- Email: [email protected]
Poster 11 alkaptonuria 3-year follow-up. Monique B. Perry, MD (National Inst Health, Bethesda, MD); Pim Suwannarat, MD; Gloria Furst; William A. Gahl, MD, PhD; Lynn H. Gerber, MD, e-mail: [email protected]
E14
2004 Academy Annual Assembly Abstracts
Allergan, speakers bureau for Allergan; research grant from Elan, consulting fees or other remuneration from Allergan. Objective: To evaluate the effects of intra-articular injection of botulinum toxin type A (BTX-A) into joints with moderate to severe refractory pain. Design: Retrospective review of clinical experience. Setting: Veterans Affairs rheumatology clinic. Participants: 11 patients with rheumatoid arthritis (RA) and osteoarthritis (OA). Intervention: Intra-articular injection of BTX-A. Main Outcome Measures: Reduction in pain severity on a 0 to 10 scale and change in function (degree of active abduction and flexion in the upper extremity [UE], change in time to perform sit-to-stand 10 times for lower extremity [LE]). Patients were examined at intervals up to 9mo. Results: 15 joints in 11 patients were injected with 25 to 100U of BTX-A (3 knees, 3 ankles, 9 shoulders). Patients aged 42 to 82y, and had RA or OA for 10 to 30y. Pain decrease was noted 2 to 3d after the injection. Pain severity decreased by 61% in the LE joints, from 7.0 to 2.75 on 0 to 10 scale (P⫽.013), and decreased by 71% in the shoulders, from 8.2 to 2.4 (P⬍.001). UE function improved by 61% in flexion, from 68° to 113° (P⫽.001), and by 49% in abduction, from 50° to 74° (P⫽.01). LE function improved by 36% on 10 times timed stands, from 36 to 23s (P⫽.044). There was no increase in joint inflammation, no periarticular muscle weakness, and no systemic effects of fever or fatigue. Duration of effects ranged from 3 to 10mo. 6 joints were reinjected at 3 to 10mo, with a 43% to 100% pain decrease within 1mo. Conclusions: Intra-articular injection of BTX-A decreased pain and improved function without any deleterious effects. These encouraging results remain to be confirmed in a prospective, randomized, placebo-controlled trial, which is underway. Key Words: Botulinum toxin type A; Joint pain; Rehabilitation.
Poster 8 Undo Pain for Little Gain: Advanced Osteoarthritis of the Glenohumeral Joint. The Fallibility of Physical Therapy: A Case Series. Heather A. Blackburn, MD (William Beaumont Hosp, Royal Oak, MI); Myron M. LaBan, MD, MMSC; Ronald S. Taylor, MD, e-mail: [email protected]. Disclosure: H.A. Blackburn, None; M.M. LaBan, None; R.S. Taylor, None. Setting: Outpatient physiatric clinic. Patients: 7 men with clinical and radiographic evidence of advanced osteoarthritis (OA) of the glenohumeral joint (GHJ). Case Description: Patients ranged in age from 56 to 86y (avg age, 67y). Each demonstrated audible and palpable crepitance with active and passive range of motion (ROM) of the involved shoulder joint. Individual shoulder ROM was, in every instance, ⬍90° of abduction and forward flexion with a complete loss of internal rotation. Nonsteroidal anti-inflammatory drugs (NSAIDs) were prescribed for all patients as well as a physical therapy, which included therapeutic ultrasound followed by hydrocollator packing, active, and active-assisted ROM complimented by an ongoing home flexibility program. Assessment/ Results: In each instance, therapy was stopped because of intolerable increasing pain and lack of significant improvement in joint ROM despite aggressive therapy. Patients were subsequently referred for surgical consideration. Discussion: In a rapidly aging population, there has been dramatic increases in patients seeking treatment for complaints of shoulder pain associated with advanced glenohumeral OA. In our experience, physical treatment antecedent to surgical consideration has been less successful. Articular pain can be mitigated by simply limiting voluntary shoulder motion and by the judicious use of NSAIDs. Lost mobility cannot be regained and/or maintained by therapeutic shoulder manipulation without excessive pain. Contributing factors include cartilage erosion and joint incongruity due to reactive osteophyte formation as well as capsular and 2-joint muscular contracture. The subtle, progressive loss of glenohumeral ROM may initially be masked by the expedient substitution of scapulothoracic motion for diminishing GHJ excursion. Conclusions: Although a trial of therapy in selective cases of advanced glenohumeral OA is not inappropriate, more often than not it will fail to respond to conservative therapy. Key Words: Arthritis, degenerative; Rehabilitation; Shoulder.
Arthritis Poster 9 A Novel Ankle Osteoarthritis Treatment? Fluoroscopically Guided Viscosupplementation: A Case Series. Todd P. Stitik, MD (UMDNJ-New Jersey Med Sch, Newark, NJ); George C. Lin IV, MS; Patrick M. Foye, MD; Lisa A. Schoenherr, BA, e-mail: [email protected]. Disclosure: T.P. Stitik, None; G.C. Lin, None; P.M. Foye, None; L. Schoenherr, None. Setting: Office-based single specialty group practice. Patients: 2 posttraumatic ankle osteoarthritis patients. Case Description: Patients reported severe worsening of posttraumatic osteoarthritic unilateral ankle pain that had developed after remote ankle fracture treated with open reduction and fixation and subsequent hardware removal. Both had failed conservative therapy and were reluctant to undergo arthrodesis. Both instead underwent fluoroscopically guided ankle viscosupplementation injections (1mL of sodium hyaluronate [Hyalgan 20mg/2mL]) for 5 consecutive weeks. Treatment response was assessed with the Western Ontario and McMaster Universities Index (WOMAC) before the first injection and 1wk and 3mo after the last injection. Assessment/Results: Changes in the WOMAC scores were noted as soon as 1wk after the injection cycle and lasted at least 3mo. Patient 1’s baseline WOMAC scores improved at 1wk and at 3mo after final injection, as follows: global score: 35 to 28 to 27; pain subscale: 7 to 5 to 4; and physical function subscale: 22 to 17 to 17. Patient 2’s baseline WOMAC scores improved at 1wk and at 3mo after final injection, as follows: global score: 58 to 27 to 21; pain subscale: 9 to 5 to 4; stiffness subscale: 6 to 5 to 2, and physical function subscale: 43 to 18 to 15. Discussion: Given the limited amount of data, the statistical significance of the WOMAC score improvements cannot be determined. Both patients, however, subsequently requested an additional injection cycle, despite the significant out-of-pocket expense it currently represents to them. Conclusions: While the results of ankle viscosupplementation from these 2 patients are encouraging, larger controlled studies are needed to determine the benefit of this treatment. Key Words: Ankle; Osteoarthritis; Rehabilitation.
Arch Phys Med Rehabil Vol 85, September 2004
Poster 10 Saphenous Nerve Injury After Medial Knee Joint Injection: A Case Report. Masayuki Iizuka (Montefiore Med Ctr/Albert Einstein Coll Med, Bronx, NY); Ruijin Yao; Stanley Wainapel, e-mail: [email protected]. Disclosure: M. Iizuka, None; R. Yao, None; S. Wainapel, None. Setting: Outpatient rehabilitation clinic. Patient: A 68-yo woman with a history of bilateral knee osteoarthritis. Case Description: The patient decided to undergo a set of hyaluronic acid injections to the right knee. The first injection was performed via medial approach. A needle was inserted at the midpoint of medial edge of the patella. Immediately, she complained of severe local pain. The needle was withdrawn slightly, redirected, and advanced into the patellofemoral joint space. 2mL of hyaluronic acid was injected without excessive resistance. 1h later at home, she started feeling numbness at the infrapatellar and medial calf area. At the following visit, physical examination showed hypalgesia at the same region. Motor strength and deep tendon reflexes were normal. Assessment/Results: 3mo later, nerve conduction study of the bilateral saphenous nerves demonstrated normal latency and amplitude on the left side (2.5ms, 4mV), whereas the right saphenous action potential was unobtainable. 8mo after the injection, she started feeling pain at the medial calf. Physical examination revealed a positive Tinel’s sign at the anteromedial knee, with pain radiating down to the medial ankle. Vertical location of the tender point was at the same level as the midpoint between inferior pole of patella and tibial tuberosity. Discussion: Common causes of saphenous neuropathy include entrapment at Hunter’s canal and iatrogenic etiology such as knee arthroscopy. The point of tenderness, however, was much more distal to Hunter’s canal in this case. Close timing between the injection and the onset of symptom strongly suggests their cause-effect relationship. This is the first report in the literature of saphenous nerve injury after medial knee joint injection. Conclusions: Practitioners should be aware of the potential complication of medial knee joint injection. Lateral approach is probably safer and should be recommended. Key Words: Injections; Neuropathy; Rehabilitation.
Poster 11 Alkaptonuria 3-Year Follow-Up. Monique B. Perry, MD (National Inst Health, Bethesda, MD); Pim Suwannarat, MD; Gloria Furst; William A. Gahl, MD, PhD; Lynn H. Gerber, MD, e-mail: [email protected]. Disclosure: M.B. Perry, None; P. Suwannarat, None; G. Furst, None; W.A. Gahl, None; L.H. Gerber, None. Objective: To describe the progression of impairments and functional performance over a 3-y period in patients with alkaptonuria. Design: Prospective longitudinal descriptive study. Setting: Biomedical research facility. Participants: 16 subjects with alkaptonuria (9 men, 7 women; age range, 32– 64y; mean, 47.3y). Interventions: Not applicable. Main Outcome Measures: The Human Activity Profile (HAP), a self-report of physical activity; Health Assessment Questionnaire (HAQ), a measure of activities of daily living and health status; the SF-36 health survey, a measure of health status and quality of life; Fatigue Assessment Instrument (FAI); and joint range of motion (ROM). Results: The adjusted activity score, as reported in the HAP, declined in 8 subjects, improved in 5, and was unchanged in 1 of 14 subjects. HAQ score declined in 8 subjects, improved in 5, and was unchanged in 1 of 14. FAI score worsened in 9 subjects and improved in 5 of 14. The SF-36 physical function score decreased in 9 subjects and improved in 5; and the mental health score deteriorated in 6, improved in 6, and was unchanged in 2 of 14. Schober’s test demonstrated worsening in 9 subjects, improvement in 4, and was unchanged in 3 of 16. Shoulder external rotation decreased in 12 subjects and was unchanged in 4 of 16. Shoulder internal rotation decreased in 9 subjects, improved in 2, and was unchanged in 5 of 16. Internal hip rotation decreased in 14 subjects and was unchanged in 2 of 16. External hip rotation decreased in 11 subjects and was unchanged in 5 subjects. Conclusions: The great majority of patients with alkaptonuria showed significant loss in ROM in the shoulders and hips over a 3-y period. Functional loss and loss of spine mobility also occurred in most. Key Words: Alkaptonuria; Rehabilitation.
Brain Injury Poster 12 Sensitivity to Change of the Depression Intensity Scale Circles: A Simple Rating Scale for Depression in Patients After Brain Injury. Lynne Turner-Stokes, DM, FRCP (King’s Coll London, Middlesex, UK); Margot Kalmus; Frances Clegg, PhD, e-mail: [email protected]. Disclosure: L. Turner-Stokes, None; M. Kalmus, None; F. Clegg, None. Objectives: To assess sensitivity to change of the Depression Intensity Scale Circles (DISCs), a simple rating scale for depression in patients with cognitive and/or communicative deficits after brain injury. Design: Cohort analysis of consecutive patients entered into an integrated care pathway (ICP) for screening and management of depression. Setting: Inpatient neurologic rehabilitation unit. Participants: 27 patients with complex disabilities (physical, cognitive, and/or communicative deficits) after acquired brain injury (any cause). Mean age ⫾ SD was 40.1⫾13.1y. Patients were selected if they screened positive for depression (DSM-IV criteria major [n⫽12] or minor [n⫽9], or Beck Depression Inventory [BDI] score ⱖ9), and were subsequently reassessed postintervention. Interventions: Treatment according to ICP (medication/counseling/support, depending on patient need and preference). Main Outcome Measures: DISCs (a graphic rating scale depicting 6 circles [0 –5] with increasing proportion of dark shading), a vertical 10-cm visual analog scale (VAS) with tick-marks numbered 1 to 10, and BDI-II. Results: The median DISCs score on first assessment was 3 (IQR, 2– 4; range, 0 –5). Mean VAS score was 5.3⫾2.3 and mean BDI score was 20.0⫾7.0 (range, 7–31). There was a significant change in DISCs scores between initial and repeat assessment (Wilcoxon z⫽⫺2.450; P⬍.02). The change in DISCs score correlated with change in VAS score (Spearman ⫽.55, P⬍.005) and change in total BDI score (⫽.41, P⬍.05). Conclusions: Data from this small cohort of patients with brain injury provide preliminary support for the sensitivity of the DISCs to change after treatment, despite the cohort’s relatively mild degree of depression. Further study with a larger sample is required on confirm whether the DISCs can be used as a simple rating
2004 Academy Annual Assembly Abstracts
Allergan, speakers bureau for Allergan; research grant from Elan, consulting fees or other remuneration from Allergan. Objective: To evaluate the effects of intra-articular injection of botulinum toxin type A (BTX-A) into joints with moderate to severe refractory pain. Design: Retrospective review of clinical experience. Setting: Veterans Affairs rheumatology clinic. Participants: 11 patients with rheumatoid arthritis (RA) and osteoarthritis (OA). Intervention: Intra-articular injection of BTX-A. Main Outcome Measures: Reduction in pain severity on a 0 to 10 scale and change in function (degree of active abduction and flexion in the upper extremity [UE], change in time to perform sit-to-stand 10 times for lower extremity [LE]). Patients were examined at intervals up to 9mo. Results: 15 joints in 11 patients were injected with 25 to 100U of BTX-A (3 knees, 3 ankles, 9 shoulders). Patients aged 42 to 82y, and had RA or OA for 10 to 30y. Pain decrease was noted 2 to 3d after the injection. Pain severity decreased by 61% in the LE joints, from 7.0 to 2.75 on 0 to 10 scale (P⫽.013), and decreased by 71% in the shoulders, from 8.2 to 2.4 (P⬍.001). UE function improved by 61% in flexion, from 68° to 113° (P⫽.001), and by 49% in abduction, from 50° to 74° (P⫽.01). LE function improved by 36% on 10 times timed stands, from 36 to 23s (P⫽.044). There was no increase in joint inflammation, no periarticular muscle weakness, and no systemic effects of fever or fatigue. Duration of effects ranged from 3 to 10mo. 6 joints were reinjected at 3 to 10mo, with a 43% to 100% pain decrease within 1mo. Conclusions: Intra-articular injection of BTX-A decreased pain and improved function without any deleterious effects. These encouraging results remain to be confirmed in a prospective, randomized, placebo-controlled trial, which is underway. Key Words: Botulinum toxin type A; Joint pain; Rehabilitation.
Poster 8 Undo Pain for Little Gain: Advanced Osteoarthritis of the Glenohumeral Joint. The Fallibility of Physical Therapy: A Case Series. Heather A. Blackburn, MD (William Beaumont Hosp, Royal Oak, MI); Myron M. LaBan, MD, MMSC; Ronald S. Taylor, MD, e-mail: [email protected]. Disclosure: H.A. Blackburn, None; M.M. LaBan, None; R.S. Taylor, None. Setting: Outpatient physiatric clinic. Patients: 7 men with clinical and radiographic evidence of advanced osteoarthritis (OA) of the glenohumeral joint (GHJ). Case Description: Patients ranged in age from 56 to 86y (avg age, 67y). Each demonstrated audible and palpable crepitance with active and passive range of motion (ROM) of the involved shoulder joint. Individual shoulder ROM was, in every instance, ⬍90° of abduction and forward flexion with a complete loss of internal rotation. Nonsteroidal anti-inflammatory drugs (NSAIDs) were prescribed for all patients as well as a physical therapy, which included therapeutic ultrasound followed by hydrocollator packing, active, and active-assisted ROM complimented by an ongoing home flexibility program. Assessment/ Results: In each instance, therapy was stopped because of intolerable increasing pain and lack of significant improvement in joint ROM despite aggressive therapy. Patients were subsequently referred for surgical consideration. Discussion: In a rapidly aging population, there has been dramatic increases in patients seeking treatment for complaints of shoulder pain associated with advanced glenohumeral OA. In our experience, physical treatment antecedent to surgical consideration has been less successful. Articular pain can be mitigated by simply limiting voluntary shoulder motion and by the judicious use of NSAIDs. Lost mobility cannot be regained and/or maintained by therapeutic shoulder manipulation without excessive pain. Contributing factors include cartilage erosion and joint incongruity due to reactive osteophyte formation as well as capsular and 2-joint muscular contracture. The subtle, progressive loss of glenohumeral ROM may initially be masked by the expedient substitution of scapulothoracic motion for diminishing GHJ excursion. Conclusions: Although a trial of therapy in selective cases of advanced glenohumeral OA is not inappropriate, more often than not it will fail to respond to conservative therapy. Key Words: Arthritis, degenerative; Rehabilitation; Shoulder.
Arthritis Poster 9 A Novel Ankle Osteoarthritis Treatment? Fluoroscopically Guided Viscosupplementation: A Case Series. Todd P. Stitik, MD (UMDNJ-New Jersey Med Sch, Newark, NJ); George C. Lin IV, MS; Patrick M. Foye, MD; Lisa A. Schoenherr, BA, e-mail: [email protected]. Disclosure: T.P. Stitik, None; G.C. Lin, None; P.M. Foye, None; L. Schoenherr, None. Setting: Office-based single specialty group practice. Patients: 2 posttraumatic ankle osteoarthritis patients. Case Description: Patients reported severe worsening of posttraumatic osteoarthritic unilateral ankle pain that had developed after remote ankle fracture treated with open reduction and fixation and subsequent hardware removal. Both had failed conservative therapy and were reluctant to undergo arthrodesis. Both instead underwent fluoroscopically guided ankle viscosupplementation injections (1mL of sodium hyaluronate [Hyalgan 20mg/2mL]) for 5 consecutive weeks. Treatment response was assessed with the Western Ontario and McMaster Universities Index (WOMAC) before the first injection and 1wk and 3mo after the last injection. Assessment/Results: Changes in the WOMAC scores were noted as soon as 1wk after the injection cycle and lasted at least 3mo. Patient 1’s baseline WOMAC scores improved at 1wk and at 3mo after final injection, as follows: global score: 35 to 28 to 27; pain subscale: 7 to 5 to 4; and physical function subscale: 22 to 17 to 17. Patient 2’s baseline WOMAC scores improved at 1wk and at 3mo after final injection, as follows: global score: 58 to 27 to 21; pain subscale: 9 to 5 to 4; stiffness subscale: 6 to 5 to 2, and physical function subscale: 43 to 18 to 15. Discussion: Given the limited amount of data, the statistical significance of the WOMAC score improvements cannot be determined. Both patients, however, subsequently requested an additional injection cycle, despite the significant out-of-pocket expense it currently represents to them. Conclusions: While the results of ankle viscosupplementation from these 2 patients are encouraging, larger controlled studies are needed to determine the benefit of this treatment. Key Words: Ankle; Osteoarthritis; Rehabilitation.
Arch Phys Med Rehabil Vol 85, September 2004
Poster 10 Saphenous Nerve Injury After Medial Knee Joint Injection: A Case Report. Masayuki Iizuka (Montefiore Med Ctr/Albert Einstein Coll Med, Bronx, NY); Ruijin Yao; Stanley Wainapel, e-mail: [email protected]. Disclosure: M. Iizuka, None; R. Yao, None; S. Wainapel, None. Setting: Outpatient rehabilitation clinic. Patient: A 68-yo woman with a history of bilateral knee osteoarthritis. Case Description: The patient decided to undergo a set of hyaluronic acid injections to the right knee. The first injection was performed via medial approach. A needle was inserted at the midpoint of medial edge of the patella. Immediately, she complained of severe local pain. The needle was withdrawn slightly, redirected, and advanced into the patellofemoral joint space. 2mL of hyaluronic acid was injected without excessive resistance. 1h later at home, she started feeling numbness at the infrapatellar and medial calf area. At the following visit, physical examination showed hypalgesia at the same region. Motor strength and deep tendon reflexes were normal. Assessment/Results: 3mo later, nerve conduction study of the bilateral saphenous nerves demonstrated normal latency and amplitude on the left side (2.5ms, 4mV), whereas the right saphenous action potential was unobtainable. 8mo after the injection, she started feeling pain at the medial calf. Physical examination revealed a positive Tinel’s sign at the anteromedial knee, with pain radiating down to the medial ankle. Vertical location of the tender point was at the same level as the midpoint between inferior pole of patella and tibial tuberosity. Discussion: Common causes of saphenous neuropathy include entrapment at Hunter’s canal and iatrogenic etiology such as knee arthroscopy. The point of tenderness, however, was much more distal to Hunter’s canal in this case. Close timing between the injection and the onset of symptom strongly suggests their cause-effect relationship. This is the first report in the literature of saphenous nerve injury after medial knee joint injection. Conclusions: Practitioners should be aware of the potential complication of medial knee joint injection. Lateral approach is probably safer and should be recommended. Key Words: Injections; Neuropathy; Rehabilitation.
Poster 11 Alkaptonuria 3-Year Follow-Up. Monique B. Perry, MD (National Inst Health, Bethesda, MD); Pim Suwannarat, MD; Gloria Furst; William A. Gahl, MD, PhD; Lynn H. Gerber, MD, e-mail: [email protected]. Disclosure: M.B. Perry, None; P. Suwannarat, None; G. Furst, None; W.A. Gahl, None; L.H. Gerber, None. Objective: To describe the progression of impairments and functional performance over a 3-y period in patients with alkaptonuria. Design: Prospective longitudinal descriptive study. Setting: Biomedical research facility. Participants: 16 subjects with alkaptonuria (9 men, 7 women; age range, 32– 64y; mean, 47.3y). Interventions: Not applicable. Main Outcome Measures: The Human Activity Profile (HAP), a self-report of physical activity; Health Assessment Questionnaire (HAQ), a measure of activities of daily living and health status; the SF-36 health survey, a measure of health status and quality of life; Fatigue Assessment Instrument (FAI); and joint range of motion (ROM). Results: The adjusted activity score, as reported in the HAP, declined in 8 subjects, improved in 5, and was unchanged in 1 of 14 subjects. HAQ score declined in 8 subjects, improved in 5, and was unchanged in 1 of 14. FAI score worsened in 9 subjects and improved in 5 of 14. The SF-36 physical function score decreased in 9 subjects and improved in 5; and the mental health score deteriorated in 6, improved in 6, and was unchanged in 2 of 14. Schober’s test demonstrated worsening in 9 subjects, improvement in 4, and was unchanged in 3 of 16. Shoulder external rotation decreased in 12 subjects and was unchanged in 4 of 16. Shoulder internal rotation decreased in 9 subjects, improved in 2, and was unchanged in 5 of 16. Internal hip rotation decreased in 14 subjects and was unchanged in 2 of 16. External hip rotation decreased in 11 subjects and was unchanged in 5 subjects. Conclusions: The great majority of patients with alkaptonuria showed significant loss in ROM in the shoulders and hips over a 3-y period. Functional loss and loss of spine mobility also occurred in most. Key Words: Alkaptonuria; Rehabilitation.
Brain Injury Poster 12 Sensitivity to Change of the Depression Intensity Scale Circles: A Simple Rating Scale for Depression in Patients After Brain Injury. Lynne Turner-Stokes, DM, FRCP (King’s Coll London, Middlesex, UK); Margot Kalmus; Frances Clegg, PhD, e-mail: [email protected]. Disclosure: L. Turner-Stokes, None; M. Kalmus, None; F. Clegg, None. Objectives: To assess sensitivity to change of the Depression Intensity Scale Circles (DISCs), a simple rating scale for depression in patients with cognitive and/or communicative deficits after brain injury. Design: Cohort analysis of consecutive patients entered into an integrated care pathway (ICP) for screening and management of depression. Setting: Inpatient neurologic rehabilitation unit. Participants: 27 patients with complex disabilities (physical, cognitive, and/or communicative deficits) after acquired brain injury (any cause). Mean age ⫾ SD was 40.1⫾13.1y. Patients were selected if they screened positive for depression (DSM-IV criteria major [n⫽12] or minor [n⫽9], or Beck Depression Inventory [BDI] score ⱖ9), and were subsequently reassessed postintervention. Interventions: Treatment according to ICP (medication/counseling/support, depending on patient need and preference). Main Outcome Measures: DISCs (a graphic rating scale depicting 6 circles [0 –5] with increasing proportion of dark shading), a vertical 10-cm visual analog scale (VAS) with tick-marks numbered 1 to 10, and BDI-II. Results: The median DISCs score on first assessment was 3 (IQR, 2– 4; range, 0 –5). Mean VAS score was 5.3⫾2.3 and mean BDI score was 20.0⫾7.0 (range, 7–31). There was a significant change in DISCs scores between initial and repeat assessment (Wilcoxon z⫽⫺2.450; P⬍.02). The change in DISCs score correlated with change in VAS score (Spearman ⫽.55, P⬍.005) and change in total BDI score (⫽.41, P⬍.05). Conclusions: Data from this small cohort of patients with brain injury provide preliminary support for the sensitivity of the DISCs to change after treatment, despite the cohort’s relatively mild degree of depression. Further study with a larger sample is required on confirm whether the DISCs can be used as a simple rating