OBJECTIVES To examine the effect of a multi-component intervention on pain and function following orthopedic surgery. DESIGN Controlled prospective propensity score matched clinical trial. SETTING New York City acute rehabilitation hospital. PARTICIPANTS 249 patients admitted to rehabilitation following hip fracture repair (N=51) hip (N=64) or knee (N=134) arthroplasty. INTERVENTION Pain assessment at rest and with physical therapy (PT) by staff using numeric rating scales (1 to 5). Physician protocols for standing analgesia and pre-emptive analgesia prior to PT were implemented on the intervention unit. Control unit patients received usual care. MAIN OUTCOME MEASURES Pain, analgesic prescribing, gait speed, transfer time, and percent of PT sessions completed during admission. Pain and difficulty walking at 6, 12, 18, and 24 weeks following discharge. RESULTS In multivariable analyses compared to controls, intervention patients were significantly more likely to report no or mild pain at rest (66% versus 49%, P=.004) and with PT (52% versus 38%, P=.02) on average for the first 7 days of rehabilitation; had faster 8 foot walk times on days four (9.3 seconds versus 13.2 seconds, P=.02) and seven (6.9 versus 9.2 seconds, P=.02); received more analgesia (8.0 milligrams of morphine sulfate equivalents/day, P<0.001); were more likely to receive standing analgesia (98% versus 48%, P<.001); and had significantly shorter lengths of stay (10.1 versus 11.3 days, P=.005). At 6 months compared to controls, intervention patients were less likely to report moderate/severe pain with walking (15% versus 4%, P=.02), that pain did not interfere with walking (7% versus 18%, P=.004), and were less likely to be taking analgesics (35% versus 51%, P=.03). CONCLUSION The intervention improved post-operative pain, reduced chronic pain, and improved function.

Objective: The frequency of self reported sexual difficulties was examined in a group of 322 individuals with traumatic brain injury (TBI) (N = 193 men; 129 women) and contrasted with reports of sexual difficulties in 264 individuals without disability (152 men; 112 women) residing in the community. Physiological, physical, and body images problems impacting sexual functioning were examined individually and then summed into a sexual dysfunction score. Mood, quality of life, health status and presence of an endocrine disorder were examined as predictors of sexual difficulties post TBI.Study design: In this retrospective study, data about sexual difficulties were analyzed separately for men and women with TBI and without disability. ANOVAs with post hoc analysis for continuous variables, chi-square analyses for categorical variables, and ANCOVAs for predictors of sexual difficulties were utilized.Results: When contrasted to individuals without disability, individuals with TBI reported more frequent: (1) physiological difficulties influencing their energy for sex, sex drive, ability to initiate sexual activities and achieve orgasm;(2) physical difficulties influencing body positioning, body movement and sensation, and (3) body image difficulties influencing feelings of attractive and comfort with having a partner view one's body during sexual activity. Additional gender specific TBI findings were observed. In comparison to gender matched groups without disability, men with TBI reported less frequent involvement in sexual activity and relationships, and more frequent difficulties in sustaining an erection; women with TBI reported more frequent difficulties in sexual arousal, pain with sex, masturbation and vaginal lubrication. While groups differed in core demographic variables, age was the only demographic variable that was related to reports of sexual difficulties in individuals with TBI and men without disability. Age at onset and severity of injury were negatively related to reports of sexual difficulties in individuals with TBI. In men with TBI and without disability, the most sensitive predictor of sexual dysfunction was level of depression. For women without disability, an endocrine disorder was the most sensitive predictor of sexual dysfunction. For women with TBI, an endocrine disorder and level depression combined were the most sensitive predictors of sexual difficulties.Conclusion: Individuals post TBI report frequent physiological, physical and body images difficulties which negatively impact sexual activity and interest. For men post TBI, predictors of sexual difficulties included age at interview, age at injury, and having milder injuries, however, depression was the most sensitive predictor of sexual dysfunctions. For women post TBI, predictors of their sexual difficulties included age at injury and having milder injuries, however, depression and an endocrine disorder combined were the most sensitive predictors of sexual dysfunction. Implications of this study include the need for broad-based assessmen...

Background Early neurorehabilitation improves outcomes in patients with disorders of consciousness (DoC) after brain injury, but its applicability in COVID-19 is unknown. We describe our experience implementing an early neurorehabilitation protocol for patients with COVID-19-associated DoC in the intensive care unit (ICU) and evaluate factors associated with recovery. Methods During the initial COVID-19 surge in New York City between March 10 and May 20, 2020, faced with a disproportionately high number of ICU patients with prolonged unresponsiveness, we developed and implemented an early neurorehabilitation protocol, applying standard practices from brain injury rehabilitation care to the ICU setting. Twenty-one patients with delayed recovery of consciousness after severe COVID-19 participated in a pilot early neurorehabilitation program that included serial Coma Recovery Scale-Revised (CRS-R) assessments, multimodal treatment, and access to clinicians specializing in brain injury medicine. We retrospectively compared clinical features of patients who did and did not recover to the minimally conscious state (MCS) or better, defined as a CRS-R total score (TS) ≥ 8, before discharge. We additionally examined factors associated with best CRS-R TS, last CRS-R TS, hospital length of stay, and time on mechanical ventilation. Results Patients underwent CRS-R assessments a median of six (interquartile range [IQR] 3–10) times before discharge, beginning a median of 48 days (IQR 40–55) from admission. Twelve (57%) patients recovered to MCS after a median of 8 days (IQR 2–14) off continuous sedation; they had lower body mass index ( p = 0.009), lower peak serum C-reactive protein levels ( p = 0.023), higher minimum arterial partial pressure of oxygen ( p = 0.028), and earlier fentanyl discontinuation ( p = 0.018). CRS-R scores fluctuated over time, and the best CRS-R TS was significantly higher than the last CRS-R TS (median 8 [IQR 5–23] vs. 5 [IQR 3–18], p = 0.002). Earlier fentanyl ( p = 0.001) and neuromuscular blockade ( p = 0.015) discontinuation correlated with a higher last CRS-R TS. Conclusions More than half of our cohort of patients with prolonged unresponsiveness following severe COVID-19 recovered to MCS or better before hospital discharge, achieving a clinical benchmark known to have relatively favorable long-term prognostic implications in DoC of other etiologies. Hypoxia, systemic inflammation, sedation, and neuromuscular blockade may impact diagnostic assessment and prognosis, and fluctuations in level of consciousness make serial assessments essential. Early neurorehabilitation of these patients in the ICU can be accomplished but is associated with unique challenges. Further research should evaluate factors associated...