- Email: [email protected]
Poster 165 botulinum toxin type a for radiation-induced trismus and facial pain: a case report. Linda I. Okereke, MD (New York-Presbyterian Hosp, New York, NY); Michael D. Stubblefield, MD; Christian M. Custodio, MD, e-mail: [email protected]
2004 Academy Annual Assembly Abstracts 3/7 showed bilateral increased activity at the cingulate gyrus, right superior frontal gyrus, and left posterior central gyrus. 2/7 subjects showed bilateral increased temporal activity. 4/7 subjects showed increased activity at the left superior frontal gyrus, with 1/7 subjects revealing bilateral activation. The control subject showed no activity. Conclusions: Auditory-motor processing is complex, working through multiple neuronetworks. This study provides a preliminary analysis of possible structures, specifically the cingulate gyrus, temporal gyrus, and superior frontal gyrus. Of significance was the bilateral activation. Repetitive auditory-motor training, specifically Interactive Metronome, holds promise for neuroplasticity of higher and lower brain centers. Key Words: Magnetic resonance imaging; functional; Rehabilitation. Poster 162 Single Muscle Fiber Contractile Properties in Dermatomyositis and Inclusion Body Myositis. Lisa S. Krivickas, MD (Harvard Med Sch, Boston, MA); Anthony A. Amato, MD; Gomathi Krishnan, BS; Angelique V. Murray, MS; Walter R. Frontera, MD, PhD, e-mail: [email protected]. Disclosure: L.S. Krivickas, None; A.A. Amato, None; G. Krishnan, None; A.V. Murray, None; W.R. Frontera, None. Objectives: To compare single muscle fiber contractile properties in patients with dermatomyositis (DM) and inclusion body myositis (IBM); to assess whether they differ from healthy controls; and to determine whether contractile apparatus dysfunction plays a role in the pathophysiology of muscle weakness in IBM and DM. Design: Cross-sectional comparison study. Setting: Muscle physiology laboratory. Participants: 5 patients with untreated DM and 5 with IBM (mean age for DM, 61y; for IBM, 68y). Interventions: Muscle biopsy; activation of chemically skinned single muscle fibers with Ca⫹2 for force measurement; slack test to determine maximal unloaded shortening velocity (Vo); and sodim dodecyl sulfate-polyacrylamide gel electrophoresis to determine myosin heavy chain composition and fiber type. Main Outcome Measures: Single fiber crosssectional area (CSA), maximal force, specific force (force per CSA), and velocity for type I and IIA fibers. Results: 155 type I fibers (DM⫽68; IBM⫽87) and 61 type IIA fibers (DM⫽33; IBM⫽28) were studied. CSA and maximal force were greater in the IBM than in the DM for type I and IIA fibers (P⬍.001), but there was no difference in specific force. Vo was greater in type I, but not IIA, fibers in the DM patients compared with the IBM patients (P⬍.001). Specific force and Vo were not reduced in patients with DM or IBM when compared with our database of healthy older control subjects; however, CSA and maximal force were increased in the IBM patients when compared with the control subjects. Conclusions: The force- and velocity-generating capacity of single muscle fibers was preserved in patients with DM and IBM, suggesting that dysfunction of the contractile elements does not contribute to clinical muscle weakness. Patients with IBM had compensatory muscle fiber hypertrophy accompanied by a proportional increase in force-generating capacity such that the specific force of single muscle fibers was unchanged. Key Words: Dermatomyositis; Muscle fibers; Myositis, inclusion body; Rehabilitation. Poster 163 A Longitudinal Study Comparing Resident Performance on the Self-Assessment and American Board of Physical Medicine and Rehabilitation Examinations. Laura W. Lee, MD, MBA (Univ Virginia, Charlottesville, VA); Mary G. Bryant, MD, e-mail: [email protected]. Disclosure: L.W. Lee, None; M.G. Bryant, None. Objective: To test the hypothesis that 1 residency program’s postgraduate year 4 (PGY-4) self-assessment exam (SAE), American Board of Physical Medicine and Rehabilitation (ABPMR) Part I (BP1), and ABPMR Part II (BP2) scores were highly correlated. Design: Retrospective cohort study. Setting: Academic residency program. Participants: All resident physicians who graduated over an 11-y period (N⫽38). BP1 and BP2 scores were available from 1993 to 2003, and PGY-4 SAE scores were available from 1996 to 2003. Interventions: Not applicable. Main Outcome Measures: SAE and BP1 scores (after 1997) reported in percentiles were converted into rank order: 0 to 25th percentile as low, 26th to 50th as midlow, 51st to 75th as midhigh, and 76th to 100th as high. BP1 (pre-1997) and BP2 scores were reported in rank order. Spearman correlations were performed between each resident’s PGY-4 SAE and first attempt BP1 scores, PGY-4 SAE and first attempt BP2 scores, and first attempt BP1 and BP2 scores. Using a Bonferroni adjustment, significance was defined at P⬍.017. Results: There were 24 data points between PGY-4 SAE and BP1 scores (r⫽.49. P⫽.016). Comparison of PGY-4 and BP2 scores yielded 22 data points (r⫽.31, P⫽NS). 33 data points were noted for BP1 and BP2 scores (r⫽.24, P⫽NS). Conclusions: There was a moderately strong correlation between PGY-4 SAE and BP1 scores. Surprisingly, there was no significant correlation between BP1 and BP2, suggesting that the different testing skills required for the 2 exams outweighed the foundation of knowledge tested or that knowledge assessed on the 2 exams differed markedly. From these data, residency directors can use PGY-4 SAE scores to predict BP1 performance but should not rely on either SAE or BP1 scores to anticipate success on the BP2. Key Words: Education, medical, graduate; Rehabilitation.
Pain Rehabilitation Poster 164 Thermography Changes After Treatment of Cervical Myofascial Trigger Points With Injection of Botulinum Toxin: A Case Report. Wesley L. Smeal, MD (Rehabil Inst Chicago, Chicago, IL); Patricia T. Daschbach, BS; R. Norm Harden, MD, e-mail: wsmeal@ rehabchicago.org. Disclosure: W.L. Smeal, None; P.T. Daschbach, None; R.N. Harden, None. Setting: Outpatient clinic, rehabilitation hospital. Patient: A 56-yo man with 19-y history of cervicogenic headaches. Case Description: Patient had posterior cervical Travel-type myofascial trigger points (TPs), which recreated his headache. Botulinum toxin type A (BTX-A) was reconstituted with 0.9% normal saline to a concentration of 100U/mL and 25U were injected into each of 4 posterior cervical TPs. Infrared telethermography (ITT) photographs of the cervical region were taken to assess the impact of BTX-A on superficial heat emission over TPs at baseline and on day
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34 postinjection. Assessment/Results: At day 34 postinjection, the patient reported improvement in the frequency of his headaches (22 test⫽5.65, P⫽.017). Initially, at 1 superficial TP in the left splenius capitis, an ITT “cold spot” was present, with a temperature of 34.8°C versus 35.8°C on the contralateral (unaffected) side. On day 34 postinjection, the ITT heat pattern over the site of the TP had normalized, with a temperature of 33.2°C equal to the 33.2°C at the contralateral site. Discussion: This case supports the hypotheses that TPs are areas of focal spasm and ischemia and that BTX-A may help treat such TPs. BTX-A may relieve the focal spasm and restore blood flow to the TP, as shown by normalization of the heat pattern over the TP. Multiple alternate explanations will be discussed. Conclusions: BTX-A injections may be a valid pharmacologic probe to test the hypothesis that myofascial TPs represent areas of intense focal spasm and ischemia, and ITT may be an objective and quantifiable way to evaluate interventions. Further investigation is needed to prove these related hypotheses. Key Words: Botulinum toxin type A; Myofascial pain; Rehabilitation; Trigger points, myofascial. Poster 165 Botulinum Toxin Type A for Radiation-Induced Trismus and Facial Pain: A Case Report. Linda I. Okereke, MD (New York-Presbyterian Hosp, New York, NY); Michael D. Stubblefield, MD; Christian M. Custodio, MD, e-mail: [email protected]. Disclosure: L.I. Okereke, None; M.D. Stubblefield, None; C.M. Custodio, None. Setting: Tertiary care cancer hospital. Patient: A patient with facial cancer after resection and radiation developed severe trismus and facial pain. Case Description: A 59-yo man with a history of low-grade polymorphous adenocarcinoma of the left infratemporal fossa after resection, reconstruction, and radiation developed severe trismus and facial pain over the cheeks and mandible bilaterally. Pain, measured daily on a visual analog scale (VAS), was 10/10 pain on the right and VAS 6/10 pain on the left overlying his surgical scar. Treatment with high-dose gabapentin and a fentanyl patch was unsuccessful. The patient was referred for a rehabilitation consultation and botulinum toxin injections. Physical examination demonstrated severe trismus and spasm of the right temporalis and masseter muscles. The left facial and masticatory muscles had been resected and marked scarring and dermal sclerosis was present on the right side of the face. Active and passive jaw excursion was limited to ⯝3mm. Assessment/Results: The diagnosis of trismus, jaw contracture, and neurogenic facial pain from radiation fibrosis was made. 50U of botulinum toxin type A (BTX-A) was injected using electromyographic guidance into the right masseter, and provided transient relief. 7wk later, a repeat injection using 100U of BTX-A into the right masseter was done under electromyographic guidance and an additional 100U was injected subdermally into the area of maximal discomfort overlying the right cheek and the scar tissue of the left maxillary area. The patient’s pain, as measured on the VAS, decreased to 5/10 on the right and 0 to 2/10 pain on the left for several weeks. Discussion: Botulinum toxin exerts analgesic properties separate from its antispasmodic effects and may benefit patients with radiation-induced facial pain. This analgesic benefit occurred without a significant decrease in trismus. Conclusions: Botulinum toxin may be effective treatment for radiation-induced facial pain. Key Words: Botulinum toxins; Electrophysiology; Neoplasms; Pain; Rehabilitation. Poster 166 Treatment of Herpes Zoster With Botulinum Toxin Type A Injections: A Case Report. Dennis D. Dykstra, MD, PhD (Univ Minnesota, Minneapolis, MN); Paul J. Amundson, MD, e-mail: [email protected]. Disclosure: D.D. Dykstra, research grant from Allergan, speakers bureau for Allergan; P.J. Amundson, None. Setting: Rehabilitation hospital. Patient: A 66-yo man with refractory posttherapeutic neuralgia following herpes zoster of the left forehead in January 2001. Case Description: Patient complained of chronic pain (5– 6/10-point scale) over the left forehead. Pain was sharp and burning. Combing his hair, blowing wind, or wearing a cap or glasses made his pain worse. He had tried numerous oral medications, topical ointments and creams, and acupuncture without relief. Because botulinum toxin has been used successfully to treat painful conditions such as headache and myofascial pain, it was administered to this patient. The patient received 50U of botulinum toxin type A (BTX-A; Botox), diluted in 1mL of normal saline, and injected equally into 10 painful areas in the left frontalis and periorbial area. Injections were done subcutaneously with a 30-gauge, 1-in needle without electromyographic guidance. The patient noted minimal response to these injections. 1mo later, he was injected again, this time with 100U of BTX-A, diluted in 2mL of normal saline, into 20 painful areas. Assessment/Results: 1wk later, the skin over his scalp was less sensitive to showering, touch, wind, and wearing his glasses. His pain was reduced by 15%. The results lasted 1mo. The patient has undergone 2 more injections using this same protocol. Each injection has had a greater effect and longer duration. The patient’s last injection lasted 6mo and gave him ⬎50% relief. Discussion: Recent research has shown that botulinum toxin can inhibit the release of neuropeptides involved in pain of nociceptive origin. Conclusions: BTX-A significantly reduced pain in a patient with herpes zoster who was refractory to other pain management. Further studies are warranted. Key words: Botulinum toxin type A; Herpes zoster; Pain; Rehabilitation.
Poster 167 Subcutaneous Botulinum Toxin Type A in the Treatment of Postherpetic Neuralgia: A Case Series of 24 Patients. Brian Freund, MD (Crown Institute, Pickering, ON, Canada); Marvin Schwartz, DDS, e-mail: [email protected]. Disclosure: B. Freund, research grant from Allergan; M. Schwartz, research grant from Allergan. Setting: Private pain and rehabilitation clinic. Patient: 24 patients (14 women, 10 men; mean age, 68.2y; range, 49 – 83y) with postherpetic neuralgia (PHN) of ⬎6mo in duration. Torso dematomes were involved in 11 patients, inguinal dermatomes in 5, while 8 were affected on the face or scalp. Case Description: Botulinum toxin type A (BTX-A; 5U per 0.1mL of normal saline) was injected intradermally with a 30-gauge needle at a dose of 5U per 9cm2 into the torso and inguinal regions and 5U per 1cm2 into the head area. The total dose did not exceed 200U. The increased dose per unit area in the head relative to the lower body compensated for the relatively smaller affected dermatomes of the head. Assessment/Results: An 11-point visual analog scale
Arch Phys Med Rehabil Vol 85, September 2004
Pain Rehabilitation Poster 164 Thermography Changes After Treatment of Cervical Myofascial Trigger Points With Injection of Botulinum Toxin: A Case Report. Wesley L. Smeal, MD (Rehabil Inst Chicago, Chicago, IL); Patricia T. Daschbach, BS; R. Norm Harden, MD, e-mail: wsmeal@ rehabchicago.org. Disclosure: W.L. Smeal, None; P.T. Daschbach, None; R.N. Harden, None. Setting: Outpatient clinic, rehabilitation hospital. Patient: A 56-yo man with 19-y history of cervicogenic headaches. Case Description: Patient had posterior cervical Travel-type myofascial trigger points (TPs), which recreated his headache. Botulinum toxin type A (BTX-A) was reconstituted with 0.9% normal saline to a concentration of 100U/mL and 25U were injected into each of 4 posterior cervical TPs. Infrared telethermography (ITT) photographs of the cervical region were taken to assess the impact of BTX-A on superficial heat emission over TPs at baseline and on day
E37
34 postinjection. Assessment/Results: At day 34 postinjection, the patient reported improvement in the frequency of his headaches (22 test⫽5.65, P⫽.017). Initially, at 1 superficial TP in the left splenius capitis, an ITT “cold spot” was present, with a temperature of 34.8°C versus 35.8°C on the contralateral (unaffected) side. On day 34 postinjection, the ITT heat pattern over the site of the TP had normalized, with a temperature of 33.2°C equal to the 33.2°C at the contralateral site. Discussion: This case supports the hypotheses that TPs are areas of focal spasm and ischemia and that BTX-A may help treat such TPs. BTX-A may relieve the focal spasm and restore blood flow to the TP, as shown by normalization of the heat pattern over the TP. Multiple alternate explanations will be discussed. Conclusions: BTX-A injections may be a valid pharmacologic probe to test the hypothesis that myofascial TPs represent areas of intense focal spasm and ischemia, and ITT may be an objective and quantifiable way to evaluate interventions. Further investigation is needed to prove these related hypotheses. Key Words: Botulinum toxin type A; Myofascial pain; Rehabilitation; Trigger points, myofascial. Poster 165 Botulinum Toxin Type A for Radiation-Induced Trismus and Facial Pain: A Case Report. Linda I. Okereke, MD (New York-Presbyterian Hosp, New York, NY); Michael D. Stubblefield, MD; Christian M. Custodio, MD, e-mail: [email protected]. Disclosure: L.I. Okereke, None; M.D. Stubblefield, None; C.M. Custodio, None. Setting: Tertiary care cancer hospital. Patient: A patient with facial cancer after resection and radiation developed severe trismus and facial pain. Case Description: A 59-yo man with a history of low-grade polymorphous adenocarcinoma of the left infratemporal fossa after resection, reconstruction, and radiation developed severe trismus and facial pain over the cheeks and mandible bilaterally. Pain, measured daily on a visual analog scale (VAS), was 10/10 pain on the right and VAS 6/10 pain on the left overlying his surgical scar. Treatment with high-dose gabapentin and a fentanyl patch was unsuccessful. The patient was referred for a rehabilitation consultation and botulinum toxin injections. Physical examination demonstrated severe trismus and spasm of the right temporalis and masseter muscles. The left facial and masticatory muscles had been resected and marked scarring and dermal sclerosis was present on the right side of the face. Active and passive jaw excursion was limited to ⯝3mm. Assessment/Results: The diagnosis of trismus, jaw contracture, and neurogenic facial pain from radiation fibrosis was made. 50U of botulinum toxin type A (BTX-A) was injected using electromyographic guidance into the right masseter, and provided transient relief. 7wk later, a repeat injection using 100U of BTX-A into the right masseter was done under electromyographic guidance and an additional 100U was injected subdermally into the area of maximal discomfort overlying the right cheek and the scar tissue of the left maxillary area. The patient’s pain, as measured on the VAS, decreased to 5/10 on the right and 0 to 2/10 pain on the left for several weeks. Discussion: Botulinum toxin exerts analgesic properties separate from its antispasmodic effects and may benefit patients with radiation-induced facial pain. This analgesic benefit occurred without a significant decrease in trismus. Conclusions: Botulinum toxin may be effective treatment for radiation-induced facial pain. Key Words: Botulinum toxins; Electrophysiology; Neoplasms; Pain; Rehabilitation. Poster 166 Treatment of Herpes Zoster With Botulinum Toxin Type A Injections: A Case Report. Dennis D. Dykstra, MD, PhD (Univ Minnesota, Minneapolis, MN); Paul J. Amundson, MD, e-mail: [email protected]. Disclosure: D.D. Dykstra, research grant from Allergan, speakers bureau for Allergan; P.J. Amundson, None. Setting: Rehabilitation hospital. Patient: A 66-yo man with refractory posttherapeutic neuralgia following herpes zoster of the left forehead in January 2001. Case Description: Patient complained of chronic pain (5– 6/10-point scale) over the left forehead. Pain was sharp and burning. Combing his hair, blowing wind, or wearing a cap or glasses made his pain worse. He had tried numerous oral medications, topical ointments and creams, and acupuncture without relief. Because botulinum toxin has been used successfully to treat painful conditions such as headache and myofascial pain, it was administered to this patient. The patient received 50U of botulinum toxin type A (BTX-A; Botox), diluted in 1mL of normal saline, and injected equally into 10 painful areas in the left frontalis and periorbial area. Injections were done subcutaneously with a 30-gauge, 1-in needle without electromyographic guidance. The patient noted minimal response to these injections. 1mo later, he was injected again, this time with 100U of BTX-A, diluted in 2mL of normal saline, into 20 painful areas. Assessment/Results: 1wk later, the skin over his scalp was less sensitive to showering, touch, wind, and wearing his glasses. His pain was reduced by 15%. The results lasted 1mo. The patient has undergone 2 more injections using this same protocol. Each injection has had a greater effect and longer duration. The patient’s last injection lasted 6mo and gave him ⬎50% relief. Discussion: Recent research has shown that botulinum toxin can inhibit the release of neuropeptides involved in pain of nociceptive origin. Conclusions: BTX-A significantly reduced pain in a patient with herpes zoster who was refractory to other pain management. Further studies are warranted. Key words: Botulinum toxin type A; Herpes zoster; Pain; Rehabilitation.
Poster 167 Subcutaneous Botulinum Toxin Type A in the Treatment of Postherpetic Neuralgia: A Case Series of 24 Patients. Brian Freund, MD (Crown Institute, Pickering, ON, Canada); Marvin Schwartz, DDS, e-mail: [email protected]. Disclosure: B. Freund, research grant from Allergan; M. Schwartz, research grant from Allergan. Setting: Private pain and rehabilitation clinic. Patient: 24 patients (14 women, 10 men; mean age, 68.2y; range, 49 – 83y) with postherpetic neuralgia (PHN) of ⬎6mo in duration. Torso dematomes were involved in 11 patients, inguinal dermatomes in 5, while 8 were affected on the face or scalp. Case Description: Botulinum toxin type A (BTX-A; 5U per 0.1mL of normal saline) was injected intradermally with a 30-gauge needle at a dose of 5U per 9cm2 into the torso and inguinal regions and 5U per 1cm2 into the head area. The total dose did not exceed 200U. The increased dose per unit area in the head relative to the lower body compensated for the relatively smaller affected dermatomes of the head. Assessment/Results: An 11-point visual analog scale
Arch Phys Med Rehabil Vol 85, September 2004