Posttraumatic Heterotopic Ossification Follow-up

Updated: Apr 23, 2019
  • Author: Auri Bruno-Petrina, MD, PhD; Chief Editor: Stephen Kishner, MD, MHA  more...
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Follow-up

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.

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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. [28] 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.

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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.

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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. [29]

Evidence indicates that a short course of perioperative nonsteroidal anti-inflammatory drugs (NSAIDs) can substantially limit the development of ectopic bone. [21]  Moreover, a retrospective report by Zakrasek et al suggested that prophylactic treatment with NSAIDs can help to prevent HO development during the post–spinal cord injury acute phase. The odds ratio of being diagnosed with HO in spinal cord injury patients who underwent 15 or more days of NSAID therapy was 0.1. [30]

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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.

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Prognosis

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

A study by Pavey et al indicated that in patients who have undergone amputation for combat-related injury who then undergo excision of HO, recurrence of HO requiring reexcision is more common if only partial excision of immature HO lesions initially took place or if the initial excision was made within 180 days of the injury’s occurrence. The study involved 172 patients in whom HO was excised after amputation for blast-related trauma. [31]

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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.

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