eMedicine Specialties > Physical Medicine and Rehabilitation > Traumatic Brain Injury

Posttraumatic Heterotopic Ossification: Follow-up

Author: Auri Bruno-Petrina, MD, PhD, Clinical Trainee, Pemberton Marine Medical Clinic, N Vancouver
Contributor Information and Disclosures

Updated: Jul 28, 2008

Follow-up

Further Inpatient Care

  • If, at discharge from acute care, the residual impairments are of such severity that the patient remains dependent, options include an acute or a subacute rehabilitation program.22 The typical candidate for a TBI acute rehabilitation unit is the patient who consistently is able to follow a 1-step command but who often is confused, disoriented, and restless, if not overtly agitated; many patients have a combination of physical limitations or medical complications.

    The ideal goal of this phase of rehabilitation is to assist the patient during the period ranging from the late stages of unconsciousness through the clearing of posttraumatic amnesia, resolution of agitation, and at least minimal independence in activities of daily living (ADL). For the patient and his/her family, the most salient goal of the acute rehabilitation phase is to regain optimal independence in ADL. To remain in this rehabilitation environment, the patient must be able to tolerate and benefit from a minimum of 3 hours of therapy, 5 days per week.
  • Subacute rehabilitation programs are largely based in nursing homes. Such programs do not require that the patient tolerate 8 hours of therapy per day. Consequently, subacute rehabilitation programs are most appropriate for patients who remain in the coma stages, inconsistently respond to simple commands, or show a low rate of progress. The typical length of stay is considerably longer than the present national average of approximately 30 days in acute rehabilitation. Largely because of staffing and overhead, subacute rehabilitation offers health care providers a less expensive form of specialized intervention. Although data support the importance of early rehabilitation interventions to outcome, virtually no data compare the outcome of acute intervention with that of subacute intervention.

Further Outpatient Care

  • After documenting the extent of impairment and estimating functional outcome, the physiatrist should determine the most appropriate rehabilitation interventions. Early rehabilitation is initiated while the patient remains on the trauma or neurosurgical service unit. Rehabilitation options after this early stage are predicated on the nature of residual impairments. In the unlikely event that a patient with severe TBI recovers sufficiently during acute care to permit rehabilitation management on an outpatient basis, individual outpatient services or a day treatment program may be recommended. Day treatment rehabilitation typically offers integrated programs of physical therapy, occupational therapy, speech therapy, cognitive remediation, and psychological services up to 8 hours per day, 5 days per week.

Transfer

  • Once the patient is ready to be transferred from inpatient rehabilitation, a number of postacute management strategies are available. If the patient can be given effective treatment at home, then rehabilitation options include individual in-home or outpatient therapy or comprehensive day treatment services. If the patient in an acute rehabilitation setting fails to achieve basic functional independence in a timely fashion, transfer to a subacute rehabilitation program may be warranted. In the event that behavioral problems, such as agitation, preclude discharge to the home, more specialized inpatient behavioral treatment programs are indicated. Another level in the continuum of rehabilitation includes transitional living programs, which typically are residential community – based alternatives for patients with primarily cognitive and neurobehavioral deficits.

Deterrence

  • Various recommendations have been made to prevent recurrence of heterotopic ossification (HO). Low-dose radiation is thought to be effective in the immediate postoperative phase. Low-dose radiation also has been used to prevent HO. The recommended dose is 2000 rads over 12 days for extensive HO lesions and 1000 rads over 5-7 days for small HO lesions. Radiation is thought to prevent the conversion of mesenchymal cells to bone precursor cells. As a result, concerns about neoplasia limit its application in younger patient groups.
  • Evidence indicates that a short course of perioperative NSAIDs can substantially limit the development of ectopic bone.15

Complications

  • Once developed, heterotopic ossification (HO) may cause complications through pressure on surrounding anatomic structures. Peripheral nerve compression and vascular compression with subsequent thrombophlebitis and lymphedema may result from HO. As a result, serial evaluation of deep tendon reflexes is recommended to track peripheral nerve function. The most common complication is decreased ROM, which in rare cases may progress to joint ankylosis.

Prognosis

  • A recurrence of heterotopic ossification (HO) is less likely in patients who have higher functional abilities and exhibit normal alkaline phosphatase levels.

Patient Education

  • At 3 months after injury, families often have high hopes for recovery, especially if certain milestone signs have recently appeared. The patient recently may have begun to speak and follow some voluntary commands. Family members are elated to see these signs, which give them hope for future recovery and possible avoidance of many other problems. Moreover, because speech seems to be returning spontaneously, the family could hope for spontaneous remission of deformities.
  • Expectations tend to color the family's perception and understanding of the limits of recovery, the nature of the various pathologies, and the effects and side effects of medical intervention. For example, spasticity of a muscle may give way to voluntary activity as neurologic recovery unfolds during the first 9-18 months after head injury. Families may therefore think that contracture of the same spastic muscle also disappears when voluntary movement recovers. Aggressive interventions for contracture in the spastic state, therefore, may not make sense to the family. Education of the family clearly is needed, but what they need to know may well depend on drawing out their beliefs, hopes, and expectations. The education campaign is designed to promote compliance with clinical goals.

Miscellaneous

Medicolegal Pitfalls

  • Surgery for heterotopic ossification (HO) is challenging, because the ossified mass is highly vascular; postoperative bleeding, hematoma, and infection are common complications. Trauma to nerves also may occur. Preoperative CT scans may guide the surgeon and lower the rate of complications. Active ROM exercises may be initiated 2-3 days after surgery. More active exercises may begin about 10-14 days after pain and swelling have subsided. Patients with more severe cognitive and motor deficits may require several months of postoperative physical therapy to maintain ROM. If HO recurs, it becomes evident within 3 months after surgery.

Special Concerns

  • Indications for the treatment of increased muscle tone include the following:
    • Interference with active movement
    • Contracture formation or progression in a posturing limb
    • Interference with appropriate positioning or hygiene
    • Self-inflicted trauma during muscle spasms
    • Excessive pain with ROM exercises or during muscle spasms
    • Excessive therapy time devoted to contracture prevention rather than to functional activities
    • Prevention of heterotopic ossification (HO)
 


More on Posttraumatic Heterotopic Ossification

Overview: Posttraumatic Heterotopic Ossification
Differential Diagnoses & Workup: Posttraumatic Heterotopic Ossification
Treatment & Medication: Posttraumatic Heterotopic Ossification
Follow-up: Posttraumatic Heterotopic Ossification
Multimedia: Posttraumatic Heterotopic Ossification
References
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Further Reading

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Keywords

posttraumatic heterotopic ossification, heterotopic calcification, heterotopic ossification, HO, posttraumatic brain injury heterotopic ossification, traumatic brain injury, TBI, post-TBI heterotopic ossification, etidronate disodium, EHDP

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Contributor Information and Disclosures

Author

Auri Bruno-Petrina, MD, PhD, Clinical Trainee, Pemberton Marine Medical Clinic, N Vancouver
Auri Bruno-Petrina, MD, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Canadian Association of Physical Medicine and Rehabilitation, College of Physicians and Surgeons of British Columbia, and International Society of Physical and Rehabilitation Medicine
Disclosure: Nothing to disclose.

Medical Editor

Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School
Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service, University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center
Disclosure: Nothing to disclose.

Chief Editor

Denise I Campagnolo, MD, MS, Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St. Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consort
Denise I Campagnolo, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, and Consortium of Multiple Sclerosis Centers
Disclosure: Teva Neuroscience Honoraria Speaking and teaching; Serono-Pfizer Honoraria Speaking and teaching

 
 
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