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Long-term functional outcomes in children following hypoxic-ischemic encephalopathy
1037
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
occupational low back injury. We recently evaluated 50 patients with shoulder pain from an industrial injury. This prospective study utilized the Distress and Risk Assessment Method (DRAM) as described by Main, et al to delineate somatic and depressive symptomatology. Concomitantly, 5 clinical nonorganic maneuvers were utilized to determine if there was a correlation between the nonorganic findings and the psychosocial testing in reference to the patient's perception of their shoulder pain and loss of function. Shoulder ultrasonography was utilized to document if there was rotator cuff or biceps tendon pathology. The 50 patients filled out the Distress Risk and Assessment Method Questionnaire, underwent a clinical evaluation, and a sonographic analysis. Results demonstrated that there was a significant correlation (p > .03) between a high DRAM score and greater than 2/5 nonorganic findings on the clinical evaluation. When there was greater than 2/5 nonorganic signs and a high DRAM score, a negative ultrasound for any rotator cuff or biceps tendon pathology was found in 88% of the patients studied. Utilization of nonorganic clinical findings, therefore, is analogous to the application of "positive Waddell findings" in the diagnosis and treatment of occupational shoulder injury. With greater than 2/5 nonorganic clinical findings, there is a strong correlation for psychosocial dysfunction as per the Distress Risk and Assessment Method. This information can be incorporated as part of the entire history and physical examination for use in patient management.
"Acute Onset of Breast Pain After Massage Therapy." Susan R. Ehrenthai, MD (Spaulding Rehabilitation, Boston, MA). Breast pain (mastalgia) is an unusual chief complaint in a physiatric patient. A 46-year-old woman was referred to an outpatient pain program after developing severe bilateral breast pain during a massage therapy session. Initially she had seen her gynecologist, who was unsure of the etiology of her pain after her physical, blood test results, and ultrasound were all normal. Two weeks after onset she was admitted to a psychiatric hospital for depression. She continued to complain of breast pain and this prompted her referral for a physiatric evaluation as part of a multidisciplinary pain program. On presentation she continued to focus on her "swollen, heavy, and painful" breasts. Physical examination was significant for dysthesias of both breasts, which disappeared with distraction. There were no signs of infection, tumor, or chostochondritis. No physiological explanation of her pain was evident. After input from the pain program team, it was believed that her pain was primarily of psychological origin and not a result of direct trauma from her massage. A "hands off" approach was undertaken with good results. The differential diagnosis of mastalgia and the role of a physiatrist in the treatment of a patient with psychogenic pain manifesting as somatic complaints will be discussed.
"lntrathecal Morphine Pain Relief after Instrumented Lumbosacrai Spinal Fusion: Dose/Benefit of Analgesia." Abraham Rogozinski, MD (Rogozinski Orthopedic Clinic, Jacksonville, FL); Chaim Rogozinski, MD; Howard B. Weiss, DO. This study was undertaken to define a safe and effective dose of intrathecal morphine and to explore the relationship of side effects to doserelated factors. Over a period from September 1990 to December 1993, 51 patients were given lmg intrathecal morphine injection within 1 ½hours of closure in the course of spinal arthrodesis. After review of this patient series, a trial was conducted with 46 patients given 0.5 mg of intrathecal morphine injection prior to operative closure. Patients were monitored for efficacy of analgesia, side effects, and duration of analgesia as calculated from time of intrathecal injection to initiation of patient-controlled analgesia (PCA) via pump or intramuscular administration of adjunctive narcotic or narcotic-like drugs. Use of pedicle screws with the instrumentation system is currently the subject of an FDA investigational device exemption study. Results involved a total of 97 patients who were given intrathecal morphine injection. Three patients developed symptoms requiring reversal of intrathecal morphine analgesia by naloxone. Two of these were symptomatic for respiratory depression (both given a 1-mg dose) and one for CNS depression (lmg dose). One patient (given a 0.5-mg dose) had hypersomnolence and delayed pain response. Among the remaining 93 patients, average duration of pain relief was 20.7 hours overall, 21.23 hours for the 1mg dose, and 20.15 hours for the 0.5-mg dose of intrathecal morphine. Results suggest that a dose of 0.5rag morphine, given intrathecally in
the course of instrumented spinal arthrodesis, yields a duration of pain control approximately that of a 1-mg dose. Serious side effects are not as prevalent with the lower dosage but are not avoided entirely. Localized allergic reaction and urinary retention occurred with both dosage regimens.
"Recurrent Hemarthrosis Associated with Reflex Sympathetic Dystrophy." Dehra L. Braverman, MD (The New York Hospital-Cornell University Medical Center, New York, NY); Hilary B. Kern, MD. Reflex sympathetic dystrophy continues to be a mysterious entity with unclear pathogenesis. The diagnosis is largely clinical and based on signs and symptoms of pain and vasomotor dysfunction. Treatment is a challenge because the underlying mechanism remains unknown. Our patient is a 75-year-old woman 2 years status post left total knee replacement who presents with her second episode of spontaneous hemarthrosis in 3 months. Shortly after arthrocentesis, dusky discoloration, mild edema, hyperesthesia, and decreased range of motion of the left knee and entire distal extremity were noted. The patient reported that she developed burning pain in her left leg subsequent to her first hemarthrosis. Despite aggressive analgesia and physical therapy her symptoms worsened. X-ray of her left knee showed severe periprosthetic osteopenia and a triple phase bone was negative. Reflex sympathetic dystrophy was considered likely based on clinical presentation and a lumbar sympathetic block was performed. The patient improved significantly with both decreased pain and enhanced functional status and continued to do well after a series of blocks. To our knowledge, this is the first reported case of recurrent nontraumatic hemarthrosis associated with the development of reflex sympathetic dystrophy.
"Epidurai Steroid Injections and the Management of Sciatica: A Meta-Analysis." Jodie K. Haselkorn, MD (Veterans Medical Center/University of Washington, Seattle, WA); Suzanne Rapp; Marcia Ciol, PhD; Kenneth C. Eiam, MD; Richard A. Deyo, MD. The purpose of this study was to use meta-analysis to synthesize the existing, conflicting literature to determine whether or not epidural steroid injections are beneficial in the management of low back pain. Studies were identified through MEDLINE search, retrospective bibliographic review, and expert referral. A priori inclusion criteria included: randomized comparison trials, human adult subjects, low back pain, abstractable data, and English language. The search produced over 300 articles, 16 of which were comparison trials. Of these, 6 met inclusion criteria. The majority of these had patient populations that were characterized by low back pain with sciatica. The outcome variable that the studies had in common was relief of pain. Authors, journal, and year of publication were masked. Article quality was assessed and data were abstracted by two reviewers. Discrepancies in abstraction were resolved by consensus. Articles scored a mean of 18.6 (13-23) on the Detsky quality scale. Five of the six articles individually demonstrated small mean positive effect, but the confidence intervals included zero (ie, results were not statistically significant). Meta-analysis was performed using the DerSimonian-Laird method. The test for heterogeneity was nonsignificant, so the data could be pooled. In the pooled analysis, the overall effect of an epidural injection was .14 CI (.032, .242). These results suggest that epidural steroid injections have a small but statistically significant benefit in the pain relief low back pain with sciatica.
Pediatric Rehabilitation "Long-Term Functional Outcomes in Children Following HypoxicIschemic Encephalopathy." Michael J. Ward, MD (University of Michigan Medical Center, Ann Arbor, MI); Edward A. Hurvitz, MD; Virginia S. Nelson, MD; Lorraine Washer, MD; Jeanne Oh, MD. We identified 263 children who received inpatient care for submersion, cardiac arrest, or pulmonary arrest over a 10-year period. Chart review provided initial data on 49 survivors who met study criteria of medical contact through at least 1 year of follow-up. There were 26 boys and 23 girls whose average age was 6.2 years (range 1.0 to 17.8 yrs) at onset. Etiologies were 38% submersions, 41% cardiac, and 21% pulmonary. Data on cognition, communication, mobility, ADL independence, and school placement allowed groupings into 4 categories: high function (26%), moderate disability (35%), severe disability (26%), and death
Arch Phys Med Rehabil Vol 76, November 1995
1038
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
(6%). Functional Independence Measure (FIM) scores were obtained on 29 survivors at a mean of 5 years after insult. Average score was 85.6 (range 20 to 126) and FIM score had strong correlation across the earlier identified functional groupings (p < .0001 by ANOVA, Kruskil Wallis test). There was a trend for older age in higher outcome groups (ANOVA, p = .06). There was no significant association between etiology and outcome. Early cognitive status and motor response correlated with functional outcomes. At 24 hours, unresponsiveness had a relative risk (RR) of 6.4 (CI 1.6 to 25.9) and flaccid or posturing motor responses a RR of 3.9 (CI 1.5 to 10.2) for outcomes of death or severe disability. A relation was also noted between responsiveness at 24 hours and the average FIM score: unresponsive (61%), FIM = 67.8; lethargic (25%), FIM = 106.6; alert (14%), FIM = 117.5; p = .02. Pupillary reactions were not significantly correlated with functional level. Seizures in the first 24 hours were associated with poorer FIM score (p = .02). Patients with significantly impaired cognitive status at one month were at greater risk to have impaired cognition at one year (RR = 3.2; CI, 1.7 to 6.3) and at long term follow-up (RR = 3.8; CI, 1.8 to 7.8). These children were also at risk of needing special education services at one year (RR = 1.9; CI, 1.2 to 2.9). This relation was not seen at long-term followup. All of the children returning to regular education within one year were unresponsive less than 6 hours and all those returning by last follow-up were unresponsive less than 1 week. Overall functional abilities were: 31% age appropriate in all ADLs, 52% bowel and bladder continent, 56% independent in all mobility skills, and 13% at age appropriate communication and cognition levels. Many long term needs for this population are identified and include: therapy services (69%), increased supervision requirements (48%), rehospitalization (21%), visual impairment (48%), spasticity (21%), and nonoral feedings (14%).
"Safety and Efficacy of Lioresai® Intrathecal (Badofen Injection) for the Management of Spastic Cerebral Palsy." Richard C. Gilmartin, MD (Neurology Center of Wichita, Wichita, KS); Derek Bruce, MD; Bruce Storrs, MD; Linda E. Krach, MD; Patrice S. Rawlins, ARNP, MN. Multicenter investigation evaluated safety and efficacy of intrathecal baclofen (IB) for patients with spastic cerebral palsy (CP) during a randomized, double-masked, placebo-controlled, crossover design with long-term, open-label follow-up. Fifty-one patients (22 female, 29 male, mean age 11 years) received a 50 #g bolus trial IB dose or an equivalent volume of placebo followed by a masked evaluation. After positive response to trial, 43 patients (84%) proceeded pump implant for longterm infusion. The primary efficacy measurement wa s reduction in muscle tone measured by decrease in the average Ashworth score in the lower extremities. The 5-point Ashworth Scale was used to assess spasticity in specific muscle groups. The Wilcoxon signed rank test was employed to test for differences between (1) baseline and 4-hour postbolus mean scores, and (2) baclofen and placebo scores at 4 hours. Results favored baclofen's efficacy over placebo (p < .05). Secondary efficacy related to upper extremities and was also significant (p < .05). Pairwise comparison of baseline Ashworth average score to 2, 4, 6 and 8 hours postinjection all were highly significant (/7 < .05) for lower and upper extremities. Safety measures included vital signs and chemistry profiles with neither statistically nor clinically significant changes. Forty patients reported 138 adverse events including vomiting (13.6%), nausea (9.8%) and weakness (9.8%). Long-term follow-up averaged 10 months, and more than 80% of implanted patients maintenaned goal Ashworth scores. Results of this multicenter investigation correlate with previously reported studies. Continuous infusion of IB appears to be effective in reducing spasticity of cerebral palsy with an acceptable safety profile.
"Aging Effects on Cerebral Palsy." Nadya G. Swedan, MD (Rehabilitation Institute of Chicago, Chicago, IL); Deborah J. GaeblerSpira, MID. Cerebral palsy affects approximately 2 of 1,000 individuals in the United States as a lifelong neurological motor impairment. Forty percent of patients with cerebral palsy are children with fairly predictable medical and rehabilitation needs and complications based on the extent of their impairments. As in the general population, life expectancy of children with cerebral palsy is increasing. The focus of the literature, however, remains on children. The lack of research regarding adults with cerebral palsy is becoming more evident, especially research that correlates adult outcome with functional abilities and rehabilitation services received in
Arch Phys Med Rehabil Vol 76, November 1995
childhood. This study surveyed adults with cerebral palsy to determine their previous and current experiences with functional, social, and medical issues. Participating patients were surveyed by mail, with follow-up telephone or personal interviews, to assess difficulties with orthopedic deficits, swallowing, gastrointestinal problems, respiratory problems, spasticity, athetosis, and pain. The most significant medical problems reported include hypertension, seizure, and obesity; orthopedic problems included neck pain and lower extremity complications. This research will define the adult experience with medical, rehabilitative, and social services, and will evaluate continuity of childhood care versus adult care. Study results will provide information for the development of preventative health and rehabilitation programs for the adult cerebral palsy population.
"Therapeutic Electrical Stimulation Effect on Gait in Children with Cerebral Palsy." Deborah J. Gaebler-Spira, MD (Rehabilitation Institute of Chicago/The Rehabilitation Research and Training Center in Aging with Mental Retardation, Chicago, IL); David Rich. man, MD; Paulo Selber, MD; Lnciano Dias, MD. This study assess change by gait analysis in 3 children with cerebral palsy who have utilized therapeutic electrical stimulation (TES) for strengthening. The setting was outpatient. Two of the children had right hemiplegia and one child had left hemiplegia. Their ages at entry were 5 years, 6 years, and 11 years. They were chosen by convenience to compare results of gait analysis pre/post TES. Three demensional gait: analysis was performed recording gait parameters, joint kinematics and kinetics and dynamic surface EMG activity patterns. The interpretation of the study was by the gait lab staff. Parents were directly questioned concerning changes appreciated. TES is a treatment that uses nighty low intensity transcutaneous electrcal stimulation to reduce muscle atrophy. The mechanism of action is not fully understood; the proposed mechanism is that electrical stimulation increases local blood flow and growth factors to atrophis muscles. One to 2 years of treatment is recommended. Case 1: 5-year-old right hempligia gage type 11, left SMO right hinged AFO, (TES) quadriceps, tibialis anterior. Gait Analysis and EMG, no change; kinematics, knee motion improved with better extension in early stance to midstance. Case 2: 6-year-old right hempligia gage type 11, hinged AFO (TES) quadriceps, tibialis anterior. EMG, gastrocnemius activity decreased in late swing. Kinematics, knee flexion improved in stance, parent report tripping decreased, bulked leg. Case 3 will be presented. Gait analysis for children with hemiplegia demonstrated increase knee motion for the two youngest children. Parental reports are consistent with improvement in stability. This intervention should be subjected to larger number analysis with defined groups.
"Aging with a Disability: Outcomes of Early Intervention." Angeles Badell, MD (Saint Agnes Hospital Children's Rehabilitation Center, White Plains, NY); Maria A.B. Pici, MD. This presentation reports the health status and level of function of a sample of individuals who have aged with severe physical disabilities. As children they attended an Early Intervention Program and Children's Rehabilitation Center. They graduated at ages 5 to 6 and were included in community education programs in the early 1970s when legislation opened the doors of public education to the disabled. Three hundred forty-five children graduated from the Day Program before 1985. Of this group, 41 are known dead, 37 were placed in institutions before age 10, and 199 could not be located. Sixty-eight still reside in the nearby community and were contacted for the study. We compared the present health status and level of functional ability of the 68 persons included in the study with their function at age 5 as recorded in the medical records. The analysis of the data indicates that their functional ability as adults has either decreased or at best remained unchanged from that attained at 5 years of age. There are important differences related to the 3 major diagnostic/disability groups: (1) cerebral palsy, (2) hypotonic encephalopathy with mental retardation, and (3) spina bifida. The major findings in the health status survey are the frequency of obesity, and problems caused by social isolation and inactivity, as well as overt behavioral disturbances worsening as those individuals have become older.
"Cause of Death in Children Growing with Physical Disabilities." Angeles Badell, MD (Saint Agnes Hospital Children's Rehabilitation Center, White Plains, NY); Maria A.B. Pici, MD.
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
occupational low back injury. We recently evaluated 50 patients with shoulder pain from an industrial injury. This prospective study utilized the Distress and Risk Assessment Method (DRAM) as described by Main, et al to delineate somatic and depressive symptomatology. Concomitantly, 5 clinical nonorganic maneuvers were utilized to determine if there was a correlation between the nonorganic findings and the psychosocial testing in reference to the patient's perception of their shoulder pain and loss of function. Shoulder ultrasonography was utilized to document if there was rotator cuff or biceps tendon pathology. The 50 patients filled out the Distress Risk and Assessment Method Questionnaire, underwent a clinical evaluation, and a sonographic analysis. Results demonstrated that there was a significant correlation (p > .03) between a high DRAM score and greater than 2/5 nonorganic findings on the clinical evaluation. When there was greater than 2/5 nonorganic signs and a high DRAM score, a negative ultrasound for any rotator cuff or biceps tendon pathology was found in 88% of the patients studied. Utilization of nonorganic clinical findings, therefore, is analogous to the application of "positive Waddell findings" in the diagnosis and treatment of occupational shoulder injury. With greater than 2/5 nonorganic clinical findings, there is a strong correlation for psychosocial dysfunction as per the Distress Risk and Assessment Method. This information can be incorporated as part of the entire history and physical examination for use in patient management.
"Acute Onset of Breast Pain After Massage Therapy." Susan R. Ehrenthai, MD (Spaulding Rehabilitation, Boston, MA). Breast pain (mastalgia) is an unusual chief complaint in a physiatric patient. A 46-year-old woman was referred to an outpatient pain program after developing severe bilateral breast pain during a massage therapy session. Initially she had seen her gynecologist, who was unsure of the etiology of her pain after her physical, blood test results, and ultrasound were all normal. Two weeks after onset she was admitted to a psychiatric hospital for depression. She continued to complain of breast pain and this prompted her referral for a physiatric evaluation as part of a multidisciplinary pain program. On presentation she continued to focus on her "swollen, heavy, and painful" breasts. Physical examination was significant for dysthesias of both breasts, which disappeared with distraction. There were no signs of infection, tumor, or chostochondritis. No physiological explanation of her pain was evident. After input from the pain program team, it was believed that her pain was primarily of psychological origin and not a result of direct trauma from her massage. A "hands off" approach was undertaken with good results. The differential diagnosis of mastalgia and the role of a physiatrist in the treatment of a patient with psychogenic pain manifesting as somatic complaints will be discussed.
"lntrathecal Morphine Pain Relief after Instrumented Lumbosacrai Spinal Fusion: Dose/Benefit of Analgesia." Abraham Rogozinski, MD (Rogozinski Orthopedic Clinic, Jacksonville, FL); Chaim Rogozinski, MD; Howard B. Weiss, DO. This study was undertaken to define a safe and effective dose of intrathecal morphine and to explore the relationship of side effects to doserelated factors. Over a period from September 1990 to December 1993, 51 patients were given lmg intrathecal morphine injection within 1 ½hours of closure in the course of spinal arthrodesis. After review of this patient series, a trial was conducted with 46 patients given 0.5 mg of intrathecal morphine injection prior to operative closure. Patients were monitored for efficacy of analgesia, side effects, and duration of analgesia as calculated from time of intrathecal injection to initiation of patient-controlled analgesia (PCA) via pump or intramuscular administration of adjunctive narcotic or narcotic-like drugs. Use of pedicle screws with the instrumentation system is currently the subject of an FDA investigational device exemption study. Results involved a total of 97 patients who were given intrathecal morphine injection. Three patients developed symptoms requiring reversal of intrathecal morphine analgesia by naloxone. Two of these were symptomatic for respiratory depression (both given a 1-mg dose) and one for CNS depression (lmg dose). One patient (given a 0.5-mg dose) had hypersomnolence and delayed pain response. Among the remaining 93 patients, average duration of pain relief was 20.7 hours overall, 21.23 hours for the 1mg dose, and 20.15 hours for the 0.5-mg dose of intrathecal morphine. Results suggest that a dose of 0.5rag morphine, given intrathecally in
the course of instrumented spinal arthrodesis, yields a duration of pain control approximately that of a 1-mg dose. Serious side effects are not as prevalent with the lower dosage but are not avoided entirely. Localized allergic reaction and urinary retention occurred with both dosage regimens.
"Recurrent Hemarthrosis Associated with Reflex Sympathetic Dystrophy." Dehra L. Braverman, MD (The New York Hospital-Cornell University Medical Center, New York, NY); Hilary B. Kern, MD. Reflex sympathetic dystrophy continues to be a mysterious entity with unclear pathogenesis. The diagnosis is largely clinical and based on signs and symptoms of pain and vasomotor dysfunction. Treatment is a challenge because the underlying mechanism remains unknown. Our patient is a 75-year-old woman 2 years status post left total knee replacement who presents with her second episode of spontaneous hemarthrosis in 3 months. Shortly after arthrocentesis, dusky discoloration, mild edema, hyperesthesia, and decreased range of motion of the left knee and entire distal extremity were noted. The patient reported that she developed burning pain in her left leg subsequent to her first hemarthrosis. Despite aggressive analgesia and physical therapy her symptoms worsened. X-ray of her left knee showed severe periprosthetic osteopenia and a triple phase bone was negative. Reflex sympathetic dystrophy was considered likely based on clinical presentation and a lumbar sympathetic block was performed. The patient improved significantly with both decreased pain and enhanced functional status and continued to do well after a series of blocks. To our knowledge, this is the first reported case of recurrent nontraumatic hemarthrosis associated with the development of reflex sympathetic dystrophy.
"Epidurai Steroid Injections and the Management of Sciatica: A Meta-Analysis." Jodie K. Haselkorn, MD (Veterans Medical Center/University of Washington, Seattle, WA); Suzanne Rapp; Marcia Ciol, PhD; Kenneth C. Eiam, MD; Richard A. Deyo, MD. The purpose of this study was to use meta-analysis to synthesize the existing, conflicting literature to determine whether or not epidural steroid injections are beneficial in the management of low back pain. Studies were identified through MEDLINE search, retrospective bibliographic review, and expert referral. A priori inclusion criteria included: randomized comparison trials, human adult subjects, low back pain, abstractable data, and English language. The search produced over 300 articles, 16 of which were comparison trials. Of these, 6 met inclusion criteria. The majority of these had patient populations that were characterized by low back pain with sciatica. The outcome variable that the studies had in common was relief of pain. Authors, journal, and year of publication were masked. Article quality was assessed and data were abstracted by two reviewers. Discrepancies in abstraction were resolved by consensus. Articles scored a mean of 18.6 (13-23) on the Detsky quality scale. Five of the six articles individually demonstrated small mean positive effect, but the confidence intervals included zero (ie, results were not statistically significant). Meta-analysis was performed using the DerSimonian-Laird method. The test for heterogeneity was nonsignificant, so the data could be pooled. In the pooled analysis, the overall effect of an epidural injection was .14 CI (.032, .242). These results suggest that epidural steroid injections have a small but statistically significant benefit in the pain relief low back pain with sciatica.
Pediatric Rehabilitation "Long-Term Functional Outcomes in Children Following HypoxicIschemic Encephalopathy." Michael J. Ward, MD (University of Michigan Medical Center, Ann Arbor, MI); Edward A. Hurvitz, MD; Virginia S. Nelson, MD; Lorraine Washer, MD; Jeanne Oh, MD. We identified 263 children who received inpatient care for submersion, cardiac arrest, or pulmonary arrest over a 10-year period. Chart review provided initial data on 49 survivors who met study criteria of medical contact through at least 1 year of follow-up. There were 26 boys and 23 girls whose average age was 6.2 years (range 1.0 to 17.8 yrs) at onset. Etiologies were 38% submersions, 41% cardiac, and 21% pulmonary. Data on cognition, communication, mobility, ADL independence, and school placement allowed groupings into 4 categories: high function (26%), moderate disability (35%), severe disability (26%), and death
Arch Phys Med Rehabil Vol 76, November 1995
1038
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
(6%). Functional Independence Measure (FIM) scores were obtained on 29 survivors at a mean of 5 years after insult. Average score was 85.6 (range 20 to 126) and FIM score had strong correlation across the earlier identified functional groupings (p < .0001 by ANOVA, Kruskil Wallis test). There was a trend for older age in higher outcome groups (ANOVA, p = .06). There was no significant association between etiology and outcome. Early cognitive status and motor response correlated with functional outcomes. At 24 hours, unresponsiveness had a relative risk (RR) of 6.4 (CI 1.6 to 25.9) and flaccid or posturing motor responses a RR of 3.9 (CI 1.5 to 10.2) for outcomes of death or severe disability. A relation was also noted between responsiveness at 24 hours and the average FIM score: unresponsive (61%), FIM = 67.8; lethargic (25%), FIM = 106.6; alert (14%), FIM = 117.5; p = .02. Pupillary reactions were not significantly correlated with functional level. Seizures in the first 24 hours were associated with poorer FIM score (p = .02). Patients with significantly impaired cognitive status at one month were at greater risk to have impaired cognition at one year (RR = 3.2; CI, 1.7 to 6.3) and at long term follow-up (RR = 3.8; CI, 1.8 to 7.8). These children were also at risk of needing special education services at one year (RR = 1.9; CI, 1.2 to 2.9). This relation was not seen at long-term followup. All of the children returning to regular education within one year were unresponsive less than 6 hours and all those returning by last follow-up were unresponsive less than 1 week. Overall functional abilities were: 31% age appropriate in all ADLs, 52% bowel and bladder continent, 56% independent in all mobility skills, and 13% at age appropriate communication and cognition levels. Many long term needs for this population are identified and include: therapy services (69%), increased supervision requirements (48%), rehospitalization (21%), visual impairment (48%), spasticity (21%), and nonoral feedings (14%).
"Safety and Efficacy of Lioresai® Intrathecal (Badofen Injection) for the Management of Spastic Cerebral Palsy." Richard C. Gilmartin, MD (Neurology Center of Wichita, Wichita, KS); Derek Bruce, MD; Bruce Storrs, MD; Linda E. Krach, MD; Patrice S. Rawlins, ARNP, MN. Multicenter investigation evaluated safety and efficacy of intrathecal baclofen (IB) for patients with spastic cerebral palsy (CP) during a randomized, double-masked, placebo-controlled, crossover design with long-term, open-label follow-up. Fifty-one patients (22 female, 29 male, mean age 11 years) received a 50 #g bolus trial IB dose or an equivalent volume of placebo followed by a masked evaluation. After positive response to trial, 43 patients (84%) proceeded pump implant for longterm infusion. The primary efficacy measurement wa s reduction in muscle tone measured by decrease in the average Ashworth score in the lower extremities. The 5-point Ashworth Scale was used to assess spasticity in specific muscle groups. The Wilcoxon signed rank test was employed to test for differences between (1) baseline and 4-hour postbolus mean scores, and (2) baclofen and placebo scores at 4 hours. Results favored baclofen's efficacy over placebo (p < .05). Secondary efficacy related to upper extremities and was also significant (p < .05). Pairwise comparison of baseline Ashworth average score to 2, 4, 6 and 8 hours postinjection all were highly significant (/7 < .05) for lower and upper extremities. Safety measures included vital signs and chemistry profiles with neither statistically nor clinically significant changes. Forty patients reported 138 adverse events including vomiting (13.6%), nausea (9.8%) and weakness (9.8%). Long-term follow-up averaged 10 months, and more than 80% of implanted patients maintenaned goal Ashworth scores. Results of this multicenter investigation correlate with previously reported studies. Continuous infusion of IB appears to be effective in reducing spasticity of cerebral palsy with an acceptable safety profile.
"Aging Effects on Cerebral Palsy." Nadya G. Swedan, MD (Rehabilitation Institute of Chicago, Chicago, IL); Deborah J. GaeblerSpira, MID. Cerebral palsy affects approximately 2 of 1,000 individuals in the United States as a lifelong neurological motor impairment. Forty percent of patients with cerebral palsy are children with fairly predictable medical and rehabilitation needs and complications based on the extent of their impairments. As in the general population, life expectancy of children with cerebral palsy is increasing. The focus of the literature, however, remains on children. The lack of research regarding adults with cerebral palsy is becoming more evident, especially research that correlates adult outcome with functional abilities and rehabilitation services received in
Arch Phys Med Rehabil Vol 76, November 1995
childhood. This study surveyed adults with cerebral palsy to determine their previous and current experiences with functional, social, and medical issues. Participating patients were surveyed by mail, with follow-up telephone or personal interviews, to assess difficulties with orthopedic deficits, swallowing, gastrointestinal problems, respiratory problems, spasticity, athetosis, and pain. The most significant medical problems reported include hypertension, seizure, and obesity; orthopedic problems included neck pain and lower extremity complications. This research will define the adult experience with medical, rehabilitative, and social services, and will evaluate continuity of childhood care versus adult care. Study results will provide information for the development of preventative health and rehabilitation programs for the adult cerebral palsy population.
"Therapeutic Electrical Stimulation Effect on Gait in Children with Cerebral Palsy." Deborah J. Gaebler-Spira, MD (Rehabilitation Institute of Chicago/The Rehabilitation Research and Training Center in Aging with Mental Retardation, Chicago, IL); David Rich. man, MD; Paulo Selber, MD; Lnciano Dias, MD. This study assess change by gait analysis in 3 children with cerebral palsy who have utilized therapeutic electrical stimulation (TES) for strengthening. The setting was outpatient. Two of the children had right hemiplegia and one child had left hemiplegia. Their ages at entry were 5 years, 6 years, and 11 years. They were chosen by convenience to compare results of gait analysis pre/post TES. Three demensional gait: analysis was performed recording gait parameters, joint kinematics and kinetics and dynamic surface EMG activity patterns. The interpretation of the study was by the gait lab staff. Parents were directly questioned concerning changes appreciated. TES is a treatment that uses nighty low intensity transcutaneous electrcal stimulation to reduce muscle atrophy. The mechanism of action is not fully understood; the proposed mechanism is that electrical stimulation increases local blood flow and growth factors to atrophis muscles. One to 2 years of treatment is recommended. Case 1: 5-year-old right hempligia gage type 11, left SMO right hinged AFO, (TES) quadriceps, tibialis anterior. Gait Analysis and EMG, no change; kinematics, knee motion improved with better extension in early stance to midstance. Case 2: 6-year-old right hempligia gage type 11, hinged AFO (TES) quadriceps, tibialis anterior. EMG, gastrocnemius activity decreased in late swing. Kinematics, knee flexion improved in stance, parent report tripping decreased, bulked leg. Case 3 will be presented. Gait analysis for children with hemiplegia demonstrated increase knee motion for the two youngest children. Parental reports are consistent with improvement in stability. This intervention should be subjected to larger number analysis with defined groups.
"Aging with a Disability: Outcomes of Early Intervention." Angeles Badell, MD (Saint Agnes Hospital Children's Rehabilitation Center, White Plains, NY); Maria A.B. Pici, MD. This presentation reports the health status and level of function of a sample of individuals who have aged with severe physical disabilities. As children they attended an Early Intervention Program and Children's Rehabilitation Center. They graduated at ages 5 to 6 and were included in community education programs in the early 1970s when legislation opened the doors of public education to the disabled. Three hundred forty-five children graduated from the Day Program before 1985. Of this group, 41 are known dead, 37 were placed in institutions before age 10, and 199 could not be located. Sixty-eight still reside in the nearby community and were contacted for the study. We compared the present health status and level of functional ability of the 68 persons included in the study with their function at age 5 as recorded in the medical records. The analysis of the data indicates that their functional ability as adults has either decreased or at best remained unchanged from that attained at 5 years of age. There are important differences related to the 3 major diagnostic/disability groups: (1) cerebral palsy, (2) hypotonic encephalopathy with mental retardation, and (3) spina bifida. The major findings in the health status survey are the frequency of obesity, and problems caused by social isolation and inactivity, as well as overt behavioral disturbances worsening as those individuals have become older.
"Cause of Death in Children Growing with Physical Disabilities." Angeles Badell, MD (Saint Agnes Hospital Children's Rehabilitation Center, White Plains, NY); Maria A.B. Pici, MD.