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Poster 156 Successful use of nonarticulating lower extremity prostheses in a geriatric woman: A case report
1070
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Dosage was determined by number of muscles treated and spasticity severity. Following treatment, no decline in functional status (ie, impairment in mobility, self-care task performance, or swallowing), was noted. Significant improvement in spasticity severity was observed among 8 patients. These findings suggest that BTXA dosage >-400 units may be safely administered in selected patients with spasticity. Implications of treatment with "higher" doses, including antibody formation and secondary nonresponsiveness, will be discussed.
Poster 153 "Suboptimal Response of Index Distal Phalanx Spastieity Following Treatment with Botulinum Toxin A: Indications for Precise Muscle Localization with Needle Stimulation." Donna J. Roggenbuck, MD (Baylor College of Medicine, Houston, TX); Stuart A. Yablon, MD. We reviewed the outcome of botulinum toxin A (BTXA) injections Ibr treatment of spasticity involving 95 wrist and finger flexor muscle groups among adults with acquired brain injury. Most demonstrated marked improvement in spasticity in all muscle groups treated. However, we have observed a suboptimal response in the index finger distal phalanx, as compared with adjacent digits, in four patients. Suboptimal treatment response was defined as no improvement in modified Ashworth Scale, or recurrence of pretreatment degree of spasticity in less than two months. In each patient, the FDP was identified as described by Delagi (1982), with electromyography employed for confirmation of intramuscular injection. Recent introduction of monopolar needle stimulation techniques, however, enhanced anatomic identification of the index FDP. This resulted in sustained reduction of spasticity in a patient who previously demonstrated suboptimal response at an identical BTXA dose. We propose that electrical stimulation be considered to improve precision with administration of intramuscular BTXA in the distal upper extremity musculature.
Prosthetic/Orthotic/Assistive Devices Poster 154 "Decreased Balance Performance in Cowboy Boots Compared With Tennis Shoes." J. Stephen Brecht (University of Washington, Seattie, WA); Michael W. Chang, MD, PhD; Robert Price, MSME; Justus F. Lehmann, MD. Footwear serves as a support for the body, providing static and dynamic stability. Improperly designed footwear can contribute to falls by altering the biomechanics of balance. This study was done to examine the relative balance performance of subjects wearing cowboy boots versus wearing tennis shoes when challenged with different accelerations. The end point was the highest acceleration at which the subject could maintain full foot contact with the platform. Twenty-seven healthy women, 18 to 40 years old, with shoe sizes between 6 to 9, were selected for a crossover trial. The subjects were challenged with various magnitudes of anterior acceleration on a MotionspecT M balance platform. Success was defined as keeping one's feet fiat for 2 of 3 tests at each level. The highest sustainable acceleration found for subjects in boots was 10.66 ± 6.20crrds 2 lower than those in tennis shoes (p < .001). A period effect was found that improved the results of the second footwear tested by 7.2 _+ 6.20cm/s 2 (p = .025). We conclude that cowboy boots produce a decreased balance performance compared with tennis shoes, and thus pose a risk for posterior fall. More work should be done to examine the specific features in the boot that contribute to this imbalance, and to find the body's kinematic adaptations to cowboy boots.
Poster 155 "Rehabilitation after Sacrectomy." David C. Thomas, MD (Mount Sinai Medical Center, New York, NY); Adam B. Stein, MD; Narayan Sundaresan, MD; Kristjan T. Ragnarsson, MD. The purpose of this study was to examine the functional outcomes of individuals after sacrum surgery. This is a population that is not well studied because survival rates are low and they are not traditional recipients of rehabilitation services. A total of 13 patients (7 men, 6 women) underwent this procedure in the period between 1990 and 1994; 6 patients survived and were interviewed for this study. The following findings emerged from this interview: (1) Three patients were seen by a physiatrist; (2) three patients had outpatient physical therapy; (3) four individuals had unimpaired Functional Independence Measure, ie, scores above 125, and the rest were minimally impaired, ie, scores = 118
Arch Phys Med Rehabil Vol 76, November 1995
and 115; (4) all patients reported a loss of sensation; (5) two patients experienced distal leg weakness; (6) two patients were incontinent of urine; (7) four patients require a bowel regimen; (8) four patients experienced a change in their sexual functioning. (9) Finally, 3 patients have pain of sufficient severity to interfere with function. This study indicates that the survivors of this surgery are left with diverse functional impairments that could be ameliorated with rehabilitation services. Unfortunately, these needed services are often not provided because the appropriate referrals are not made.
Poster 156 "Successful Use of Nonarticulating Lower Extremity Prostheses in a Geriatric Woman: A Case Report." Nelson V. Valena, MD (Baylor College of Medicine, Houston, TX); Susan J. Garrison, MD. Successful use of short, nonarticulating lower extremity prostheses (stubbles) has previously been reported in bilateral lower extremity amputees, typically adult men or children. This case report is of a 71year-old woman with a bilateral above knee amputation (AKA) secondary to peripheral vascular disease, who has achieved independent living by using stubbles. After initial inpatient rehabilitation she was independent with wheelchair mobility; however, she required moderate assistance for transfers and lower extremity dressing. She chose to be discharged to a family member's house because her house's bathroom was not wheelchair accessible. Over the next 4 months she gradually improved in upper extremity strength and endurance but continued to have difficulty with commode transfers and dressing after toileting. She was then readmitted to inpatient rehabilitation for stubby training with a personal goal of improving toileting activities. Significant gains were made; at discharge she was at supervision level for commode transfers and was independent with clothing management after toileting using a bodysuit with a front snap crotch. She could ambulate 100 feet using a pediatric walker. The patient then returned to her own house. The advantages of stubby use include improved balance and safety as well as more efficient energy expenditure. In this case, use of stubbles by a geriatric woman gave her bathroom accessibility and ease in independence in toileting activities and made it possible for to return to her own home.
Poster 157 "Functional Outcome of Quad Amputee Patients with End-Stage Renal Disease: A Review of Three Cases." Bradley S. Merritt, MD (Baylor College of Medicine, Houston, TX); Pare Glazener, OTR; Susan J. Garrison, MD. A rare but catastrophic complication of end-stage renal disease (ESRD) is amputation of all 4 limbs secondary to gangrene. We present 3 patients with ESRD who underwent quadruple amputation. The purpose of this case study is to investigate the functional benefit of inpatient rehabilitation for such amputee patients. Our large, tertiary acute care hospital admitted 497 patients with ESRD over a 5-year period. Of these, 36 underwent 51 amputation procedures, 41 involving the lower limbs, and 10 involving the upper limbs. Three patients had all 4 limbs amputated and were subsequently admitted to our acute inpatient rehabilitation center. Their mean functional independence measurement (FIM) scores on admission were 52 ___4 and on discharge 76 ___ 2. At discharge all 3 patients were able to perform sliding board transfers and self-propel wheelchairs modified with quad knobs and brake extenders. Each continued hemodialysis 3 times a week. All were independent with feeding using adaptive equipment, although 1 required cues. Two patients were able to write using dorsal wrist splints and pencil holders, and the third patient was able to use a speaker phone and lift lightweight objects with a left below-the-elbow hook type prosthesis. Our review of these 3 cases demonstrates that inpatient rehabilitation can improve functional scores in quadruple amputee patients with ESRD. A large multicenter study is warranted to obtain adequate sample size and generate a randomized controlled study.
Poster 158 "A New Dynamic Triceps Driven Orthosis: Achieving Elbow Flexion in Patients with Central Cord Syndrome with C5 Deficits." Brett D. Lawlor, MD (Mayo Clinic, Rochester, MN); Kathryn A. Stolp-Smith, MD. We present a unique orthosis developed for a 68-year-old man with traumatic central cord syndrome following a skiing accident. Motor examination demonstrated normal elbow extensors, wrist flexors and
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Dosage was determined by number of muscles treated and spasticity severity. Following treatment, no decline in functional status (ie, impairment in mobility, self-care task performance, or swallowing), was noted. Significant improvement in spasticity severity was observed among 8 patients. These findings suggest that BTXA dosage >-400 units may be safely administered in selected patients with spasticity. Implications of treatment with "higher" doses, including antibody formation and secondary nonresponsiveness, will be discussed.
Poster 153 "Suboptimal Response of Index Distal Phalanx Spastieity Following Treatment with Botulinum Toxin A: Indications for Precise Muscle Localization with Needle Stimulation." Donna J. Roggenbuck, MD (Baylor College of Medicine, Houston, TX); Stuart A. Yablon, MD. We reviewed the outcome of botulinum toxin A (BTXA) injections Ibr treatment of spasticity involving 95 wrist and finger flexor muscle groups among adults with acquired brain injury. Most demonstrated marked improvement in spasticity in all muscle groups treated. However, we have observed a suboptimal response in the index finger distal phalanx, as compared with adjacent digits, in four patients. Suboptimal treatment response was defined as no improvement in modified Ashworth Scale, or recurrence of pretreatment degree of spasticity in less than two months. In each patient, the FDP was identified as described by Delagi (1982), with electromyography employed for confirmation of intramuscular injection. Recent introduction of monopolar needle stimulation techniques, however, enhanced anatomic identification of the index FDP. This resulted in sustained reduction of spasticity in a patient who previously demonstrated suboptimal response at an identical BTXA dose. We propose that electrical stimulation be considered to improve precision with administration of intramuscular BTXA in the distal upper extremity musculature.
Prosthetic/Orthotic/Assistive Devices Poster 154 "Decreased Balance Performance in Cowboy Boots Compared With Tennis Shoes." J. Stephen Brecht (University of Washington, Seattie, WA); Michael W. Chang, MD, PhD; Robert Price, MSME; Justus F. Lehmann, MD. Footwear serves as a support for the body, providing static and dynamic stability. Improperly designed footwear can contribute to falls by altering the biomechanics of balance. This study was done to examine the relative balance performance of subjects wearing cowboy boots versus wearing tennis shoes when challenged with different accelerations. The end point was the highest acceleration at which the subject could maintain full foot contact with the platform. Twenty-seven healthy women, 18 to 40 years old, with shoe sizes between 6 to 9, were selected for a crossover trial. The subjects were challenged with various magnitudes of anterior acceleration on a MotionspecT M balance platform. Success was defined as keeping one's feet fiat for 2 of 3 tests at each level. The highest sustainable acceleration found for subjects in boots was 10.66 ± 6.20crrds 2 lower than those in tennis shoes (p < .001). A period effect was found that improved the results of the second footwear tested by 7.2 _+ 6.20cm/s 2 (p = .025). We conclude that cowboy boots produce a decreased balance performance compared with tennis shoes, and thus pose a risk for posterior fall. More work should be done to examine the specific features in the boot that contribute to this imbalance, and to find the body's kinematic adaptations to cowboy boots.
Poster 155 "Rehabilitation after Sacrectomy." David C. Thomas, MD (Mount Sinai Medical Center, New York, NY); Adam B. Stein, MD; Narayan Sundaresan, MD; Kristjan T. Ragnarsson, MD. The purpose of this study was to examine the functional outcomes of individuals after sacrum surgery. This is a population that is not well studied because survival rates are low and they are not traditional recipients of rehabilitation services. A total of 13 patients (7 men, 6 women) underwent this procedure in the period between 1990 and 1994; 6 patients survived and were interviewed for this study. The following findings emerged from this interview: (1) Three patients were seen by a physiatrist; (2) three patients had outpatient physical therapy; (3) four individuals had unimpaired Functional Independence Measure, ie, scores above 125, and the rest were minimally impaired, ie, scores = 118
Arch Phys Med Rehabil Vol 76, November 1995
and 115; (4) all patients reported a loss of sensation; (5) two patients experienced distal leg weakness; (6) two patients were incontinent of urine; (7) four patients require a bowel regimen; (8) four patients experienced a change in their sexual functioning. (9) Finally, 3 patients have pain of sufficient severity to interfere with function. This study indicates that the survivors of this surgery are left with diverse functional impairments that could be ameliorated with rehabilitation services. Unfortunately, these needed services are often not provided because the appropriate referrals are not made.
Poster 156 "Successful Use of Nonarticulating Lower Extremity Prostheses in a Geriatric Woman: A Case Report." Nelson V. Valena, MD (Baylor College of Medicine, Houston, TX); Susan J. Garrison, MD. Successful use of short, nonarticulating lower extremity prostheses (stubbles) has previously been reported in bilateral lower extremity amputees, typically adult men or children. This case report is of a 71year-old woman with a bilateral above knee amputation (AKA) secondary to peripheral vascular disease, who has achieved independent living by using stubbles. After initial inpatient rehabilitation she was independent with wheelchair mobility; however, she required moderate assistance for transfers and lower extremity dressing. She chose to be discharged to a family member's house because her house's bathroom was not wheelchair accessible. Over the next 4 months she gradually improved in upper extremity strength and endurance but continued to have difficulty with commode transfers and dressing after toileting. She was then readmitted to inpatient rehabilitation for stubby training with a personal goal of improving toileting activities. Significant gains were made; at discharge she was at supervision level for commode transfers and was independent with clothing management after toileting using a bodysuit with a front snap crotch. She could ambulate 100 feet using a pediatric walker. The patient then returned to her own house. The advantages of stubby use include improved balance and safety as well as more efficient energy expenditure. In this case, use of stubbles by a geriatric woman gave her bathroom accessibility and ease in independence in toileting activities and made it possible for to return to her own home.
Poster 157 "Functional Outcome of Quad Amputee Patients with End-Stage Renal Disease: A Review of Three Cases." Bradley S. Merritt, MD (Baylor College of Medicine, Houston, TX); Pare Glazener, OTR; Susan J. Garrison, MD. A rare but catastrophic complication of end-stage renal disease (ESRD) is amputation of all 4 limbs secondary to gangrene. We present 3 patients with ESRD who underwent quadruple amputation. The purpose of this case study is to investigate the functional benefit of inpatient rehabilitation for such amputee patients. Our large, tertiary acute care hospital admitted 497 patients with ESRD over a 5-year period. Of these, 36 underwent 51 amputation procedures, 41 involving the lower limbs, and 10 involving the upper limbs. Three patients had all 4 limbs amputated and were subsequently admitted to our acute inpatient rehabilitation center. Their mean functional independence measurement (FIM) scores on admission were 52 ___4 and on discharge 76 ___ 2. At discharge all 3 patients were able to perform sliding board transfers and self-propel wheelchairs modified with quad knobs and brake extenders. Each continued hemodialysis 3 times a week. All were independent with feeding using adaptive equipment, although 1 required cues. Two patients were able to write using dorsal wrist splints and pencil holders, and the third patient was able to use a speaker phone and lift lightweight objects with a left below-the-elbow hook type prosthesis. Our review of these 3 cases demonstrates that inpatient rehabilitation can improve functional scores in quadruple amputee patients with ESRD. A large multicenter study is warranted to obtain adequate sample size and generate a randomized controlled study.
Poster 158 "A New Dynamic Triceps Driven Orthosis: Achieving Elbow Flexion in Patients with Central Cord Syndrome with C5 Deficits." Brett D. Lawlor, MD (Mayo Clinic, Rochester, MN); Kathryn A. Stolp-Smith, MD. We present a unique orthosis developed for a 68-year-old man with traumatic central cord syndrome following a skiing accident. Motor examination demonstrated normal elbow extensors, wrist flexors and