported case of a pheochromocytoma in an individual with spinal cord injury.
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7/36. Reduced tidal volume increases 'air hunger' at fixed PCO2 in ventilated quadriplegics.

    The act of breathing diminishes the discomfort associated with hypercapnia and breath-holding. To investigate the mechanisms involved in this effect, we studied the effect of tidal volume (VT) on CO2-evoked air hunger in 5 high-level quadriplegic subjects whose ventilatory capacity was negligible, and who lacked sensory information from the chest wall. Subjects were ventilated at constant frequency with a hyperoxic gas mixture, and end-tidal PCO2 was maintained at a constant but elevated level. VT was varied between the subjects' normal VT and a smaller VT. Subjects used a category scale to rate their respiratory discomfort or 'air hunger' at 30-40 sec intervals. In 4 of 5 subjects there was a strong inverse relationship between breath size and air hunger ratings. The quality of the sensation associated with reduced VT was nearly identical to that previously experienced with CO2 alone. We conclude that afferent information from the lungs and upper airways is sufficient to modify the sensation of air hunger.
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keywords = capacity, volume
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8/36. Efficacy of glossopharyngeal breathing for a ventilator-dependent, high-level tetraplegic patient after cervical cord tumor resection and tracheotomy.

    This case study was undertaken to describe the use and limitations of glossopharyngeal breathing (GPB) by a ventilator-dependent, tracheotomized patient after cervical tumor resection. A 6-yr, 8-mo-old, tracheotomized, ventilator-dependent boy, after cervical tumor resection, learned GPB on his own and used it for ventilator-free breathing. Over the next 16 yrs, his GPB efficacy improved to the point that, with a vital capacity of 670 ml, his GPB maximum single-breath capacity increased to 3300 ml. This was limited by the fact that at 2.9 l of lung volume, air began to leak around the tracheostomy tube walls and out of the stoma. Still, GPB permitted up to 12 hrs/day of ventilator-free breathing. Measurements of assisted peak cough flow and GPB lung insufflations exceeding vital capacity are the main measures that demonstrate adequate tube fit to permit effective GPB in the presence of an indwelling tracheostomy tube.
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ranking = 192.08833977512
keywords = vital capacity, capacity, volume
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9/36. Postural hypotension, hyponatremia, and salt and water intake: case reports.

    PURPOSE: Postural hypotension (PH) and hyponatremia are common and often coexistent among patients with severe paralysis secondary to spinal cord injury. Volume depletion could account for these conditions. This study examined whether salt and water intake correlated with the severity of PH. PARTICIPANTS: Participants were 4 patients with tetraplegia, motor and sensory complete, aged 68 to 83 years, who were paralyzed for 9 to 54 years, who had PH. These patients were ranked by the amount of ephedrine prescribed on a daily basis to treat PH over the preceding 2-year period. methods: The total urinary output of sodium and water and the effect of orthostasis on urine output rate, osmolality, sodium concentration, and creatinine secretion were determined over a 48-hour period of collection and compared with severity of PH. RESULTS: The ephedrine requirements, in order of decreasing severity of PH, were 100 mg/d, 25 mg/d, 12.5 mg/d, and no ephedrine needed. The 24-hour sodium excretions in that order were 50, 92, 180, and 164 mEq. The urine volumes were 1.4, 3, 2.6, and 5.4 L, respectively. In the same order of decreasing PH severity, the sitting position relative to the recumbent position was characterized by increasing rates of creatinine secretion (ratios of 0.69, 0.74, 0.95, and 0.80), increasing rates of water excretion (ratios of 0.49, 0.28, 0.69, and 0.99), decreasing urine osmolality (ratios of 1.2, 1.8, 1.3, and 0.8), and increasing sodium concentrations (ratios of 0.9, 1.3, 1.2, and 2.6). CONCLUSION: In these individuals with tetraplegia, severe PH was accompanied by avid conservation of water and impaired retention of sodium in the sitting position, as well as limited salt and water intake.
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10/36. Effect of acute aminophylline administration on diaphragm function in high cervical tetraplegia: a case report.

    theophylline has been shown to have beneficial effects on phrenic nerve and diaphragm activation. This case report involves a C5-C6 chronic tetraplegic patient with acute respiratory failure and ventilator dependence. IV aminophylline was administered in increasing doses (2 mg/kg, 4 mg/kg, and 6 mg/kg) over the course of 1 day. diaphragm surface electromyography (sEMG), measures of respiration (tidal volume, minute ventilation, and frequency), and serum theophylline levels were captured. diaphragm sEMG activity increased by a maximum of 50% at therapeutic levels. The rapid shallow breathing index dropped from 112 to 86. The subject was successfully weaned from ventilatory support. We conclude that administration of aminophylline facilitated weaning from ventilatory support in this tetraplegic patient.
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