- Email: [email protected]
Poster 230
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2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Poster 225 Heterotopic Ossification With Normal Serum Alkaline Phosphatase Levels: A Case Series. Divakara Kedlaya, MD (Loma Linda University Medical Center, Loma Linda, CA); Cid Nazir, MD, e-mail: [email protected]. Disclosure: None. Setting: Acute rehabilitation unit. Patients: A 28-year-old man with T12 American Spinal Injury Association (ASIA) grade C paraplegia due to gunshot wound, a 20-year-old man with T5 ASIA grade A paraplegia due to motor vehicle collision (MVC), and a 36-year-old man with C7-8 ASIA grade A tetraplegia due to MVC. Case Descriptions: The first patient had worsening pain, swelling, and decreased range of motion (ROM) of the left knee 5 weeks after the injury. Radiographs and triple-phase bone scan showed immature heterotopic ossification (HO) in medial condyle and epicondyle of left femur. Serum alkaline phosphatase (SAP) level was normal. Follow-up SAP a month later was also normal. The second patient had decreased ROM and a palpable callus of the right hip 14 weeks after the injury. He had history of fracture of right subtrochanteric right femur, which was treated with intramedullary rod. Hip radiograph showed HO in the soft tissues of right hip. Serial SAP levels were normal. On day 18 postinjury, the third patient began spiking high-grade fevers (⬎39°C) for the next 30 days. An extensive workup revealed no source of fever. 3 weeks later, he developed swelling and limited ROM in the left hip. Further workup was negative for deep venous thrombosis, and a triple-phase bone scan revealed HO in both hips. Serial SAP levels were normal. Discussion: In these 3 cases with documented HO, serum alkaline phosphatase levels were normal. We like to question the sensitivity of SAP as a marker for HO in its early diagnosis. Further studies need to be done to evaluate the sensitivity of SAP in the diagnosis of HO. Conclusions: Serial SAP levels may be normal in documented cases of HO. Key Words: Heterotopic ossification, Rehabilitation; Serum alkaline phosphatase; Spinal cord injuries.
Poster 226 A Proximate Cause of Heterotopic Ossification—Possible Implications for Parsing Etiologic Factors? A Case Report. Eric L. Altschuler, MD, PhD (Mt. Sinai School of Medicine, New York, NY); Brian Riordan, MD; Thomas N. Bryce, MD, e-mail: [email protected]. Disclosure: None. Setting: Acute rehabilitation facility. Patient: A 32-year-old man with a traumatic C6 complete spinal cord injury (SCI). Case Description: Before the SCI, the patient had a medical history only of kidney stones. Approximately 1.5 months post-SCI, the patient developed swelling in his right hip and groin area. Venous Doppler showed no evidence for deep vein thrombosis. Magnetic resonance imaging showed a fluid collection along the anterior aspect of the right quadriceps and accompanying inflammatory changes. Approximately 4 weeks later, the patient developed a solid mass in the right anterior thigh. Assessment/Results: Radiographs of the mass showed heterotopic ossification (HO) surrounding the right proximal femoral diaphysis. The HO was clinically significant causing some decreased hip range of motion. Discussion: This patient had a number of risk factors for developing HO: complete cervical SCI and a history of kidney stones. Interestingly, the patient only developed HO in the region with the fluid collection and inflammation, a locale with disruption of mesenchymal tissues. In this case, local injury and disruption of normal milieu were likely necessary etiologic factors in the development of the HO. By similar reasoning, cases of nonbrain or SCI patients who develop HO in the area of a joint that has been replaced, but not at other joints, may indicate the necessity of trauma to local mesenchymal tissue in the development of HO. Extremity trauma with obvious mesenchymal injury in patients with SCI may increase the risk for developing HO, potentially warranting HO prophylaxis (eg, with etidrium sodium) Conclusions: We demonstrate a case in which local trauma and tissue disruption was most likely a necessary factor in the development of HO. Controlled studies of treating patients with obvious extremity mesenchymal injury and SCI to prevent HO may be warranted. Key Words: Etiology; Heterotopic ossification; Rehabilitation; Spinal cord injuries; Trauma.
Poster 227 An Unusual Etiology for a Floppy Infant: A Case Report. Marioara Bodea, MD (East Carolina University, Brody School of Medicine, Greenville, NC); David Epperson, MD; Daniel P. Moore, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care hospital, in- and outpatient pediatric rehabilitation units. Patient: White male with hypotonia at birth, followed until 3 years of age. Case Description: This white male was born at 35 weeks of gestation, 3000gm, via C-section secondary to failure to progress and preeclampsia. History included a weak cry, poor respiratory effort, and quadriplegia. A physical exam revealed axial hypotonia, quadriplegia, absent deep tendon, palmar and plantar grasp, clonus, and Moro reflexes. Differential diagnosis initially included central nervous system disorders (congenital, genetic, metabolic, infectious, vascular, traumatic), motoneuron disorders (eg, Werdnig-Hoffman disease), neuromuscular junction disorders, congenital myopathies, congenital muscular dystrophy, and myotonia congenita. Assessment/Results: Complete blood count, serum electrolytes, and head and neck computed tomography were unremarkable. Creatine phosphokinase was 349. The workup for Werdnig-Hoffman disease, myotonia congenita, and myasthenia gravis was negative. With negative initial workup, a referral was made and a magnetic resonance imaging (MRI) of the spine was performed. It revealed abnormal T1 and T2 signal within the spinal cord extending from the cervicothoracic junction to the conus, consistent with ischemia and/or intramedullary hemorrhage. Coagulopathy workup was negative. At the 3-year follow-up, the patient had some antigravity strength in the upper extremities and 0/5 strength in the lower extremities. The cognitive development was appropriate for his age, and the patient was able to use a manual wheelchair. A repeat MRI revealed intramedullary central cord mass, possibly a lipoma spanning T6-12, and a tethered cord. Discussion: Intramedullary spinal cord hemorrhage in a neonate is unusual. Other locations of hemorrhage such as subarachnoid, subdural, or epidural are more commonly seen. A systematic approach to the floppy infant is important. Conclusions: This is a rare case of intramedullary cord hemorrhage at birth with hypotonia. It demonstrates the need to consider SCI in the differential diagnosis. Key Words: Muscle hypotonia; Rehabilitation; Spinal cord diseases.
Arch Phys Med Rehabil Vol 86, September 2005
Poster 228 Use of Bladder Irrigation To Treat Bacteriuria in Persons With Neurogenic Bladder Dysfunction. Ken B. Waites, MD; Kay C. Kanupp, MSN, CRNP; James F. Roper, MD; Yuying Chen, MD, PhD (University of Alabama, Birmingham, AL); Susan M. Camp, CRNP, e-mail: [email protected]. Disclosure: None. Objective: To evaluate the potential value of bladder irrigation to treat bacteriuria in persons with neurogenic bladders. Design: Double-blind randomized controlled trial. Setting: Rehabilitation center. Participants: 52 community-residing men and women with neurogenic bladders managed with an indwelling Foley catheter or suprapubic tube. Intervention: Subjects were randomized to irrigate their bladders twice daily for 8 weeks with 30mL of: sterile saline, acetic acid, or neomycin-polymixin. Main Outcome Measures: Urinalysis and cultures were performed at baseline and weeks 2, 4, and 8 to determine the extent to which each of the solutions affected bacterial numbers, pH, urinary leukocytes, and generation of antimicrobial-resistant organisms. Results: Bladder irrigation was well tolerated with the exception of 3 subjects who had bladder spasms and could not participate further. All participants had bacteriuria with ⱖ100,000 colonies/mL at baseline. None of the 3 irrigants had a detectable effect on the degree of bacteriuria, pyuria, or urinary pH. There was no significant increase in the occurrence of oxacillin-resistant Staphylococcus aureus or multidrug resistant gram-negative bacilli in any of the 3 groups, although the baseline rates of resistance were high. No significant development of resistance to oral antimicrobials among gram-negative bacilli beyond what was observed at baseline was detected. Conclusions: Bladder irrigation was generally well tolerated for 8 weeks. No advantages were detected for neomycin-polymixin or acetic acid over saline in terms of reducing the urinary bacterial load and inflammation. We cannot recommend bladder irrigation as an alternative to systemic antibiotics for treatment of bacteriuria. Key Words: Bacteriuria; Bladder, Neurogenic; Rehabilitation; Urinary tract infections.
Poster 229 Compliance With Guidelines for Preventing Pressure Ulcers Following Spinal Cord Injury. Sunil Sabharwal, MD (VA New England Healthcare System/ Harvard Medical School, Boston, MA); Dan Berlowitz, MD, MPH; Elaine Czarnowski, RN; Elaine Hickey, RN, e-mail: [email protected]. Disclosure: None. Objectives: To measure current compliance with the pressure ulcer prevention guidelines (Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury, published by the Consortium for Spinal Cord Medicine) and to define determinants of variation from guideline recommendations and identify compliance barriers and facilitators. Design: (1) Review of 100 randomly selected medical records using a chart abstraction tool developed for abstracting information regarding compliance with pressure ulcer prevention. Inclusion criteria were SCI diagnostic ICD-9 codes and clinic visit or hospitalization at a study site in fiscal year 2003. (2) Provider focus groups conducted to identify perceived facilitators and barriers to guideline adherence. Setting: VA spinal cord injury (SCI) system of care including an SCI center and 5 SCI clinics. Interventions: Not applicable. Main Outcome Measures: Overall and facility-specific adherence rates to 14 pressure ulcer prevention guidelines. Records with outpatient visits only were analyzed separately from those with inpatient hospitalizations. Results: Guideline adherence was lower in the outpatient than inpatient group. For example, 90% of inpatients had documented pressure ulcer risk factor assessment versus 5% of outpatients. Guideline adherence varied considerably between sites. For example, nutritional status documentation varied from 15% to 85% within outpatient sites and documented pressure relief regimen ranged from 5% to 65%. Adherence was better for some guidelines than others. For example, for the outpatient group, wheelchair cushion assessment was documented in 60%, but ⬍5% documented bed support surfaces used. Focus groups indicated that standardized templates incorporating guidelines would improve documentation and also serve as a reminder checklist. The greatest perceived barrier to guideline adherence was patient compliance. Conclusions: Knowledge generated by this study has prompted development of interventions especially with outpatient focus, including standardized templates for pressure ulcer specific periodic evaluation, and patient educational material to promote compliance. Key Words: Clinical practice guidelines; Spinal cord injuries; Pressure ulcer; Rehabilitation.
Poster 230 Incidence and Outcomes of Spinal Cord Injury Clinical Syndromes. Katia Santos, MD (Virginia Commonwealth University, Richmond, VA); William McKinley, MD; Michelle Meade, PhD; Karen L. Brooke, e-mail: [email protected]. Disclosure: None. Objective: To examine and compare demographics and functional outcomes for individuals with spinal cord injury (SCI) clinical syndromes, including central cord (CCS), Brown-Sequard (BSS), anterior cord (ACS), posterior cord (PCS), cauda equina (CES), and conus medullaris (CMS). Design: Retrospective review. Setting: Tertiary care, level I trauma center inpatient rehabilitation unit. Participants: 848 consecutive admissions with acute SCI. Interventions: Not applicable. Main Outcome Measures: FIM instrument, FIM subgroups (motor, self-care, cognitive), length of stay (LOS), and discharge disposition. Results: 176 (20.8%) patients were diagnosed with SCI clinical syndromes. CCS was the most common (44.3%), followed by CES (25.6%) and BSS (17.6%). Significant differences (Pⱕ.01) were found between groups with regard to age, race, etiology, total admission FIM, motor admission FIM, self-care admission and discharge FIM, and LOS. Statistical analysis between tetraplegic BSS and CCS revealed significant difference (Pⱕ.01) with respect to age (38.9 vs 53.2) and a trend toward significance (Pⱕ.05) with regard to total discharge FIM (97.0 vs 85.0), motor discharge FIM (64.5 vs 55.0), and self-care discharge FIM (29.0 vs 23.9). No significant differences (Pⱕ.01) were found when comparing CMS with CES. Conclusions: SCI clinical syndromes represent a significant proportion of admissions to acute SCI rehabilitation with CCS presenting most commonly and representing the oldest age group with the lowest admission functional level of all SCI clinical syndromes. Cervical BBS individuals seem to achieve higher functional improvement by discharge when compared with CCS patients. CMS and
2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS CES exhibit similar functional outcomes. ACS and PCS demonstrate functional gains with inpatient rehabilitation with ACS patients displaying the longest LOS of the SCI clinical syndromes. These findings have important implications for the overall management and outcome of patients with SCI. Key Words: Central cord syndrome; Rehabilitation; Spinal cord injuries. Poster 231 Using the Symptom Checklist Questionnaire To Measure Psychologic Distress in Acute Inpatient Rehabilitation Subjects With Spinal Cord Injury or Disease. Patricia Motycka, DO (Mayo Clinic, Rochester, MN); Katherine Piderman, PhD; Donald Williams, PhD; Sandy Rackley, MD; Ronald Reeves, MD, e-mail: [email protected]. Disclosure: None. Objective: To measure psychologic distress using the revised Symptom Checklist Questionnaire (SCL-90-R) in individuals with spinal cord injury (SCI) or disease during their stay in an acute inpatient rehabilitation unit and 6 months after dismissal. Design: Prospective observational survey using patient self-reported SCL-90-R questionnaires. Setting: Acute inpatient rehabilitation hospital unit. Participants: 88 subjects admitted to an acute inpatient rehabilitation unit between January 2003 and February 2005. The exclusion criteria were age ⬍18, Folstein Mini-Mental State Examination score ⬍22, diagnosis of an acquired brain disorder that could impair cognition or perception, inability to complete the 6-month follow-up, or status as a Federal Medical Center prisoner. The group was comprised of 63 men and 25 women (age range, 19 – 84). Intervention: All patients received individualized rehabilitation services according to standard rehabilitation practice. Main Outcome Measures: Median values of global severity index scores (which measures distress) were computed for individuals who completed the SCL-90-R during their acute rehabilitation stay and 6 months after dismissal. Results: 88 subjects filled out an SCL-90-R during their acute inpatient rehabilitation stay, and 35 subjects returned a 6-month follow-up SCL-90-R that was mailed to their home. The median global severity index score for the group during their rehabilitation stay was 60. The median global severity index score for the group at 6 months postdismissal was 59. Conclusions: The global severity index score for patients with SCI or disease is comparable to scores for acutely medically ill patients. However, global distress does not appear to decrease in the first 6 months after dismissal from inpatient rehabilitation. Persistent SCL-90 score elevation has been shown to be a risk factor for adverse outcomes in other populations. Further study of “distress” within rehabilitation patients is needed. Key Words: Psychological tests; Rehabilitation; Spinal cord injuries. Poster 232 Acupuncture in the Treatment of Shoulder Pain in Individuals With Spinal Cord Injury: A Placebo-Controlled Study. Trevor A. Dyson-Hudson, MD (KMRREC, West Orange, NJ); Michael LaFountain, MA, MEd, ATC/L; Scott R. Millis, PhD, MEd, e-mail: [email protected]. Disclosure: None. Objective: To determine the effectiveness of acupuncture in treating chronic shoulder pain in manual wheelchair using individuals with chronic spinal cord injury (SCI). Design: Randomized, single-blind (subject), placebo controlled clinical trial. Setting: Rehabilitation research department. Participants: Individuals with chronic SCI (⬎1y) and chronic shoulder pain (⬎3mo) who used manual wheelchairs as their primary means of mobility (⬎40h/wk). Intervention: Participants were randomly assigned to receive either traditional needle acupuncture or placebo acupuncture (ie, sham acupuncture; light needling of nonacupuncture points). All participants received a total of 10 treatments over a 5-week period. Main Outcome Measures: The Wheelchair User’s Shoulder Pain Index (WUSPI) was used to monitor changes in shoulder pain intensity during the treatment period in each group. A 1-way analysis of covariance was conducted. The independent variable, group assignment, included 2 levels: traditional acupuncture and placebo acupuncture. The dependent variable was the WUSPI score at the end of the treatment period and the covariate was the WUSPI score prior to the beginning of treatments. Results: In the total population analyzed (N⫽13), there was no significant difference between the traditional acupuncture and placebo acupuncture groups (F1,10⫽.212, P⫽.655). The strength of the relationship between the groups and final WUSPI score was low to medium, as assessed by a partial 2, with group assignment accounting for 3% of the variance on the WUSPI. The adjusted mean for the traditional acupuncture group (M⫽18.0) was smaller than the placebo acupuncture group (M⫽23.3). Conclusions: Although the difference between traditional needle acupuncture and placebo acupuncture in reducing shoulder pain was not significant, there was a small to medium effect size associated with the acupuncture treatments. Key Words: Acupuncture; Rehabilitation; Shoulder pain; Spinal cord injuries,
Poster 233 Sympathetic Skin Response: A Simplified Testing of Sympathetic Efferents in Spinal Injury Patients. Harsha S. Nagarajarao, MB BS, MRCP (Northwest Regional Spinal Injuries Centre, Southport, UK); John Watt, MB cHB, MD, FRCA; Babu N. Kumar, MB BS, D Ortho, DNB, MRCS; B.R. Kumar, MB BS, MRCP, e-mail: [email protected]. Disclosure: None. Objective: To determine whether eliciting the sympathetic skin response (SSR) by gasp reflex would be a dependable measure of sympathetic preservation (SP) using standard bedside electrocardiogram (ECG) monitor and would be superior to visual stimuli. Design: Case-control study of 5 healthy controls and 21 nonacute spinal cord injury (SCI) patients in rehabilitation. Setting: Regional spinal injury center in the U.K. Participants: SCI patients in rehabilitation. Interventions: Not applicable. Main Outcome Measures: Complete and incomplete tetraplegics and paraplegics were tested during series of inspiratory gasps and visual stimuli in supine position for waveforms on a single-channel ECG monitor. SSRs were repeated at intervals of 1 minute to examine the influence of habituation. Presence of an SSR waveform on the ECG monitor indicated preservation of the sympathetic nervous system, and absence the loss. Results: Mean voltages in the hands and feet of controls were significantly greater after the gasp (1.03, 1.20mV) than after visual stimulus (0.26, 0.03mV) (P⫽.01). The findings were essentially the same in the hands of paraplegics, and responses appeared unaffected by anticholinergics. Most paraplegic and tetraplegic
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patients showed total absence of response below the lesion level. Sensorimotor incompleteness was not a good predictor of SSRs. Conclusions: Screening for SSR waveform on a single-channel ECG monitor after a rapid inspiration is a reliable, reproducible, noninvasive, and rapid bedside technique of assessing the neurologic status of the sympathetic system in SCI and could be used regularly to complement sensorimotor scoring. Defining sympathetic status may facilitate management of skin, bowels, postural hypotension, and autonomic dysreflexia. Key Words: Autonomic dysreflexia; Autonomic nervous system; Disability evaluation; Rehabilitation; Spinal cord injuries.
Stroke Poster 234 Effects of Robotic Therapy on Motor Impairment and Recovery in Stroke Patients. Stefano Masiero, MD (University of Padova, Padova, Italy); Andrea Celia, MD; Mario Armani, MD; Vincenzo Perticaro, MD; Claudio Ferraro, MD; Marco Ortolani, MD, e-mail: [email protected]. Disclosure: None. Objective: To test in stroke patients whether additional sensorimotor training of the paralyzed or paretic upper limb delivered by a robotic device enhanced motor recovery and functional outcome. Design: Randomized controlled trial. Setting: Hospitalized care. Participants: 20 patients with poststroke hemiparesis or hemiplegia within the first week after stroke. Intervention: Patients were randomly assigned either to early robotic training (robotic therapy group for 25 sessions of ⬇40min/d) or exposed to the robotic device without training (control group for 3 times weekly for 15 sessions of ⬇10min/d). Robot therapy by a new robot, designed and built at Padova University, provides sensorimotor stimulation for hemiplegic patients, through active and passive mobilization of the upper limb, with visual and acoustic feedback. Main Outcome Measures: Outcomes were assessed by the same masked raters, before treatment began and at 60 and 240 days, with the upper-extremity component of the Fugl-Meyer Assessment (FMA), the Motor Status Scale (MSS) score, FIM instrument, and FIM motor score. Results: The robotic therapy and control groups had comparable demography, clinical characteristics, lesion size, and pretreatment impairment scores. The robotic group demonstrated significant improvement in motor (FMA, P⫽.01; MSS shoulder and elbow, P⫽.05; wrist and hand, P⫽.05), and functional outcome (FIM, P⫽.03; FIM motor, P⫽.01) at 60⫾8 days compared with the control group. The significant improvement in the robotic group persisted at follow-up after 240⫾24 days. All treated patients had favorable impressions of robotic treatment. There were no side effects. Conclusions: This study revealed statistically significant benefits of robotic therapy in persons with stroke-related paralyzed or paretic upper limb. In these patients, an early robotic approach may usefully complement other treatments by reducing motor impairment during both acute and chronic phases of stroke recovery. Key Words: Cerebrovascular accident; Rehabilitation; Robotics. Poster 235 Cost-Effectiveness of Screening for Deep Vein Thrombosis by Ultrasound at Admission to Stroke Rehabilitation. Richard D. Wilson, MD (Case Western Reserve University/MetroHealth Medical Center, Cleveland, OH); Patrick K. Murray, MD, e-mail: rwilson@ metrohealth.org. Disclosure: None. Objective: This is a cost-effectiveness analysis of Doppler ultrasound screening for deep vein thrombosis (DVT) in patients with ischemic stroke at admission to rehabilitation. Design: A decision-analysis model was created and probabilities derived from multiple data sources to compare 2 approaches for detecting DVT in the ischemic stroke population: (1) screening patients at admission to stroke rehabilitation for DVT by Doppler ultrasound or (2) clinical surveillance for signs of DVT and treatment after confirmation by Doppler ultrasound. Cost for treatment was based on data from the literature on prevalence of DVT and risks for complications of DVT and of treatment. Costs are in 2004 dollars, and the effectiveness is in quality-adjusted life-years (QALYs) gained. The analyses are conducted from a societal perspective for the duration of a typical stroke rehabilitation admission. Setting: Inpatient stroke rehabilitation unit. Participants: Not applicable. Intervention: Screening all patients with acute ischemic stroke at admission to stroke rehabilitation for DVT by Doppler ultrasound. Main Outcome Measures: Cost in 2004 dollars per QALY gained. Results: The expected utility of screening patients with ischemic stroke for DVT on admission to rehabilitation is 1.640 QALYs and that of not screening is 1.638 QALYs. The expected gain is .0021 QALY (18h) Obtaining this increase incurs additional cost of $168 per stroke patient and a marginal cost-effectiveness of $81,200 for each QALY gained. Conclusions: This study estimates that the cost-effectiveness ratio is higher than that reported in other rehabilitation conditions. This difference primarily relates to the shorter life expectancy following stroke, the prevalence of occult DVT at admission, rate of complications of anticoagulation, and the estimates of the screening test’s characteristics. Further study of these areas is likely to contribute to improving our understanding of the most appropriate care in this clinical setting. Key Words: Cost-benefit analysis; Screening; Stroke; Rehabilitation; Venous thrombosis. Poster 236 Predictive Factors for Ambulation in Stroke Patients Using a Multivariate Analysis. Stefano Masiero, MD (University of Padova, Padova, Italy); Renato Avesani, MD; Mario Armani, MD; Roberta Pierobon, MD; Paola Zapparoli, MD; Mario Ermani, MD, e-mail: [email protected]. Disclosure: None. Objective: To investigate the predictive factors for the recovery of ambulation in stroke patients in the rehabilitation setting. Design: A prospective repeated-measures design. Setting: Rehabilitation hospital. Participants: 150 hemiplegic patients at their first stroke. Intervention: Intensive rehabilitative training. Main Outcome Measures: FIM instrument, FIM motor score, upper and lower Motricity Index, Trunk Control Test (TCT), and Functional Ambulation Classification (FAC). Results: The mean age was 68.9⫾11.52 years. The mean time between stroke and start of
Arch Phys Med Rehabil Vol 86, September 2005
2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Poster 225 Heterotopic Ossification With Normal Serum Alkaline Phosphatase Levels: A Case Series. Divakara Kedlaya, MD (Loma Linda University Medical Center, Loma Linda, CA); Cid Nazir, MD, e-mail: [email protected]. Disclosure: None. Setting: Acute rehabilitation unit. Patients: A 28-year-old man with T12 American Spinal Injury Association (ASIA) grade C paraplegia due to gunshot wound, a 20-year-old man with T5 ASIA grade A paraplegia due to motor vehicle collision (MVC), and a 36-year-old man with C7-8 ASIA grade A tetraplegia due to MVC. Case Descriptions: The first patient had worsening pain, swelling, and decreased range of motion (ROM) of the left knee 5 weeks after the injury. Radiographs and triple-phase bone scan showed immature heterotopic ossification (HO) in medial condyle and epicondyle of left femur. Serum alkaline phosphatase (SAP) level was normal. Follow-up SAP a month later was also normal. The second patient had decreased ROM and a palpable callus of the right hip 14 weeks after the injury. He had history of fracture of right subtrochanteric right femur, which was treated with intramedullary rod. Hip radiograph showed HO in the soft tissues of right hip. Serial SAP levels were normal. On day 18 postinjury, the third patient began spiking high-grade fevers (⬎39°C) for the next 30 days. An extensive workup revealed no source of fever. 3 weeks later, he developed swelling and limited ROM in the left hip. Further workup was negative for deep venous thrombosis, and a triple-phase bone scan revealed HO in both hips. Serial SAP levels were normal. Discussion: In these 3 cases with documented HO, serum alkaline phosphatase levels were normal. We like to question the sensitivity of SAP as a marker for HO in its early diagnosis. Further studies need to be done to evaluate the sensitivity of SAP in the diagnosis of HO. Conclusions: Serial SAP levels may be normal in documented cases of HO. Key Words: Heterotopic ossification, Rehabilitation; Serum alkaline phosphatase; Spinal cord injuries.
Poster 226 A Proximate Cause of Heterotopic Ossification—Possible Implications for Parsing Etiologic Factors? A Case Report. Eric L. Altschuler, MD, PhD (Mt. Sinai School of Medicine, New York, NY); Brian Riordan, MD; Thomas N. Bryce, MD, e-mail: [email protected]. Disclosure: None. Setting: Acute rehabilitation facility. Patient: A 32-year-old man with a traumatic C6 complete spinal cord injury (SCI). Case Description: Before the SCI, the patient had a medical history only of kidney stones. Approximately 1.5 months post-SCI, the patient developed swelling in his right hip and groin area. Venous Doppler showed no evidence for deep vein thrombosis. Magnetic resonance imaging showed a fluid collection along the anterior aspect of the right quadriceps and accompanying inflammatory changes. Approximately 4 weeks later, the patient developed a solid mass in the right anterior thigh. Assessment/Results: Radiographs of the mass showed heterotopic ossification (HO) surrounding the right proximal femoral diaphysis. The HO was clinically significant causing some decreased hip range of motion. Discussion: This patient had a number of risk factors for developing HO: complete cervical SCI and a history of kidney stones. Interestingly, the patient only developed HO in the region with the fluid collection and inflammation, a locale with disruption of mesenchymal tissues. In this case, local injury and disruption of normal milieu were likely necessary etiologic factors in the development of the HO. By similar reasoning, cases of nonbrain or SCI patients who develop HO in the area of a joint that has been replaced, but not at other joints, may indicate the necessity of trauma to local mesenchymal tissue in the development of HO. Extremity trauma with obvious mesenchymal injury in patients with SCI may increase the risk for developing HO, potentially warranting HO prophylaxis (eg, with etidrium sodium) Conclusions: We demonstrate a case in which local trauma and tissue disruption was most likely a necessary factor in the development of HO. Controlled studies of treating patients with obvious extremity mesenchymal injury and SCI to prevent HO may be warranted. Key Words: Etiology; Heterotopic ossification; Rehabilitation; Spinal cord injuries; Trauma.
Poster 227 An Unusual Etiology for a Floppy Infant: A Case Report. Marioara Bodea, MD (East Carolina University, Brody School of Medicine, Greenville, NC); David Epperson, MD; Daniel P. Moore, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care hospital, in- and outpatient pediatric rehabilitation units. Patient: White male with hypotonia at birth, followed until 3 years of age. Case Description: This white male was born at 35 weeks of gestation, 3000gm, via C-section secondary to failure to progress and preeclampsia. History included a weak cry, poor respiratory effort, and quadriplegia. A physical exam revealed axial hypotonia, quadriplegia, absent deep tendon, palmar and plantar grasp, clonus, and Moro reflexes. Differential diagnosis initially included central nervous system disorders (congenital, genetic, metabolic, infectious, vascular, traumatic), motoneuron disorders (eg, Werdnig-Hoffman disease), neuromuscular junction disorders, congenital myopathies, congenital muscular dystrophy, and myotonia congenita. Assessment/Results: Complete blood count, serum electrolytes, and head and neck computed tomography were unremarkable. Creatine phosphokinase was 349. The workup for Werdnig-Hoffman disease, myotonia congenita, and myasthenia gravis was negative. With negative initial workup, a referral was made and a magnetic resonance imaging (MRI) of the spine was performed. It revealed abnormal T1 and T2 signal within the spinal cord extending from the cervicothoracic junction to the conus, consistent with ischemia and/or intramedullary hemorrhage. Coagulopathy workup was negative. At the 3-year follow-up, the patient had some antigravity strength in the upper extremities and 0/5 strength in the lower extremities. The cognitive development was appropriate for his age, and the patient was able to use a manual wheelchair. A repeat MRI revealed intramedullary central cord mass, possibly a lipoma spanning T6-12, and a tethered cord. Discussion: Intramedullary spinal cord hemorrhage in a neonate is unusual. Other locations of hemorrhage such as subarachnoid, subdural, or epidural are more commonly seen. A systematic approach to the floppy infant is important. Conclusions: This is a rare case of intramedullary cord hemorrhage at birth with hypotonia. It demonstrates the need to consider SCI in the differential diagnosis. Key Words: Muscle hypotonia; Rehabilitation; Spinal cord diseases.
Arch Phys Med Rehabil Vol 86, September 2005
Poster 228 Use of Bladder Irrigation To Treat Bacteriuria in Persons With Neurogenic Bladder Dysfunction. Ken B. Waites, MD; Kay C. Kanupp, MSN, CRNP; James F. Roper, MD; Yuying Chen, MD, PhD (University of Alabama, Birmingham, AL); Susan M. Camp, CRNP, e-mail: [email protected]. Disclosure: None. Objective: To evaluate the potential value of bladder irrigation to treat bacteriuria in persons with neurogenic bladders. Design: Double-blind randomized controlled trial. Setting: Rehabilitation center. Participants: 52 community-residing men and women with neurogenic bladders managed with an indwelling Foley catheter or suprapubic tube. Intervention: Subjects were randomized to irrigate their bladders twice daily for 8 weeks with 30mL of: sterile saline, acetic acid, or neomycin-polymixin. Main Outcome Measures: Urinalysis and cultures were performed at baseline and weeks 2, 4, and 8 to determine the extent to which each of the solutions affected bacterial numbers, pH, urinary leukocytes, and generation of antimicrobial-resistant organisms. Results: Bladder irrigation was well tolerated with the exception of 3 subjects who had bladder spasms and could not participate further. All participants had bacteriuria with ⱖ100,000 colonies/mL at baseline. None of the 3 irrigants had a detectable effect on the degree of bacteriuria, pyuria, or urinary pH. There was no significant increase in the occurrence of oxacillin-resistant Staphylococcus aureus or multidrug resistant gram-negative bacilli in any of the 3 groups, although the baseline rates of resistance were high. No significant development of resistance to oral antimicrobials among gram-negative bacilli beyond what was observed at baseline was detected. Conclusions: Bladder irrigation was generally well tolerated for 8 weeks. No advantages were detected for neomycin-polymixin or acetic acid over saline in terms of reducing the urinary bacterial load and inflammation. We cannot recommend bladder irrigation as an alternative to systemic antibiotics for treatment of bacteriuria. Key Words: Bacteriuria; Bladder, Neurogenic; Rehabilitation; Urinary tract infections.
Poster 229 Compliance With Guidelines for Preventing Pressure Ulcers Following Spinal Cord Injury. Sunil Sabharwal, MD (VA New England Healthcare System/ Harvard Medical School, Boston, MA); Dan Berlowitz, MD, MPH; Elaine Czarnowski, RN; Elaine Hickey, RN, e-mail: [email protected]. Disclosure: None. Objectives: To measure current compliance with the pressure ulcer prevention guidelines (Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury, published by the Consortium for Spinal Cord Medicine) and to define determinants of variation from guideline recommendations and identify compliance barriers and facilitators. Design: (1) Review of 100 randomly selected medical records using a chart abstraction tool developed for abstracting information regarding compliance with pressure ulcer prevention. Inclusion criteria were SCI diagnostic ICD-9 codes and clinic visit or hospitalization at a study site in fiscal year 2003. (2) Provider focus groups conducted to identify perceived facilitators and barriers to guideline adherence. Setting: VA spinal cord injury (SCI) system of care including an SCI center and 5 SCI clinics. Interventions: Not applicable. Main Outcome Measures: Overall and facility-specific adherence rates to 14 pressure ulcer prevention guidelines. Records with outpatient visits only were analyzed separately from those with inpatient hospitalizations. Results: Guideline adherence was lower in the outpatient than inpatient group. For example, 90% of inpatients had documented pressure ulcer risk factor assessment versus 5% of outpatients. Guideline adherence varied considerably between sites. For example, nutritional status documentation varied from 15% to 85% within outpatient sites and documented pressure relief regimen ranged from 5% to 65%. Adherence was better for some guidelines than others. For example, for the outpatient group, wheelchair cushion assessment was documented in 60%, but ⬍5% documented bed support surfaces used. Focus groups indicated that standardized templates incorporating guidelines would improve documentation and also serve as a reminder checklist. The greatest perceived barrier to guideline adherence was patient compliance. Conclusions: Knowledge generated by this study has prompted development of interventions especially with outpatient focus, including standardized templates for pressure ulcer specific periodic evaluation, and patient educational material to promote compliance. Key Words: Clinical practice guidelines; Spinal cord injuries; Pressure ulcer; Rehabilitation.
Poster 230 Incidence and Outcomes of Spinal Cord Injury Clinical Syndromes. Katia Santos, MD (Virginia Commonwealth University, Richmond, VA); William McKinley, MD; Michelle Meade, PhD; Karen L. Brooke, e-mail: [email protected]. Disclosure: None. Objective: To examine and compare demographics and functional outcomes for individuals with spinal cord injury (SCI) clinical syndromes, including central cord (CCS), Brown-Sequard (BSS), anterior cord (ACS), posterior cord (PCS), cauda equina (CES), and conus medullaris (CMS). Design: Retrospective review. Setting: Tertiary care, level I trauma center inpatient rehabilitation unit. Participants: 848 consecutive admissions with acute SCI. Interventions: Not applicable. Main Outcome Measures: FIM instrument, FIM subgroups (motor, self-care, cognitive), length of stay (LOS), and discharge disposition. Results: 176 (20.8%) patients were diagnosed with SCI clinical syndromes. CCS was the most common (44.3%), followed by CES (25.6%) and BSS (17.6%). Significant differences (Pⱕ.01) were found between groups with regard to age, race, etiology, total admission FIM, motor admission FIM, self-care admission and discharge FIM, and LOS. Statistical analysis between tetraplegic BSS and CCS revealed significant difference (Pⱕ.01) with respect to age (38.9 vs 53.2) and a trend toward significance (Pⱕ.05) with regard to total discharge FIM (97.0 vs 85.0), motor discharge FIM (64.5 vs 55.0), and self-care discharge FIM (29.0 vs 23.9). No significant differences (Pⱕ.01) were found when comparing CMS with CES. Conclusions: SCI clinical syndromes represent a significant proportion of admissions to acute SCI rehabilitation with CCS presenting most commonly and representing the oldest age group with the lowest admission functional level of all SCI clinical syndromes. Cervical BBS individuals seem to achieve higher functional improvement by discharge when compared with CCS patients. CMS and
2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS CES exhibit similar functional outcomes. ACS and PCS demonstrate functional gains with inpatient rehabilitation with ACS patients displaying the longest LOS of the SCI clinical syndromes. These findings have important implications for the overall management and outcome of patients with SCI. Key Words: Central cord syndrome; Rehabilitation; Spinal cord injuries. Poster 231 Using the Symptom Checklist Questionnaire To Measure Psychologic Distress in Acute Inpatient Rehabilitation Subjects With Spinal Cord Injury or Disease. Patricia Motycka, DO (Mayo Clinic, Rochester, MN); Katherine Piderman, PhD; Donald Williams, PhD; Sandy Rackley, MD; Ronald Reeves, MD, e-mail: [email protected]. Disclosure: None. Objective: To measure psychologic distress using the revised Symptom Checklist Questionnaire (SCL-90-R) in individuals with spinal cord injury (SCI) or disease during their stay in an acute inpatient rehabilitation unit and 6 months after dismissal. Design: Prospective observational survey using patient self-reported SCL-90-R questionnaires. Setting: Acute inpatient rehabilitation hospital unit. Participants: 88 subjects admitted to an acute inpatient rehabilitation unit between January 2003 and February 2005. The exclusion criteria were age ⬍18, Folstein Mini-Mental State Examination score ⬍22, diagnosis of an acquired brain disorder that could impair cognition or perception, inability to complete the 6-month follow-up, or status as a Federal Medical Center prisoner. The group was comprised of 63 men and 25 women (age range, 19 – 84). Intervention: All patients received individualized rehabilitation services according to standard rehabilitation practice. Main Outcome Measures: Median values of global severity index scores (which measures distress) were computed for individuals who completed the SCL-90-R during their acute rehabilitation stay and 6 months after dismissal. Results: 88 subjects filled out an SCL-90-R during their acute inpatient rehabilitation stay, and 35 subjects returned a 6-month follow-up SCL-90-R that was mailed to their home. The median global severity index score for the group during their rehabilitation stay was 60. The median global severity index score for the group at 6 months postdismissal was 59. Conclusions: The global severity index score for patients with SCI or disease is comparable to scores for acutely medically ill patients. However, global distress does not appear to decrease in the first 6 months after dismissal from inpatient rehabilitation. Persistent SCL-90 score elevation has been shown to be a risk factor for adverse outcomes in other populations. Further study of “distress” within rehabilitation patients is needed. Key Words: Psychological tests; Rehabilitation; Spinal cord injuries. Poster 232 Acupuncture in the Treatment of Shoulder Pain in Individuals With Spinal Cord Injury: A Placebo-Controlled Study. Trevor A. Dyson-Hudson, MD (KMRREC, West Orange, NJ); Michael LaFountain, MA, MEd, ATC/L; Scott R. Millis, PhD, MEd, e-mail: [email protected]. Disclosure: None. Objective: To determine the effectiveness of acupuncture in treating chronic shoulder pain in manual wheelchair using individuals with chronic spinal cord injury (SCI). Design: Randomized, single-blind (subject), placebo controlled clinical trial. Setting: Rehabilitation research department. Participants: Individuals with chronic SCI (⬎1y) and chronic shoulder pain (⬎3mo) who used manual wheelchairs as their primary means of mobility (⬎40h/wk). Intervention: Participants were randomly assigned to receive either traditional needle acupuncture or placebo acupuncture (ie, sham acupuncture; light needling of nonacupuncture points). All participants received a total of 10 treatments over a 5-week period. Main Outcome Measures: The Wheelchair User’s Shoulder Pain Index (WUSPI) was used to monitor changes in shoulder pain intensity during the treatment period in each group. A 1-way analysis of covariance was conducted. The independent variable, group assignment, included 2 levels: traditional acupuncture and placebo acupuncture. The dependent variable was the WUSPI score at the end of the treatment period and the covariate was the WUSPI score prior to the beginning of treatments. Results: In the total population analyzed (N⫽13), there was no significant difference between the traditional acupuncture and placebo acupuncture groups (F1,10⫽.212, P⫽.655). The strength of the relationship between the groups and final WUSPI score was low to medium, as assessed by a partial 2, with group assignment accounting for 3% of the variance on the WUSPI. The adjusted mean for the traditional acupuncture group (M⫽18.0) was smaller than the placebo acupuncture group (M⫽23.3). Conclusions: Although the difference between traditional needle acupuncture and placebo acupuncture in reducing shoulder pain was not significant, there was a small to medium effect size associated with the acupuncture treatments. Key Words: Acupuncture; Rehabilitation; Shoulder pain; Spinal cord injuries,
Poster 233 Sympathetic Skin Response: A Simplified Testing of Sympathetic Efferents in Spinal Injury Patients. Harsha S. Nagarajarao, MB BS, MRCP (Northwest Regional Spinal Injuries Centre, Southport, UK); John Watt, MB cHB, MD, FRCA; Babu N. Kumar, MB BS, D Ortho, DNB, MRCS; B.R. Kumar, MB BS, MRCP, e-mail: [email protected]. Disclosure: None. Objective: To determine whether eliciting the sympathetic skin response (SSR) by gasp reflex would be a dependable measure of sympathetic preservation (SP) using standard bedside electrocardiogram (ECG) monitor and would be superior to visual stimuli. Design: Case-control study of 5 healthy controls and 21 nonacute spinal cord injury (SCI) patients in rehabilitation. Setting: Regional spinal injury center in the U.K. Participants: SCI patients in rehabilitation. Interventions: Not applicable. Main Outcome Measures: Complete and incomplete tetraplegics and paraplegics were tested during series of inspiratory gasps and visual stimuli in supine position for waveforms on a single-channel ECG monitor. SSRs were repeated at intervals of 1 minute to examine the influence of habituation. Presence of an SSR waveform on the ECG monitor indicated preservation of the sympathetic nervous system, and absence the loss. Results: Mean voltages in the hands and feet of controls were significantly greater after the gasp (1.03, 1.20mV) than after visual stimulus (0.26, 0.03mV) (P⫽.01). The findings were essentially the same in the hands of paraplegics, and responses appeared unaffected by anticholinergics. Most paraplegic and tetraplegic
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patients showed total absence of response below the lesion level. Sensorimotor incompleteness was not a good predictor of SSRs. Conclusions: Screening for SSR waveform on a single-channel ECG monitor after a rapid inspiration is a reliable, reproducible, noninvasive, and rapid bedside technique of assessing the neurologic status of the sympathetic system in SCI and could be used regularly to complement sensorimotor scoring. Defining sympathetic status may facilitate management of skin, bowels, postural hypotension, and autonomic dysreflexia. Key Words: Autonomic dysreflexia; Autonomic nervous system; Disability evaluation; Rehabilitation; Spinal cord injuries.
Stroke Poster 234 Effects of Robotic Therapy on Motor Impairment and Recovery in Stroke Patients. Stefano Masiero, MD (University of Padova, Padova, Italy); Andrea Celia, MD; Mario Armani, MD; Vincenzo Perticaro, MD; Claudio Ferraro, MD; Marco Ortolani, MD, e-mail: [email protected]. Disclosure: None. Objective: To test in stroke patients whether additional sensorimotor training of the paralyzed or paretic upper limb delivered by a robotic device enhanced motor recovery and functional outcome. Design: Randomized controlled trial. Setting: Hospitalized care. Participants: 20 patients with poststroke hemiparesis or hemiplegia within the first week after stroke. Intervention: Patients were randomly assigned either to early robotic training (robotic therapy group for 25 sessions of ⬇40min/d) or exposed to the robotic device without training (control group for 3 times weekly for 15 sessions of ⬇10min/d). Robot therapy by a new robot, designed and built at Padova University, provides sensorimotor stimulation for hemiplegic patients, through active and passive mobilization of the upper limb, with visual and acoustic feedback. Main Outcome Measures: Outcomes were assessed by the same masked raters, before treatment began and at 60 and 240 days, with the upper-extremity component of the Fugl-Meyer Assessment (FMA), the Motor Status Scale (MSS) score, FIM instrument, and FIM motor score. Results: The robotic therapy and control groups had comparable demography, clinical characteristics, lesion size, and pretreatment impairment scores. The robotic group demonstrated significant improvement in motor (FMA, P⫽.01; MSS shoulder and elbow, P⫽.05; wrist and hand, P⫽.05), and functional outcome (FIM, P⫽.03; FIM motor, P⫽.01) at 60⫾8 days compared with the control group. The significant improvement in the robotic group persisted at follow-up after 240⫾24 days. All treated patients had favorable impressions of robotic treatment. There were no side effects. Conclusions: This study revealed statistically significant benefits of robotic therapy in persons with stroke-related paralyzed or paretic upper limb. In these patients, an early robotic approach may usefully complement other treatments by reducing motor impairment during both acute and chronic phases of stroke recovery. Key Words: Cerebrovascular accident; Rehabilitation; Robotics. Poster 235 Cost-Effectiveness of Screening for Deep Vein Thrombosis by Ultrasound at Admission to Stroke Rehabilitation. Richard D. Wilson, MD (Case Western Reserve University/MetroHealth Medical Center, Cleveland, OH); Patrick K. Murray, MD, e-mail: rwilson@ metrohealth.org. Disclosure: None. Objective: This is a cost-effectiveness analysis of Doppler ultrasound screening for deep vein thrombosis (DVT) in patients with ischemic stroke at admission to rehabilitation. Design: A decision-analysis model was created and probabilities derived from multiple data sources to compare 2 approaches for detecting DVT in the ischemic stroke population: (1) screening patients at admission to stroke rehabilitation for DVT by Doppler ultrasound or (2) clinical surveillance for signs of DVT and treatment after confirmation by Doppler ultrasound. Cost for treatment was based on data from the literature on prevalence of DVT and risks for complications of DVT and of treatment. Costs are in 2004 dollars, and the effectiveness is in quality-adjusted life-years (QALYs) gained. The analyses are conducted from a societal perspective for the duration of a typical stroke rehabilitation admission. Setting: Inpatient stroke rehabilitation unit. Participants: Not applicable. Intervention: Screening all patients with acute ischemic stroke at admission to stroke rehabilitation for DVT by Doppler ultrasound. Main Outcome Measures: Cost in 2004 dollars per QALY gained. Results: The expected utility of screening patients with ischemic stroke for DVT on admission to rehabilitation is 1.640 QALYs and that of not screening is 1.638 QALYs. The expected gain is .0021 QALY (18h) Obtaining this increase incurs additional cost of $168 per stroke patient and a marginal cost-effectiveness of $81,200 for each QALY gained. Conclusions: This study estimates that the cost-effectiveness ratio is higher than that reported in other rehabilitation conditions. This difference primarily relates to the shorter life expectancy following stroke, the prevalence of occult DVT at admission, rate of complications of anticoagulation, and the estimates of the screening test’s characteristics. Further study of these areas is likely to contribute to improving our understanding of the most appropriate care in this clinical setting. Key Words: Cost-benefit analysis; Screening; Stroke; Rehabilitation; Venous thrombosis. Poster 236 Predictive Factors for Ambulation in Stroke Patients Using a Multivariate Analysis. Stefano Masiero, MD (University of Padova, Padova, Italy); Renato Avesani, MD; Mario Armani, MD; Roberta Pierobon, MD; Paola Zapparoli, MD; Mario Ermani, MD, e-mail: [email protected]. Disclosure: None. Objective: To investigate the predictive factors for the recovery of ambulation in stroke patients in the rehabilitation setting. Design: A prospective repeated-measures design. Setting: Rehabilitation hospital. Participants: 150 hemiplegic patients at their first stroke. Intervention: Intensive rehabilitative training. Main Outcome Measures: FIM instrument, FIM motor score, upper and lower Motricity Index, Trunk Control Test (TCT), and Functional Ambulation Classification (FAC). Results: The mean age was 68.9⫾11.52 years. The mean time between stroke and start of
Arch Phys Med Rehabil Vol 86, September 2005