- Email: [email protected]
Poster 122 hypervitaminosis a and worsening bone mineral density in a patient with osteoporosis: A case report. H. Michael Guo, MD, PhD (Univ Virginia, Charlottesville, VA); Mary G. Bryant, MD, e-mail: [email protected]
E30
2004 Academy Annual Assembly Abstracts
Poster 119 The Bald Trochanter. Spontaneous Rupture of the Conjoined Tendon of the Gluteus Medius and Minimus Presenting as a Trochanteric Bursitis: A Case Report. Susan K. Weir, MD (William Beaumont Hosp, Royal Oak, MI); Myron M. LaBan, MD, MMSc; Ronald S. Taylor, MD, e-mail: [email protected]. Disclosure: S.K. Weir, None; M.M. LaBan, None; R.S. Taylor, None. Setting: Outpatient physiatric clinic. Patient: A 66-yo woman with right lateral hip and thigh pain. Case Description: The patient presented with complaints of right lateral hip and thigh pain associated with a disabling limp without an antecedent history of trauma. Physical examination demonstrated localized pain to palpation over the right greater trochanter with an otherwise pain-free full hip range of motion as well as weakness in the hip abductors and a compensated right Trendelenberg gait. Magnetic resonance imaging (MRI) of the right hip subsequently revealed trochanteric bursitis with hip effusion as well as a full thickness tear of the gluteus medius muscle and disruption and retraction of the tendon of an atretic gluteus minimus muscle. Assessment/ Results: Conjoined tendon pathology of both the gluteus medius and minimus, as revealed by MRI examination, is more frequent than heretofore commonly recognized. Discussion: In patients presenting with intractable complaints of trochanteric bursitis and limp due to weakness in the hip abductors, imaging studies for a possible tendon rupture may in fact be diagnostic. Conservative approaches to rehabilitation as well as surgical options including tendon reattachment using heavy nonabsorbable sutures are reviewed. Conclusions: The pathology of the conjoined tendon of the gluteus medius and minimus muscles should be considered in the differential diagnosis of a patient with a disabling limp and hip pain. Key Words: Bursitis; Magnetic resonance imaging; Rehabilitation.
Poster 122 Hypervitaminosis A and Worsening Bone Mineral Density in a Patient With Osteoporosis: A Case Report. H. Michael Guo, MD, PhD (Univ Virginia, Charlottesville, VA); Mary G. Bryant, MD, e-mail: [email protected]. Disclosure: H.M. Guo, None; M.G. Bryant, None. Setting: Outpatient rehabilitation clinic. Patient: A 74-yo woman with osteoporosis. Case Description: The patient had a history of osteoporosis and progressively worsening bone mineral density (BMD) at her L2-4 spine and left femoral neck on dual-energy x-ray absorptiometry (DEXA) scans over a 5-y period. The patient was taking alendronate, raloxifene, calcium, vaginal estrogen cream, and vitamin D for her osteoporosis. In addition, she was taking vitamin A and a multivitamin. She also walked 3 to 4 miles 4 times a week and swam 2 times a week. Assessment/ Results: The patient’s BMD decreased from .681 to .628gm/cm2 over 5y as determined by yearly DEXA scans. The largest drop in BMD (.03gm/cm2) occurred in the last year of the 5-y period. Meanwhile her vitamin A level was checked and found to be elevated at .95mg/L (range, .30 –.65mg/L). The vitamin A supplement was discontinued. 14wk later, her vitamin A level had normalized, and 8mo later her BMD increased for the first time in 6y to .661gm/cm2. Discussion: Retinoic acid, an active metabolite of vitamin A, increases bone resorption and impairs bone remodeling by activating osteoclasts and suppressing osteoblasts. Studies have demonstrated that hypervitaminosis A is associated with decreased BMD and increased fracture risk in postmenopausal women. Physicians do not often discuss details of vitamin supplements with their patients or routinely check vitamin A levels. In patients with osteoporosis, hypervitaminosis A may decrease BMD and limit the effectiveness of conventional treatments for osteoporosis such as medications, supplements, hormone replacement, and exercise. Conclusions: Physiatrists should question patients with osteoporosis regarding their use of supplements containing vitamin A and monitor their vitamin A levels. Key Words: Hypervitaminosis A; Osteoporosis; Rehabilitation.
Poster 120 Bilateral Femoral Insufficiency Fractures as a Presentation of Vitamin D Deficiency and Osteopenia: A Case Report. Denise Chang (New York Presbyterian Hosp, New York, NY); David Lin; Julie Lin, e-mail: [email protected]. Disclosure: D. Chang, None; D. Lin, None; J. Lin, None. Setting: Acute rehabilitation unit in an urban area. Patient: A 27-yo white woman with a history of fibromyalgia and depression presented with right hip pain for 2mo leading to limited range of motion (ROM), difficulty ambulating, and left hip pain 4mo prior, which had resolved. There was no history of trauma. The patient had received several intra-articular cortisone injections without pain relief. Case Description: Radiologic imaging revealed a displaced right femoral neck fracture, osteopenia, and a nondisplaced left femoral neck fracture. The patient was surgically treated with an open reduction and fixation of the right hip and percutaneous pinning of the left. Additional workup included a dual-energy x-ray absorptiometry scan, which revealed osteopenia (T score⫽⫺1.6) of the lumbar spine. Laboratory data revealed vitamin D deficiency with a 25-hydroxyvitamin D value of 16 and an elevated N-telopeptide value of 83. Assessment/Results: The patient was started on high-dose vitamin D (150,000U) and calcium supplements as well as teriparatide (Forteo). She underwent bilateral surgical interventions and was admitted to the acute rehabilitation unit for intensive physical therapy. She was touch-toe weight bearing on the left lower extremity and weight bearing as tolerated on the right lower extremity. The patient responded well with significant improvements in ROM and ambulation with an assistive device, as reflected in improved motor FIM scores. Discussion: Nontraumatic hip fracture in young women may be an indicator of osteopenia and bone mineralization disorder, which could be of varying etiology. The etiologic workup of this patient’s vitamin D deficiency is ongoing, with the leading hypothesis being related to her use of the antidepressant medication bupropion (Wellbutrin). Conclusions: Bilateral femoral insufficiency fractures are a unique presentation of vitamin D deficiency and osteopenia in young women. Recognition of this association can aid the accurate diagnosis and treatment for these patients. Key Words: Fractures; Metabolic diseases; Rehabilitation.
Poster 123 Tolerability of Hylan G-F 20 in 4253 Patients With Symptomatic Osteoarthritis of the Knee in German Orthopedic Practice. Ferry Kemper, MD (Lohrey, Orthopa¨ die and Rheumatologie, Bad Soden-Salmu¨ nster, Germany), e-mail: [email protected]. Disclosure: F. Kemper, research grant from Wyeth Pharma. Objective: To determine the tolerability of hylan G-F 20 in patients with knee osteoarthritis (OA) in Germany. Design: Prospective, observational. Setting: Orthopedic clinics. Participants: 4253 outpatients with symptomatic knee OA treated by 873 physicians; approximately 5 consecutively treated patients were from each site. Intervention: 3 weekly intra-articular hylan G-F 20 injections as part of each clinician’s routine practice. Main Outcome Measures: Incidence of adverse events (AEs), including severity and relatedness to treatment. Patient pain assessment on a 4-point scale (none, mild, moderate, severe) before and 3wk after the first injection. Results: AEs 290 were reported in 227 of 4253 (5.3%) patients; 250 treatment-related AEs were reported in 201 (4.7%) patients; and 238 local AEs were reported in 214 patients (5.0% of patients; 1.9% of injections). The most frequently reported AEs were arthropathy (3.1% of patients), arthralgia (.94%), arthritis (.35%), injection site pain (.19%), synovitis (.12%), and rash erythematous (.12%). Most AEs were mild (27.8%) to moderate (46.7%) in nature. A patient experienced severe swelling and synovial fluid accumulation that was judged as possibly treatment related. When previous use of hyaluronan or hylans was considered, the AE rate was approximately 2-fold higher for patients who previously received hyaluronan or hylans compared with those who received hylan G-F 20 for the first time. Pain significantly (P⬍.0001) improved 3wk after the first injection compared with before treatment; most patients (91.7%) reported moderate or severe pain before treatment compared with most (81.4%) who reported no pain or mild pain after treatment. Conclusions: In the largest population of patients treated with hylan G-F 20 studied to date (4253 OA knee patients in Germany), the overall incidence of treatment-related and local AEs was low and consistent with the AEs reported in the current product information and from previous studies. Key Words: Knee; Osteoarthritis; Rehabilitation.
Poster 121 Autologous Whole Blood Injection for Refractory Plantar Fasciitis: A Case Report. Karl Klamar, MD (SUNY Upstate Med Univ, Syracuse, NY); Lynne Romeiser Logan, MA, PT; Jerry Leon, MD; Wladislaw Fedoriw, MD, e-mail: [email protected]. Disclosure: K. Klamar, None; L.R. Logan, None; J. Leon, None; W. Fedoriw, None. Setting: University hospital outpatient clinic. Patient: Ambulatory 18-yo woman with spastic left hemiplegic cerebral palsy developed left plantar fasciitis for 6wk with a gradual loss of function that required use of a wheelchair. Her symptoms progressed despite physical therapy, orthotics, nonsteriodal anti-inflammatory drugs, steroid injections, botulinum toxin type A (BTX-A) injection, lidoderm, hypnosis, and acupuncture. Case Description: Her foot was prepped in the usual sterile manner. 100U of BTX-A were injected into the gastrocnemius. 3mL of whole blood was drawn from the patient’s left brachial vein into a preservative-free syringe and immediately injected into the origin of the plantar fascia at the medial calcaneal tubercle and distally to the insertion of the fascia at the metatarsal heads. Assessment/Results: She reported decreased pain at 3d postinjection. At 10d, she had no pain on walking. Dorsiflexion increased by 10°. Ashworth Scale scores improved from 2 to 1⫹ for the gastrocnemius. Tardieu Scale R1 improved from ⫺20 to 0. A stretching program was taught and a better-fitting night splint was obtained. The patient returned to school, but not physical education. At 21d, she exhibited no pain when walking or slowly running, increased dorsiflexion, obtained an Ashworth score of 1 for the gastrocnemius, and was cleared for physical education. Discussion: Autologous blood injection has been described for treatment of epicondylitis. We hypothesized that the same treatment could be used as an alternative therapy for plantar fasciitis resistant to traditional treatments. This patient obtained relief from her debilitating symptoms with a combination of blood injection to plantar fascia and BTX-A to the gastrocnemius. Conclusions: Autologous blood injection combined with BTX-A may be an effective treatment for resistant plantar fasciitis. Key Words: Blood; Fasciitis; Injections; Rehabilitation.
Poster 124 Severe Extensive Heterotopic Ossification Associated With Inferior Vena Cava Filter Calcification and Myositis Ossificans: A Case Report. Edward G. Balbas, MD (East Carolina Univ, Greenville, NC); James Wells, MD, e-mail: [email protected]. Disclosure: E.G. Balbas, None; J. Wells, None. Setting: Acute rehabilitation hospital. Patient: Young adult man, with a moderate traumatic brain injury and multiple trauma from a motor vehicle collision. Case Description: He sustained a left hip dislocation and acetabular fracture, left patellar fracture, and underwent left hip reduction. He had deep vein thrombosis (DVT) in the right common iliac vein, which required an inferior vena cava (IVC) filter. His hospital course was remarkable for extensive myositis ossificans involving the soft tissues around the left hip, and proximal femur and heterotopic ossification (HO) of the medial left knee and patella. He was discharged and lost to follow-up. 2y later, radiographs taken by his physiatrist for low back pain showed ossification in the soft tissues around the right L1-2 vertebrae. A computed tomography scan also showed calcification about the IVC filter, representing an ectopic calcification of a clot within the filter. In rehabilitation pain clinic, physical examination was remarkable for largely ankylosed left knee and hip. There were no findings of persistent venous obstruction. He walked without assistive devices with a circumducted gait and left ankle inversion during stance. A right shoe lift helped with clearance of his left leg during swing. Assessment/ Results: HO generally occurs between 1 and 4mo after injury. The most commonly involved areas are the hips, medial aspect of the knees, shoulders, and elbows. The complications of HO can include peripheral nerve entrapment, development of pressure ulcers, increased risk of DVT, and extra-articular joint ankylosis. Discussion: To date, there have been no reported cases of HO and myositis ossificans associated with IVC filter calcification. Conclusion: Earlier recognition and treatment of HO has been shown to lead to improved recovery and function. HO can be associated with other findings of extraosseous calcification, such as in this case. Key Words: Myositis ossificans; Ossification, heterotopic; Rehabilitation.
Arch Phys Med Rehabil Vol 85, September 2004
2004 Academy Annual Assembly Abstracts
Poster 119 The Bald Trochanter. Spontaneous Rupture of the Conjoined Tendon of the Gluteus Medius and Minimus Presenting as a Trochanteric Bursitis: A Case Report. Susan K. Weir, MD (William Beaumont Hosp, Royal Oak, MI); Myron M. LaBan, MD, MMSc; Ronald S. Taylor, MD, e-mail: [email protected]. Disclosure: S.K. Weir, None; M.M. LaBan, None; R.S. Taylor, None. Setting: Outpatient physiatric clinic. Patient: A 66-yo woman with right lateral hip and thigh pain. Case Description: The patient presented with complaints of right lateral hip and thigh pain associated with a disabling limp without an antecedent history of trauma. Physical examination demonstrated localized pain to palpation over the right greater trochanter with an otherwise pain-free full hip range of motion as well as weakness in the hip abductors and a compensated right Trendelenberg gait. Magnetic resonance imaging (MRI) of the right hip subsequently revealed trochanteric bursitis with hip effusion as well as a full thickness tear of the gluteus medius muscle and disruption and retraction of the tendon of an atretic gluteus minimus muscle. Assessment/ Results: Conjoined tendon pathology of both the gluteus medius and minimus, as revealed by MRI examination, is more frequent than heretofore commonly recognized. Discussion: In patients presenting with intractable complaints of trochanteric bursitis and limp due to weakness in the hip abductors, imaging studies for a possible tendon rupture may in fact be diagnostic. Conservative approaches to rehabilitation as well as surgical options including tendon reattachment using heavy nonabsorbable sutures are reviewed. Conclusions: The pathology of the conjoined tendon of the gluteus medius and minimus muscles should be considered in the differential diagnosis of a patient with a disabling limp and hip pain. Key Words: Bursitis; Magnetic resonance imaging; Rehabilitation.
Poster 122 Hypervitaminosis A and Worsening Bone Mineral Density in a Patient With Osteoporosis: A Case Report. H. Michael Guo, MD, PhD (Univ Virginia, Charlottesville, VA); Mary G. Bryant, MD, e-mail: [email protected]. Disclosure: H.M. Guo, None; M.G. Bryant, None. Setting: Outpatient rehabilitation clinic. Patient: A 74-yo woman with osteoporosis. Case Description: The patient had a history of osteoporosis and progressively worsening bone mineral density (BMD) at her L2-4 spine and left femoral neck on dual-energy x-ray absorptiometry (DEXA) scans over a 5-y period. The patient was taking alendronate, raloxifene, calcium, vaginal estrogen cream, and vitamin D for her osteoporosis. In addition, she was taking vitamin A and a multivitamin. She also walked 3 to 4 miles 4 times a week and swam 2 times a week. Assessment/ Results: The patient’s BMD decreased from .681 to .628gm/cm2 over 5y as determined by yearly DEXA scans. The largest drop in BMD (.03gm/cm2) occurred in the last year of the 5-y period. Meanwhile her vitamin A level was checked and found to be elevated at .95mg/L (range, .30 –.65mg/L). The vitamin A supplement was discontinued. 14wk later, her vitamin A level had normalized, and 8mo later her BMD increased for the first time in 6y to .661gm/cm2. Discussion: Retinoic acid, an active metabolite of vitamin A, increases bone resorption and impairs bone remodeling by activating osteoclasts and suppressing osteoblasts. Studies have demonstrated that hypervitaminosis A is associated with decreased BMD and increased fracture risk in postmenopausal women. Physicians do not often discuss details of vitamin supplements with their patients or routinely check vitamin A levels. In patients with osteoporosis, hypervitaminosis A may decrease BMD and limit the effectiveness of conventional treatments for osteoporosis such as medications, supplements, hormone replacement, and exercise. Conclusions: Physiatrists should question patients with osteoporosis regarding their use of supplements containing vitamin A and monitor their vitamin A levels. Key Words: Hypervitaminosis A; Osteoporosis; Rehabilitation.
Poster 120 Bilateral Femoral Insufficiency Fractures as a Presentation of Vitamin D Deficiency and Osteopenia: A Case Report. Denise Chang (New York Presbyterian Hosp, New York, NY); David Lin; Julie Lin, e-mail: [email protected]. Disclosure: D. Chang, None; D. Lin, None; J. Lin, None. Setting: Acute rehabilitation unit in an urban area. Patient: A 27-yo white woman with a history of fibromyalgia and depression presented with right hip pain for 2mo leading to limited range of motion (ROM), difficulty ambulating, and left hip pain 4mo prior, which had resolved. There was no history of trauma. The patient had received several intra-articular cortisone injections without pain relief. Case Description: Radiologic imaging revealed a displaced right femoral neck fracture, osteopenia, and a nondisplaced left femoral neck fracture. The patient was surgically treated with an open reduction and fixation of the right hip and percutaneous pinning of the left. Additional workup included a dual-energy x-ray absorptiometry scan, which revealed osteopenia (T score⫽⫺1.6) of the lumbar spine. Laboratory data revealed vitamin D deficiency with a 25-hydroxyvitamin D value of 16 and an elevated N-telopeptide value of 83. Assessment/Results: The patient was started on high-dose vitamin D (150,000U) and calcium supplements as well as teriparatide (Forteo). She underwent bilateral surgical interventions and was admitted to the acute rehabilitation unit for intensive physical therapy. She was touch-toe weight bearing on the left lower extremity and weight bearing as tolerated on the right lower extremity. The patient responded well with significant improvements in ROM and ambulation with an assistive device, as reflected in improved motor FIM scores. Discussion: Nontraumatic hip fracture in young women may be an indicator of osteopenia and bone mineralization disorder, which could be of varying etiology. The etiologic workup of this patient’s vitamin D deficiency is ongoing, with the leading hypothesis being related to her use of the antidepressant medication bupropion (Wellbutrin). Conclusions: Bilateral femoral insufficiency fractures are a unique presentation of vitamin D deficiency and osteopenia in young women. Recognition of this association can aid the accurate diagnosis and treatment for these patients. Key Words: Fractures; Metabolic diseases; Rehabilitation.
Poster 123 Tolerability of Hylan G-F 20 in 4253 Patients With Symptomatic Osteoarthritis of the Knee in German Orthopedic Practice. Ferry Kemper, MD (Lohrey, Orthopa¨ die and Rheumatologie, Bad Soden-Salmu¨ nster, Germany), e-mail: [email protected]. Disclosure: F. Kemper, research grant from Wyeth Pharma. Objective: To determine the tolerability of hylan G-F 20 in patients with knee osteoarthritis (OA) in Germany. Design: Prospective, observational. Setting: Orthopedic clinics. Participants: 4253 outpatients with symptomatic knee OA treated by 873 physicians; approximately 5 consecutively treated patients were from each site. Intervention: 3 weekly intra-articular hylan G-F 20 injections as part of each clinician’s routine practice. Main Outcome Measures: Incidence of adverse events (AEs), including severity and relatedness to treatment. Patient pain assessment on a 4-point scale (none, mild, moderate, severe) before and 3wk after the first injection. Results: AEs 290 were reported in 227 of 4253 (5.3%) patients; 250 treatment-related AEs were reported in 201 (4.7%) patients; and 238 local AEs were reported in 214 patients (5.0% of patients; 1.9% of injections). The most frequently reported AEs were arthropathy (3.1% of patients), arthralgia (.94%), arthritis (.35%), injection site pain (.19%), synovitis (.12%), and rash erythematous (.12%). Most AEs were mild (27.8%) to moderate (46.7%) in nature. A patient experienced severe swelling and synovial fluid accumulation that was judged as possibly treatment related. When previous use of hyaluronan or hylans was considered, the AE rate was approximately 2-fold higher for patients who previously received hyaluronan or hylans compared with those who received hylan G-F 20 for the first time. Pain significantly (P⬍.0001) improved 3wk after the first injection compared with before treatment; most patients (91.7%) reported moderate or severe pain before treatment compared with most (81.4%) who reported no pain or mild pain after treatment. Conclusions: In the largest population of patients treated with hylan G-F 20 studied to date (4253 OA knee patients in Germany), the overall incidence of treatment-related and local AEs was low and consistent with the AEs reported in the current product information and from previous studies. Key Words: Knee; Osteoarthritis; Rehabilitation.
Poster 121 Autologous Whole Blood Injection for Refractory Plantar Fasciitis: A Case Report. Karl Klamar, MD (SUNY Upstate Med Univ, Syracuse, NY); Lynne Romeiser Logan, MA, PT; Jerry Leon, MD; Wladislaw Fedoriw, MD, e-mail: [email protected]. Disclosure: K. Klamar, None; L.R. Logan, None; J. Leon, None; W. Fedoriw, None. Setting: University hospital outpatient clinic. Patient: Ambulatory 18-yo woman with spastic left hemiplegic cerebral palsy developed left plantar fasciitis for 6wk with a gradual loss of function that required use of a wheelchair. Her symptoms progressed despite physical therapy, orthotics, nonsteriodal anti-inflammatory drugs, steroid injections, botulinum toxin type A (BTX-A) injection, lidoderm, hypnosis, and acupuncture. Case Description: Her foot was prepped in the usual sterile manner. 100U of BTX-A were injected into the gastrocnemius. 3mL of whole blood was drawn from the patient’s left brachial vein into a preservative-free syringe and immediately injected into the origin of the plantar fascia at the medial calcaneal tubercle and distally to the insertion of the fascia at the metatarsal heads. Assessment/Results: She reported decreased pain at 3d postinjection. At 10d, she had no pain on walking. Dorsiflexion increased by 10°. Ashworth Scale scores improved from 2 to 1⫹ for the gastrocnemius. Tardieu Scale R1 improved from ⫺20 to 0. A stretching program was taught and a better-fitting night splint was obtained. The patient returned to school, but not physical education. At 21d, she exhibited no pain when walking or slowly running, increased dorsiflexion, obtained an Ashworth score of 1 for the gastrocnemius, and was cleared for physical education. Discussion: Autologous blood injection has been described for treatment of epicondylitis. We hypothesized that the same treatment could be used as an alternative therapy for plantar fasciitis resistant to traditional treatments. This patient obtained relief from her debilitating symptoms with a combination of blood injection to plantar fascia and BTX-A to the gastrocnemius. Conclusions: Autologous blood injection combined with BTX-A may be an effective treatment for resistant plantar fasciitis. Key Words: Blood; Fasciitis; Injections; Rehabilitation.
Poster 124 Severe Extensive Heterotopic Ossification Associated With Inferior Vena Cava Filter Calcification and Myositis Ossificans: A Case Report. Edward G. Balbas, MD (East Carolina Univ, Greenville, NC); James Wells, MD, e-mail: [email protected]. Disclosure: E.G. Balbas, None; J. Wells, None. Setting: Acute rehabilitation hospital. Patient: Young adult man, with a moderate traumatic brain injury and multiple trauma from a motor vehicle collision. Case Description: He sustained a left hip dislocation and acetabular fracture, left patellar fracture, and underwent left hip reduction. He had deep vein thrombosis (DVT) in the right common iliac vein, which required an inferior vena cava (IVC) filter. His hospital course was remarkable for extensive myositis ossificans involving the soft tissues around the left hip, and proximal femur and heterotopic ossification (HO) of the medial left knee and patella. He was discharged and lost to follow-up. 2y later, radiographs taken by his physiatrist for low back pain showed ossification in the soft tissues around the right L1-2 vertebrae. A computed tomography scan also showed calcification about the IVC filter, representing an ectopic calcification of a clot within the filter. In rehabilitation pain clinic, physical examination was remarkable for largely ankylosed left knee and hip. There were no findings of persistent venous obstruction. He walked without assistive devices with a circumducted gait and left ankle inversion during stance. A right shoe lift helped with clearance of his left leg during swing. Assessment/ Results: HO generally occurs between 1 and 4mo after injury. The most commonly involved areas are the hips, medial aspect of the knees, shoulders, and elbows. The complications of HO can include peripheral nerve entrapment, development of pressure ulcers, increased risk of DVT, and extra-articular joint ankylosis. Discussion: To date, there have been no reported cases of HO and myositis ossificans associated with IVC filter calcification. Conclusion: Earlier recognition and treatment of HO has been shown to lead to improved recovery and function. HO can be associated with other findings of extraosseous calcification, such as in this case. Key Words: Myositis ossificans; Ossification, heterotopic; Rehabilitation.
Arch Phys Med Rehabil Vol 85, September 2004