Mary Elizabeth Nelson - Academia.edu (original) (raw)

Papers by Mary Elizabeth Nelson

Frontiers in Rehabilitation Sciences

It is estimated that about 50% of people in low- and middle- income countries who require rehabil... more It is estimated that about 50% of people in low- and middle- income countries who require rehabilitation do not get it. Multidisciplinary rehabilitation services led by Physical and Rehabilitation Medicine (PRM) physicians have been shown to improve functioning, independence and the quality of life of persons with reduced functioning or disability. However, there is a dearth of PRM physicians in low to middle income countries (LMICs), particularly in sub-Saharan Africa. One potential solution to this lack of specialists is the establishment of PRM training programs, which are currently lacking. The International Rehabilitation Forum (IRF) developed and implemented a fellowship program to train physicians in rehabilitation medicine and has been successful in Ghana, Ethiopia and Cameroon, all LMICs in sub-Saharan Africa. However, ongoing challenges include inadequate PRM trainers, availability of logistics and services for hands on experience, and funding. The fellowship program has a...

Neuromodulation: Technology at the Neural Interface, 2021

Intrathecal baclofen (ITB) is a cost‐effective therapy for patients with severe spasticity. The m... more Intrathecal baclofen (ITB) is a cost‐effective therapy for patients with severe spasticity. The most common complications are catheter‐related complications (CRCs) including kinking/occlusion, blockage, migration, fracture, disconnection, and CSF leak. Our objective was to determine the CRC rate in a large cohort of adults with newly implanted ITB pump systems with polymer reinforced silicone catheters.

The Journal of Spinal Cord Medicine, 2019

Context: Need for evidential support of practice guideline recommendations for management of neur... more Context: Need for evidential support of practice guideline recommendations for management of neurogenic bowel management in adults with spinal cord injury. Objective: To determine evidence for digital rectal stimulation (DRS) as an intervention in the management of upper motor neuron neurogenic bowels (UMN-NB) in persons with spinal cord injury (SCI). Methods: A systematic review of the literature including research articles and practice guidelines evaluating upper motor neuron neurogenic bowel treatments and the use of digital rectal stimulation was performed using OvidMedline, PubMed and the Cochrane database and included research articles and practice guidelines. Limitations were made related to English language, patient age and focus on spinal cord injured patients. Strength of evidence was assessed using the Johns Hopkins Nursing evidence-based practice model. Results: Eleven articles were included in the systematic review. Only one used DRS as a primary intervention. There was moderate evidence for DRS in persons with SCI and UMN-NB. There was evidence of the physiologic effect of DRS and support for combining DRS with other treatment regimens. Conclusion: There is insufficient evidence to promote any one intervention for the management of UMN-NB. The promotion of DRS, and education as to the proper technique for DRS should remain an emphasis of education of home management of UMN-NB in persons with SCI. Future research should focus on the use of standardized, validated tools to evaluate management techniques for UMN-NB.

Neuromodulation: Technology at the Neural Interface, 2016

Introduction: Intrathecal baclofen (ITB) screening assesses response to a test dose of ITB on spa... more Introduction: Intrathecal baclofen (ITB) screening assesses response to a test dose of ITB on spasticity and function and identifies adverse reactions. Method: An expert panel consulted on best practices after conducting an extensive literature search and conducting an online survey. Results: A successful trial may confirm predetermined goals, which may include improved mobility/positioning, decreased time/ improved independence for activities, less home exercise, better wheelchair tolerance, decreased caregiver time, improved sleep, and reduced pain, or may modify goals and expectations. Individuals should not be tested in the presence of active medical issues (e.g., MS exacerbations, active urinary tract infection, nonhealing wounds). Oral antispasmodics can be weaned before trial if a goal is to eliminate them. The standard baclofen test dose is a 50-mcg bolus, 25 mcg in very small children or patients who rely on spasticity for mobility. Patients unresponsive to the standard dose may require 75 mcg or 100 mcg; 24 hours should elapse between bolus doses. Cardiopulmonary parameters should be checked frequently during the first two hours postinjection, and spasticity measures assessed at least twice within four hours. Observation continues until the patient is stable and recovers from hypertonia. Adverse events include spinal headaches, nausea/vomiting, urinary retention, hypotension, seizures, drowsiness/ sedation, respiratory depression, and coma. Before implantation, team members must discuss starting dose, drug concentration, delivery mode, pump size and location, and catheter tip placement. Patients/caregivers should understand the commitment necessary for ITB therapy. Conclusions: Screening helps identify appropriate candidates for ITB.

Neuromodulation: Technology at the Neural Interface, 2015

Objectives: To examine dosing patterns in patients receiving baclofen via intrathecal baclofen pu... more Objectives: To examine dosing patterns in patients receiving baclofen via intrathecal baclofen pumps to assess for common patterns by diagnosis, ambulation ability, and affected limbs distribution. Materials and Methods: This trial study included 25 patients with baclofen pumps selected from the 356 patients enrolled in our center's baclofen pump program. Selection was done by splitting all patients into diagnostic categories of stroke, multiple sclerosis, traumatic/anoxic brain injury, cerebral palsy, and spinal cord injury, and then, five patients were randomly selected from each diagnosis.A systematic chart review was then conducted for each patient from Jan 1, 2008, through September 16, 2013, to look at factors including mean daily dose at end of study, and among those implanted during the study mean initial stable dose and time to initial stable dose. Results: Analysis of mean daily dose across diagnoses found significant differences, with brain injury, cerebral palsy, and spinal cord injury patients having higher doses while multiple sclerosis and stroke patients required lower doses. Nonambulatory patients strongly trended to have higher daily doses than ambulatory patients. Similar trends of mean initial stable dose being higher in a similar pattern as that of end mean daily dose were seen according to diagnoses and ambulatory status, although statistical significance could not be achieved with the small sample size. Conclusion: Significant differences in dosing were found between diagnoses and trended to differ by ambulatory status at the end of the study, and similar trends could be observed in achieving initial stable dose.

PM&R, 2015

an MRI of the cervical and thoracic spine, EMG/NCS and PM&R evaluation. Setting: Outpatient r... more an MRI of the cervical and thoracic spine, EMG/NCS and PM&R evaluation. Setting: Outpatient rehabilitation clinic. Results or Clinical Course: Patient evaluated in PM&R clinic after MRI was performed, with results noting T2 hyperintense signal from C1 until at least T12, conistent with spinal cord syrinx. Physical examination notable for atrophy of the FDI, thenar, and hypothenar eminences and weakness at the elbow, wrist and hand; lower extremity examination with trace contraction of the dorsi/plantarflexors. MRI L spine was ordered to evaluate extent of syrinx, which was found as caudal as the conus (L1-L2). Neurosurgical plan was to proceed with placement of a syringosubarachnoid shunt. Further rehabilitation needs would be addressed postoperatively. Discussion: Syringomyelia is a serious condition in which the usual cerebrospinal fluid (CSF) mechanics are disturbed, and can be seen in as many as 3-4% of patients after traumatic spinal cord injury, with an interval of occurrence from several months to many years. Normally, this is a benign prognosis, likely representing an area of liquefaction necrosis of cord tissue, but may progress to worsened or new neurological symptoms, as seen in this case. Holocord involvement had been noted in 1 recent case report, and other studies identified patients with as many as 19 segments involved, though this was in the significant minority (1-3). This study noted that patients appeared to have more desirable outcomes when opting for duraplasty and arachnolysis vs shunting. Conclusion: Spinal cord injury can cause a myriad of consequential conditions that affect a patient’s functional mobility and ADLs. Syringomyelia can be a potentially serious sequela in SCI patients and it is important to be aware of in that patient population as the dysfunctional CSF mechanics may continue to expand the syrinx, both proximally and distally, to a level distant from the original injury.

Acta Neurochirurgica Supplements

Introduction: Two patients previously implanted with intrathecal Baclofen (ITB) pumps for managem... more Introduction: Two patients previously implanted with intrathecal Baclofen (ITB) pumps for management of intractable spasticity due to multiple sclerosis (MS) were referred to our center for ongoing management of their spasticity. Initial evaluation of these patients revealed high levels of spasticity in the presence of ITB doses 10 times the average daily dose of our other MS patients. Clinical Facts: High doses of ITB required frequent clinical visits and result in high drug and procedure costs. Both patients' daily doses were greater than 1000 mcg/day resulting in clinical visits every 1-2 months with drug and procedure costs ranging from 16 to 23 thousand dollars annually based on Medicare national average pricing for physician's office. Of the 59 MS patients receiving ITB therapy at our institution, the mean, median, and mode daily doses for ITB are 184, 115, and 159 mcg/day, respectively. The high ITB doses in these patients and poor spasticity control raised suspicion for pump/catheter malfunction and prompted immediate troubleshooting. Findings: One patient's catheter was found to be disconnected from the pump and the other's catheter tip was outside the intrathecal space. In both cases, the patients were not receiving the therapy. After pump/catheter replacement, both patients received excellent clinical benefits from ITB at significantly lower daily doses. This reduction in dose resulted in decreased frequency of medication refills (twice annually) which resulted in decreased cost of care (12-19 thousand dollars savings annually per patient). Discussion: These cases illustrate the need for early ITB pump troubleshooting to identify catheter problems, improve efficacy, and avoid unnecessary healthcare costs.

PM&R, 2010

A retrospective chart review was undertaken of cases of intrathecal baclofen (ITB) pump/catheter ... more A retrospective chart review was undertaken of cases of intrathecal baclofen (ITB) pump/catheter malfunction and the diagnostic tests performed to identify the problem. An internal review was performed to develop a diagnostic flow chart to have a systematic method for identifying ITB pump and catheter complications. Retrospective chart review. Tertiary care hospital. A total of 167 adult patients currently followed in outpatient clinic with intractable spasticity and ITB pump implanted between January 1994 and May 2009. None. Catheter malfunction was identified either by anterior/posterior and lateral thoracic/lumbar radiographs, fluoroscopic guided side port access, contrast agent injection followed by CT (fluoro/CT) scan, or indium radionuclide studies. During the study period, 33 patients had 37 catheter revisions. Radiographs were obtained in all cases; fluoro/CT studies in 22, and indium studies in 6. Four cases had both fluoro/CT and indium studies. A total of 13 cases (35.1%) were diagnosed with radiographs; 9 cases (24.3%) were diagnosed by inability to withdraw cerebral spinal fluid from the side port; 13 cases (35.1%) were diagnosed with fluoro/CT studies; and 2 cases (5.4%) were diagnosed with indium studies. Fluoro/CT studies demonstrated subdural catheter location in 7 cases. A total of 2 of 4 cases with both fluoro/CT and indium studies had normal-appearing indium scans and an abnormal fluoro/CT study confirming subdural catheter placement. On the basis of an internal review of the diagnostic studies used to identify patients with suspected ITB pump/catheter malfunction, a troubleshooting flow chart was developed. Timely identification and correction of potential ITB complications could improve the clinical effectiveness of ITB and may reduce unnecessary health-care costs.

PM&R, 2009

Disclosures: P. Azari, None. Patients or Programs: A 65-year-old man with coronary artery disease... more Disclosures: P. Azari, None. Patients or Programs: A 65-year-old man with coronary artery disease status post coronary artery bypass graft, hypothyroidism and poor wound healing presents to an acute inpatient rehabilitation unit after a prolonged hospital course due to deconditioning. Program Description: On admission to the rehabilitation unit the patient presented with decreased endurance, a stage III ulcer on the left calf, and a stage II ulcer on his left heel. He was placed on continuous tube feeds throughout his stay in the acute inpatient hospital and despite adequate feeding and vitamin supplementation, his wounds did not heal. On admission to the rehabilitation unit the patient had an elevated TSH of 33.290 despite having been on his normal dose of Synthroid. During his rehabilitation stay the patient was changed to bolus tube feeds and his TSH levels subsequently normalized. Setting: Tertiary care rehabilitation hospital. Results: Following the change to bolus feeds the patient was able to absorb the Synthroid and his TSH levels decreased. The patient’s hypothyroidism contributed to his poor wound healing, fatigue, and decreased endurance. As his thyroid levels normalized, his energy level improved and he increased time spent in physical therapy. But despite aggressive attempts to salvage his leg with wound care and nutritional supplementation, the wounds led to osteomyelitis resulting in an above the knee amputation. Discussion: Hypothyroidism causes many problems including poor wound healing, decreased endurance, fatigue, irritability, muscle cramps, weakness, and depression. The quicker the adverse effects are managed, the better the patient will improve medically and functionally. As physiatrists doing consults or working in inpatient units, we often see patients on continuous tube feeds. It is important for us to recognize patients with a history of hypothyroidism receiving Synthroid along with continuous tube feeds. To ensure proper absorption of Synthroid, it must be taken on an empty stomach. If we can recognize these patients early on then we can avoid the effects of uncontrolled hypothyroidism. Conclusions: In hypothyroid patients on continuous tube feeds, a break should be initiated in which the Synthroid is given to ensure proper absorption of the medication to avoid the unwanted effects of hypothyroidism.

Neurology, 2012

Objective: To improve clinician education in the use of deep brain stimulation and intrathecal ba... more Objective: To improve clinician education in the use of deep brain stimulation and intrathecal baclofen device therapy for movement disorders through the systematic development of competency-based curricula as part of an overarching competency-based neuromodulation curriculum. Background Although competency-based curricula are effective in developing continuing competence in clinical practice, the process of identifying competencies is often cumbersome. To streamline the process, a short-term, modified Nominal Group Technique (NGT) was tested as a means of more efficiently validating and stratifying clinical competencies. Design/Methods: Educational planners used evidence-based methodologies to review existing course content and derive competencies for FDA-approved uses of DBS and ITB device implantation. The content covered DBS for Parkinson9s disease, tremor, and dystonia, and ITB for spasticity in disorders such as cerebral palsy, multiple sclerosis, deep brain injury, and stroke. In three rounds of NGT, therapy-specific physician and midlevel provider panels reviewed the competencies to validate their accuracy, reliability, and relevance; to identify whether they are core or therapy specific; to assess their appropriate learner level (novice, intermediate-to-advanced, or master); and to specify their sequence within clinical practice (preoperative, operative, postoperative, and postoperative with complications). Educational planners revised the competencies based on the panelists9 feedback and assisted panelists in coming to consensus. Results: Panelists validated and delineated relevance, type, learner level, and sequencing for 220 ITB-specific competencies for physicians/fellows and 232 for midlevel providers; and 121 DBS-specific competencies for physicians/fellows and 98 for midlevels. The process took ten weeks. The validated competencies were then used in developing a competency-based curriculum to train clinicians in patient identification, stimulation and implantation, programming, pharmacological action and safety profile, and postoperative management. Conclusions: The NGT method was successful in streamlining the process of identifying competencies, learner levels, and prerequisites for use in developing comprehensive, competency-based curricula for training in DBS and ITB therapies. Supported by: Medtronic, Inc. Disclosure: Dr. Bellande has nothing to disclose. Dr. Winicur has nothing to disclose. Dr. Gallo has received personal compensation for activities with Medtronic, St Jude Medical, Teva Neuroscience, Boeringher Ingelheim Pharmaceuticals and Novartis as a consultant. Dr. Gallo has received research support from St. Jude Medical. Dr. Turner has received personal compensation for activities with Medtronic as consultant, speaker and a participant on an advisory board. Dr. Turner has received research support from Medtoronic. Dr. Saulino has received personal compensation for activities with Einstein Physician Practice Incorporated and Albert Einstein Healthcare Network. Dr. Saulino has received research support from Albert Einstein Healthcare Network. Dr. Heath has received personal compensation for activities with Medtronic as a speaker. Dr. Bennett has nothing to disclose. Dr. Nelson has received personal compensation for activities with Medtronic, Inc. Ms. Reese has received personal compensation for activities with Medtronic as an employee. Ms. Larson has received personal compensation for activities with Medtronic, Inc. as an employee. Ms. Dawidowicz has received personal compensation for activities with Medtronic as an employee. Dr. Boche has received personal compensation for activities with Medtronic, Inc as an employee. Dr. Cox has nothing to disclose.

Archives of Physical Medicine and Rehabilitation, 2007