To test the hypothesis that recovering stroke patients with initially good sitting balance or those who develop good sitting balance during rehabilitation have better Barthel Index-based functional assessment outcomes than recovering stroke patients with poor sitting balance, we prospectively studied 24 of 25 consecutive stroke patients admitted to a tertiary-care hospital rehabilitation unit Sitting balance, a prerequisite for most functional activities, was scored using a four-point scale evaluating static and dynamic sitting balance on admission to the rehabilitation unit and weekly until discharge. Functional status was assessed using the Barthel Index 4 or 12 weeks after the stroke. We found a strong positive correlation between Barthel Index score and each weekly sitting balance score. Multiple evaluations over time identified those patients whose sitting balance improved during rehabilitation in our unit; after grouping the patients into those with normal, improved, and poor sitting balance, we found a significant difference in the Barthel Index scores among the three groups. The group of patients whose sitting balance improved had higher Barthel Index scores than the group whose sitting balance did not improve. Ongoing evaluation of sitting balance can be helpful in anticipating functional status at discharge in stroke patients undergoing comprehensive rehabilitation. (Stroke 1990^1:82-86)

SummaryThe effects of intrathecal baeZofen infusion were studied in 9 spinal cord injury patients whose spasticity had been refractory to oral medications. In a two stage, placebo controlled trial, baeZofen was administered into the lumbar intrathecal space and subsequent eZinical and neurophysiologic changes were assessed.In stage 1, 9 patients underwent a 5 day percutaneous infusion of baeZofen and placebo via an external pump. Ashworth and reflex scores were assessed at time of enrollment, after infusion of that amount of baeZofen which provided optimal spasticity control and after intrathecal infusion of placebo. The mean Ashworth grade decreased from 3·78 ± 1·34 to 1·16 ± 0·48 (p < 0·001) while mean reflex score decreased from 3·57 ± 1·05 to 0·64 ± 0·87 (p < 0·001). These values differed significantly from those associated with placebo therapy (Ashworth grade-2·54 ± 1·04, P < 0·001; reflex score-2·56 ± 1·04, P < 0·01). Objective improvements in functional abilities and independence were noted in 8 patients, while somatosensory and brainstem auditory evoked potentials were unchanged in all patients. Urodynamic evaluation revealed increased bladder capacity in 3 patients, while in 4 no change was observed.In Stage 2, permanent programmable infusion pumps were implanted in 7 patients who demonstrated a good response during Stage 1. In this group, mean Ashworth score decreased from 3·79 ± 0·69 to 2 ± 0·96 (p < 0·001) and mean reflex score decreased from 3·85 ± 0·62 to 2·18 ± 0·43 (p < 0·001). BaeZofen dosage increased from 182 ± 135 to 528 ± 266 mcg/day over the 3-22 month follow-up period. Most of the dosage increase occurred within the initial 12 months following infusion pump implantation and tended to plateau thereafter.Minor complications such as catheter dislodgement/kinking and nausea occurred infrequently while no device related infections were observed. There was no eZinical evidence of any significant baeZofen neurotoxicity either in Stage 1 or 2. The only ambulatory patient developed marked lower extremity weakness during Stage 1 intrathecal baeZofen infusio� and was temporarily unable to walk.We coneZude that continuous administration of intrathecal baeZofen is an effective and safe modality for spasticity control in patients who are refractory to oral medications.

Extensive research has documented that medical care in the United States is not of optimal quality, meaning that well-established care processes are not consistently provided to the patients who would benefit from them. To assess and improve quality of care, specific measures are needed. The objective of this study was to develop quality measures for electrodiagnostic testing in suspected carpal tunnel syndrome (CTS). We used a variation of the well-established RAND/UCLA Appropriateness Method to develop the measures. A physiatrist and quality measurement experts developed draft measures based on guidelines and literature. Subsequently, in a two-round, modified-Delphi process, a multidisciplinary panel of 11 national experts in CTS reviewed a summary of the evidence and then rated the measures for validity and feasibility. Seven draft measures were developed. The expert panel combined two, modified the others, and then judged all resulting measures to be valid and feasible. The measures cover compelling indications for testing, essential test components when CTS is suspected, skin temperature measurement and normalization, and the appropriate interpretation of test results. These measures define a minimum standard of care for the use of electrodiagnostic tests in suspected CTS and are consistent with recent guidelines developed by the American Association of Neuromuscular and Electrodiagnostic Medicine. Provider organizations, insurance companies, and professional societies can use these measures in efforts to monitor and improve quality of care for this common and disabling condition.

Introduction: Providing higher quality medical care to workers with occupationally associated carpal tunnel syndrome (CTS) may reduce disability, facilitate return to work, and lower the associated costs. Although many workers’ compensation systems have adopted treatment guidelines to reduce the overuse of unnecessary care, limited attention has been paid to ensuring that the care workers do receive is high quality. Further, guidelines are not designed to enable objective assessments of quality of care. This study sought to develop quality measures for the diagnostic evaluation and non-operative management of CTS, including managing occupational activities and functional limitations. Methods: Using a variation of the well-established RAND/UCLA Appropriateness Method, we developed draft quality measures using guidelines and literature reviews. Next, in a two-round modified-Delphi process, a multidisciplinary panel of 11 U.S. experts in CTS rated the measures on validity and feasibility. Results: Of 40 draft measures, experts rated 31 (78%) valid and feasible. Nine measures pertained to diagnostic evaluation, such as assessing symptoms, signs, and risk factors. Eleven pertain to non-operative treatments, such as the use of splints, steroid injections, and medications. Eleven others address assessing the association between symptoms and work, managing occupational activities, and accommodating functional limitations. Conclusions: These measures will complement existing treatment guidelines by enabling providers, payers, policymakers, and researchers to assess quality of care for CTS in an objective, structured manner. Given the characteristics of previous measures developed with these methods, greater adherence to these measures will probably lead to improved patient outcomes at a population level.

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