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Poster 292: Neurosarcoidosis Presenting as Progressive Low Back Pain and Weakness Years After Laminectomy: A Case Report
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
wound while serving in Operation Iraqi Freedom. Case Description: We report a systematic retrospective case review of his acute SCI rehabilitation, which was medically complicated by infection with acinetobacter calcoaceticus-baumannii complex contracted while in Iraq. Isolation equipment and protocols were designed to enable regular hands on contact for proprioceptive neuromuscular facilitation, transfers, wheelchair fitting, mobility training, and environmental control. Assessment/Results: After 1 month of comprehensive acute interdisciplinary rehabilitation in an isolated hospital room on the SCI unit, he attained a functional level comparable to C5 complete patients rehabilitated in our unit. Patient and wife team achieved 1-person assist Hoyer lift transfers, wheelchair sitting for 1 hour twice daily, independent recline pressure releases, and joystick control of a power wheelchair, as well as minimum assistance upper-body dressing and independence in self-feeding after setup. The “Yes You Can” educational manual was reviewed in its entirety. Discussion: Concerns about serious infectious organisms are increasing in rehabilitation facilities. Isolation has been implemented to protect patients and staff. Isolation can also potentially challenge patients’ rights of access to medical care, psychologic adaptation, mobility options, and environmental interaction. However, innovations in intervention of rehabilitation practice can improve function in this setting. These challenges were overcome with increased education, greater inclusion of the spouse and primary nurse in the rehabilitation process and scheduled visits of the entire team. Conclusions: If isolation on an SCI unit is necessary, it is still feasible to conduct a comprehensive multidisciplinary rehabilitation program while strictly adhering to contact isolation. Further study is required to establish interdisciplinary protocols for patients and families requiring isolation in the rehabilitation setting. Key Words: Acinetobacter calcoaceticus; Isolation, patient; Rehabilitation; Spinal cord injuries. Poster 290 Quality of Life Evaluation in Spinal Cord Injury Patients Comparing Different Bladder Management Techniques. Miguel Angel Go`nzalez Viejo, MD, PhD (Vall d’Hebron Hospitals, Barcelona, Spain); Judith Sa´nchez Raya, MD; Georgia Romero, MD; Joan Conejero, MD. Disclosure: M. Go`nzalez Viejo, None; J. Sa´nchez Raya, None; G. Romero, None; J. Conejero, None. Objective: To examine the quality of life (QOL) among patients with spinal cord injury (SCI) requiring bladder management techniques, using the King’s Health Questionnaire (KHQ). Design: Crosssectional study. Setting: SCI unit in a tertiary university public hospital. Participants: 91 SCI patients (76% men, 24% women) were randomly chosen (average age, 40y; range, 16⫺75y; average time since spinal injury, 11.4y). They were classified according to the use of different bladder management techniques: clean intermittent selfcatheterization (n⫽22) (CISC), external condom catheter (n⫽21) (ECC), and indwelling (Foley) catheter (n⫽48) (IC). Interventions: Patients completed a validated QOL questionnaire for urinary incontinence (KHQ), as well as a subjective evaluation of the main problems related to spinal injury. Main Outcome Measure: The KHQ. We evaluated the existence of statistically significant differences among them. Results: Total score in the KHQ for the sample was 39.9⫾54.4, with higher scores in those patients with ECC (43.5⫾24). A thorough analysis of the test did not show any significant differences. Patients treated with ECC reported higher physical role limitation scores (P⫽.02) than patients treated with IC and CISC. Sexuality was the main concern of most patients, followed by defectory dysfunction, urinary incontinence, and deambulatory problems. Conclusions: Patients treated with ECC reported a higher global score on the KHQ, although no significant differences were reported among the 3 groups.
E95
Our patients are mainly concerned about sexual problems. Key Words: Bladder; Rehabilitation; Spinal cord injuries; Urinary incontinence. Poster 291 Asymptomatic Persistent Bradycardia in Ventilator-Dependent Tetraplegia: A Case Report. Matt P. West, MD (Medical College of Wisconsin, Milwaukee, WI); Kevin White, MD. Disclosure: M.P. West, None; K. White, None. Setting: Tertiary inpatient hospital spinal cord injury (SCI) unit. Patient: A 65-year-old man with C2 complete tetraplegia secondary to a fall. Case Description: Since the injury, he has been ventilatordependent and persistently bradycardic despite medical treatment including theophylline. He has a cardiac history of atrial fibrillation over the last 10 years for which he has undergone cardioversion twice and has been on amiodarone. Amiodarone was discontinued with the onset of bradycardia following his SCI. 1 month postinjury, the patient had worsening bradycardia, with a heart rate in the mid 30s corresponding with episode of unresponsiveness. 5 months postinjury, he had asymptomatic persistent bradycardia with heart rate in the mid 30s and no signs of cardiopulmonary distress. Bradycardia is a known complication to acute injury secondary to dissociation between the parasympathetic and sympathetic response during spinal shock; however, he persistently had asymptomatic bradycardia for over 6 months. Assessment/Results: Cardiology was consulted to re-evaluate the patient’s bradycardia. The patient’s heart rate was monitored using a pulse oximeter machine. Recordings were made every 20 minutes over a 3-day period to evaluate trends. Although the patient was asymptomatic, for brief periods he maintained rates in the 30s. After discussing his case with everyone involved, including the patient’s family, a cardiac pacemaker was implanted. Discussion: Cardiac pacemaker implantation as a treatment for symptomatic bradycardia in acute high-level tetraplegia has been known to occur but the incidence of pacemaker placement in asymptomatic persons is not known. Conclusions: Though bradycardia is a known complication of high-level cervical cord injuries within the first few months, there is continued autonomic dysregulation in the chronic phase. Even in the face of asymptomatic bradycardia, there is often the possible indication for cardiac pacemaker implementation. Key Words: Bradycardia; Cardiac pacemaker, artificial; Rehabilitation; Spinal cord injuries; Tetraplegia. Poster 292 Neurosarcoidosis Presenting as Progressive Low Back Pain and Weakness Years After Laminectomy: A Case Report. Jeffrey A. Gehret, DO (Thomas Jefferson Univ. Hospital, Philadelphia, PA); Guy W. Fried, MD. Disclosure: J.A. Gehret, None; G.W. Fried, None. Setting: Acute inpatient rehabilitation hospital. Patient: A 65-yearold African-American woman with a 45-year history of progressive low back pain (LBP), lower-extremity weakness, and gait instability worsened after each pregnancy. Case Description: The patient presented 4 years after initial thoracic laminectomy for LBP, lowerextremity weakness, and gait instability. The patient underwent thoracic laminectomy (T10-11) for presumed stenosis in 2002, with partial improvement of early myelopathy. Years later the patient presented with progressive myelopathy, diffuse lymphadenopathy, and an intracranial mass, in addition to a large enhancing lesion in the thoracic cord. Assessment/Results: The spinal lesion was consistent with a neoplastic intramedullary lesion at the site of the prior laminectomy. She underwent surgery for biopsy and possible excision. Frozen section was consistent with noncaseating granuloma. It was Arch Phys Med Rehabil Vol 88, September 2007
E96
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
decided not to excise the abnormal tissue. Treatment with steroids and intensive rehabilitation with ambulation training using a reciprocating walker resulted in remarkable functional improvement. Discussion: Intramedullary spinal neurosarcoidosis is an uncommon manifestation of sarcoidosis. It occurs in less than 1% of sarcoidosis cases. Usually spinal cord involvement is not an isolated or first manifestation of the disease. Correlation between symptom resolution and resolution of imaging findings is poor, especially with spinal cord lesions. Conclusions: Although rare, sarcoidosis of the spine should be considered in the differential diagnosis of LBP and weakness, particularly in patients considering surgery. Correct diagnosis and early treatment with steroids can minimize neurologic complications and decrease morbidity. Key Words: Myelopathy; Rehabilitation; Sarcoidosis. Poster 293 Man With Cervical Myelopathy Syndrome With PoliomyelitisType Motoneuron Disease Secondary to West Nile Virus: A Case Report. Harvey J. Navrkal, MD (Mercy Hospital PM&R Residency Program, Pittsburgh, PA). Disclosure: H.J. Navrkal, None. Setting: Acute care hospital. Patient: A 50-year-old man with motoneuron disease secondary to West Nile virus (WNV). Case Description: Following a “flu” syndrome, a 50-year-old man developed a cervical myelopathy syndrome. This rapidly progressed to generalized weakness and an encephalitis and meningitis presentation. He was hospitalized and placed on a mechanical ventilator for 4 months. Diagnostic workup revealed WNV infection (confirmed by the Centers for Disease Control and Prevention) with a complicated course involving poliomyelitis-type motoneuron disease. 24 months after discharge, he has been followed for a cervical myelopathy type syndrome. Magnetic resonance imaging of his brain and cervical cord remained unremarkable. Nerve conduction studies (NCS) of bilateral upper extremities showed diffuse motor-sensory polyneuropathy. There were components of median and ulnar tunnel syndrome as well, with dispersion of sensory amplitudes. Electromyography of bilateral upper extremities showed severe diffuse nerve root and muscle denervation consistent with diffuse motoneuron disease. He is undergoing rehabilitation of his upper-extremity function. Assessment/Results: At more than 2 years after his hospitalization for a paralytic poliomyelitis type of infection caused by WNV, the patient continues to make progress in his rehabilitation. Further developments will be discussed. Discussion: This is the first reported case, to our knowledge, of a severe generalized polio-like syndrome caused by WNV, with almost complete resolution of all symptoms at 24 months, with the exception of a slowly improving cervical myelopathy syndrome. Chronic inflammatory demyelinating polyneuropathy with secondary axonal changes was a diagnostic consideration, although the patient lacked any significant sensory symptoms. Conclusions: It is possible to have a residual segmental disorder of the anterior horn cells following a paralytic poliomyelitis syndrome caused by WNV. Superimposed tunnel syndromes may complicate the NCS. Key Words: Poliomyelitis; Rehabilitation; West Nile virus. Poster 294 Mechanical Insufflation-Exsufflation Use in Persons With Tetraplegia: A Population-Based Study. James Crew, MD (University of Washington, Seattle, WA); Stephen Burns, MD. Disclosure: J. Crew, None; S. Burns, None. Objectives: To describe the characteristics of persons with spinal cord injury (SCI) who have been prescribed mechanical insufflationexsufflation (MIE) units for outpatient use, and to examine pulmonary morbidity and mortality pre- and post-MIE prescription. Design: RetArch Phys Med Rehabil Vol 88, September 2007
rospective cohort study. Prescription of MIE was verified from a prosthetic equipment database, and clinical data were abstracted from electronic medical records. Setting: Veterans Affairs SCI service. Participants: All persons receiving care through the SCI service who received MIE units for outpatient use during 2000 to 2006. Interventions: Not applicable. Main Outcome Measures: Patient demographics, hospitalization rates, and respiratory complications. Results: From a population of 883 persons who received care through the service during the study period, 41 (4.6%) were prescribed MIE units. Among chart-reviewed participants, mean age ⫾ SD was 57.4⫾13.8 years (range, 28⫺83y) and mean age at onset of tetraplegia was 42.8⫾16.0 years. All participants had tetraplegia, and the most common neurologic level was C5 (22% of participants). Pulmonary comorbidities were common in this cohort, with 65% of participants having at least one. Median time from first hospital admission to MIE prescription was 26 months. The pre-MIE rate of hospitalization with respiratory complications was .48 per year. Post-MIE hospitalization rate determination is ongoing. Conclusions: Approximately 5% of persons with SCI followed at the study center have received MIE units for outpatient use. Subsequent analyses will determine whether respiratory complication rates decreased following prescription of MIE units. Key Words: Pneumonia; Rehabilitation; Respiratory therapy; Spinal cord injuries. Poster 295 Botulinum Toxin Type A to Improve Sitting Ability in a Patient With Tetraplegia and Hip Dislocation: A Case Report. Adam Berliner, DO (Jackson Memorial Hospital, Miami, FL); Suzanne Duncan, MD; Ronald Tolchin, DO. Disclosure: A. Berliner, None; S. Duncan, None; R. Tolchin, None. Setting: University-based multidisciplinary tertiary care center. Patient: A 24-year-old man with tetraplegia and left hip dislocation. Case Description: The patient, who was involved in a motor vehicle collision resulting in C5 complete tetraplegia, later developed difficulty in lying supine and propelling his wheelchair. Left hip imaging revealed a dislocation with sclerosis superiorly. Orthopedic evaluation determined that relocation was not possible. On examination, he was found to have severe lower-extremity spasticity. The left hip was internally rotated and the greater trochanter was superior to the right. An initial trial of 500U of botulinum toxin type A (BTX-A) was administered to reduce spasticity in the muscles surrounding the left hip. 3 months later, another 500U of BTX-A was administered in conjunction with dehydrated alcohol motor point blocks. Both sets of injections were followed by comprehensive physical therapy to reduce tone in the hip. Assessment/Results: Within 2 weeks of the initial treatment, the patient reported improved sitting posture and ability to operate his wheelchair. He noted significantly more improvement following the second procedure. Discussion: The use of neurotoxin injections for the management of spasticity is supported by several studies. Several case reports describe the use of BTX-A for dislocation of the temporomandibular or cricoarytenoid joints with favorable results. However, there are currently no studies addressing the use of neurotoxin injections for hip dislocation in spinal cord injury. A comprehensive review of the literature revealed 1 retrospective study looking at combining botulinum toxin with phenol to treat spasticity in children with cerebral palsy. Conclusions: The use of injected neurotoxins may be beneficial in treating patients with hip dislocation associated with lower-extremity spasticity and should be further investigated. Additional studies should address the safety and efficacy of combining neurotoxins to achieve greater spasticity reduction. Key Words: Botulinum toxin type A; Hip dislocation; Rehabilitation; Spinal cord injuries.
wound while serving in Operation Iraqi Freedom. Case Description: We report a systematic retrospective case review of his acute SCI rehabilitation, which was medically complicated by infection with acinetobacter calcoaceticus-baumannii complex contracted while in Iraq. Isolation equipment and protocols were designed to enable regular hands on contact for proprioceptive neuromuscular facilitation, transfers, wheelchair fitting, mobility training, and environmental control. Assessment/Results: After 1 month of comprehensive acute interdisciplinary rehabilitation in an isolated hospital room on the SCI unit, he attained a functional level comparable to C5 complete patients rehabilitated in our unit. Patient and wife team achieved 1-person assist Hoyer lift transfers, wheelchair sitting for 1 hour twice daily, independent recline pressure releases, and joystick control of a power wheelchair, as well as minimum assistance upper-body dressing and independence in self-feeding after setup. The “Yes You Can” educational manual was reviewed in its entirety. Discussion: Concerns about serious infectious organisms are increasing in rehabilitation facilities. Isolation has been implemented to protect patients and staff. Isolation can also potentially challenge patients’ rights of access to medical care, psychologic adaptation, mobility options, and environmental interaction. However, innovations in intervention of rehabilitation practice can improve function in this setting. These challenges were overcome with increased education, greater inclusion of the spouse and primary nurse in the rehabilitation process and scheduled visits of the entire team. Conclusions: If isolation on an SCI unit is necessary, it is still feasible to conduct a comprehensive multidisciplinary rehabilitation program while strictly adhering to contact isolation. Further study is required to establish interdisciplinary protocols for patients and families requiring isolation in the rehabilitation setting. Key Words: Acinetobacter calcoaceticus; Isolation, patient; Rehabilitation; Spinal cord injuries. Poster 290 Quality of Life Evaluation in Spinal Cord Injury Patients Comparing Different Bladder Management Techniques. Miguel Angel Go`nzalez Viejo, MD, PhD (Vall d’Hebron Hospitals, Barcelona, Spain); Judith Sa´nchez Raya, MD; Georgia Romero, MD; Joan Conejero, MD. Disclosure: M. Go`nzalez Viejo, None; J. Sa´nchez Raya, None; G. Romero, None; J. Conejero, None. Objective: To examine the quality of life (QOL) among patients with spinal cord injury (SCI) requiring bladder management techniques, using the King’s Health Questionnaire (KHQ). Design: Crosssectional study. Setting: SCI unit in a tertiary university public hospital. Participants: 91 SCI patients (76% men, 24% women) were randomly chosen (average age, 40y; range, 16⫺75y; average time since spinal injury, 11.4y). They were classified according to the use of different bladder management techniques: clean intermittent selfcatheterization (n⫽22) (CISC), external condom catheter (n⫽21) (ECC), and indwelling (Foley) catheter (n⫽48) (IC). Interventions: Patients completed a validated QOL questionnaire for urinary incontinence (KHQ), as well as a subjective evaluation of the main problems related to spinal injury. Main Outcome Measure: The KHQ. We evaluated the existence of statistically significant differences among them. Results: Total score in the KHQ for the sample was 39.9⫾54.4, with higher scores in those patients with ECC (43.5⫾24). A thorough analysis of the test did not show any significant differences. Patients treated with ECC reported higher physical role limitation scores (P⫽.02) than patients treated with IC and CISC. Sexuality was the main concern of most patients, followed by defectory dysfunction, urinary incontinence, and deambulatory problems. Conclusions: Patients treated with ECC reported a higher global score on the KHQ, although no significant differences were reported among the 3 groups.
E95
Our patients are mainly concerned about sexual problems. Key Words: Bladder; Rehabilitation; Spinal cord injuries; Urinary incontinence. Poster 291 Asymptomatic Persistent Bradycardia in Ventilator-Dependent Tetraplegia: A Case Report. Matt P. West, MD (Medical College of Wisconsin, Milwaukee, WI); Kevin White, MD. Disclosure: M.P. West, None; K. White, None. Setting: Tertiary inpatient hospital spinal cord injury (SCI) unit. Patient: A 65-year-old man with C2 complete tetraplegia secondary to a fall. Case Description: Since the injury, he has been ventilatordependent and persistently bradycardic despite medical treatment including theophylline. He has a cardiac history of atrial fibrillation over the last 10 years for which he has undergone cardioversion twice and has been on amiodarone. Amiodarone was discontinued with the onset of bradycardia following his SCI. 1 month postinjury, the patient had worsening bradycardia, with a heart rate in the mid 30s corresponding with episode of unresponsiveness. 5 months postinjury, he had asymptomatic persistent bradycardia with heart rate in the mid 30s and no signs of cardiopulmonary distress. Bradycardia is a known complication to acute injury secondary to dissociation between the parasympathetic and sympathetic response during spinal shock; however, he persistently had asymptomatic bradycardia for over 6 months. Assessment/Results: Cardiology was consulted to re-evaluate the patient’s bradycardia. The patient’s heart rate was monitored using a pulse oximeter machine. Recordings were made every 20 minutes over a 3-day period to evaluate trends. Although the patient was asymptomatic, for brief periods he maintained rates in the 30s. After discussing his case with everyone involved, including the patient’s family, a cardiac pacemaker was implanted. Discussion: Cardiac pacemaker implantation as a treatment for symptomatic bradycardia in acute high-level tetraplegia has been known to occur but the incidence of pacemaker placement in asymptomatic persons is not known. Conclusions: Though bradycardia is a known complication of high-level cervical cord injuries within the first few months, there is continued autonomic dysregulation in the chronic phase. Even in the face of asymptomatic bradycardia, there is often the possible indication for cardiac pacemaker implementation. Key Words: Bradycardia; Cardiac pacemaker, artificial; Rehabilitation; Spinal cord injuries; Tetraplegia. Poster 292 Neurosarcoidosis Presenting as Progressive Low Back Pain and Weakness Years After Laminectomy: A Case Report. Jeffrey A. Gehret, DO (Thomas Jefferson Univ. Hospital, Philadelphia, PA); Guy W. Fried, MD. Disclosure: J.A. Gehret, None; G.W. Fried, None. Setting: Acute inpatient rehabilitation hospital. Patient: A 65-yearold African-American woman with a 45-year history of progressive low back pain (LBP), lower-extremity weakness, and gait instability worsened after each pregnancy. Case Description: The patient presented 4 years after initial thoracic laminectomy for LBP, lowerextremity weakness, and gait instability. The patient underwent thoracic laminectomy (T10-11) for presumed stenosis in 2002, with partial improvement of early myelopathy. Years later the patient presented with progressive myelopathy, diffuse lymphadenopathy, and an intracranial mass, in addition to a large enhancing lesion in the thoracic cord. Assessment/Results: The spinal lesion was consistent with a neoplastic intramedullary lesion at the site of the prior laminectomy. She underwent surgery for biopsy and possible excision. Frozen section was consistent with noncaseating granuloma. It was Arch Phys Med Rehabil Vol 88, September 2007
E96
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
decided not to excise the abnormal tissue. Treatment with steroids and intensive rehabilitation with ambulation training using a reciprocating walker resulted in remarkable functional improvement. Discussion: Intramedullary spinal neurosarcoidosis is an uncommon manifestation of sarcoidosis. It occurs in less than 1% of sarcoidosis cases. Usually spinal cord involvement is not an isolated or first manifestation of the disease. Correlation between symptom resolution and resolution of imaging findings is poor, especially with spinal cord lesions. Conclusions: Although rare, sarcoidosis of the spine should be considered in the differential diagnosis of LBP and weakness, particularly in patients considering surgery. Correct diagnosis and early treatment with steroids can minimize neurologic complications and decrease morbidity. Key Words: Myelopathy; Rehabilitation; Sarcoidosis. Poster 293 Man With Cervical Myelopathy Syndrome With PoliomyelitisType Motoneuron Disease Secondary to West Nile Virus: A Case Report. Harvey J. Navrkal, MD (Mercy Hospital PM&R Residency Program, Pittsburgh, PA). Disclosure: H.J. Navrkal, None. Setting: Acute care hospital. Patient: A 50-year-old man with motoneuron disease secondary to West Nile virus (WNV). Case Description: Following a “flu” syndrome, a 50-year-old man developed a cervical myelopathy syndrome. This rapidly progressed to generalized weakness and an encephalitis and meningitis presentation. He was hospitalized and placed on a mechanical ventilator for 4 months. Diagnostic workup revealed WNV infection (confirmed by the Centers for Disease Control and Prevention) with a complicated course involving poliomyelitis-type motoneuron disease. 24 months after discharge, he has been followed for a cervical myelopathy type syndrome. Magnetic resonance imaging of his brain and cervical cord remained unremarkable. Nerve conduction studies (NCS) of bilateral upper extremities showed diffuse motor-sensory polyneuropathy. There were components of median and ulnar tunnel syndrome as well, with dispersion of sensory amplitudes. Electromyography of bilateral upper extremities showed severe diffuse nerve root and muscle denervation consistent with diffuse motoneuron disease. He is undergoing rehabilitation of his upper-extremity function. Assessment/Results: At more than 2 years after his hospitalization for a paralytic poliomyelitis type of infection caused by WNV, the patient continues to make progress in his rehabilitation. Further developments will be discussed. Discussion: This is the first reported case, to our knowledge, of a severe generalized polio-like syndrome caused by WNV, with almost complete resolution of all symptoms at 24 months, with the exception of a slowly improving cervical myelopathy syndrome. Chronic inflammatory demyelinating polyneuropathy with secondary axonal changes was a diagnostic consideration, although the patient lacked any significant sensory symptoms. Conclusions: It is possible to have a residual segmental disorder of the anterior horn cells following a paralytic poliomyelitis syndrome caused by WNV. Superimposed tunnel syndromes may complicate the NCS. Key Words: Poliomyelitis; Rehabilitation; West Nile virus. Poster 294 Mechanical Insufflation-Exsufflation Use in Persons With Tetraplegia: A Population-Based Study. James Crew, MD (University of Washington, Seattle, WA); Stephen Burns, MD. Disclosure: J. Crew, None; S. Burns, None. Objectives: To describe the characteristics of persons with spinal cord injury (SCI) who have been prescribed mechanical insufflationexsufflation (MIE) units for outpatient use, and to examine pulmonary morbidity and mortality pre- and post-MIE prescription. Design: RetArch Phys Med Rehabil Vol 88, September 2007
rospective cohort study. Prescription of MIE was verified from a prosthetic equipment database, and clinical data were abstracted from electronic medical records. Setting: Veterans Affairs SCI service. Participants: All persons receiving care through the SCI service who received MIE units for outpatient use during 2000 to 2006. Interventions: Not applicable. Main Outcome Measures: Patient demographics, hospitalization rates, and respiratory complications. Results: From a population of 883 persons who received care through the service during the study period, 41 (4.6%) were prescribed MIE units. Among chart-reviewed participants, mean age ⫾ SD was 57.4⫾13.8 years (range, 28⫺83y) and mean age at onset of tetraplegia was 42.8⫾16.0 years. All participants had tetraplegia, and the most common neurologic level was C5 (22% of participants). Pulmonary comorbidities were common in this cohort, with 65% of participants having at least one. Median time from first hospital admission to MIE prescription was 26 months. The pre-MIE rate of hospitalization with respiratory complications was .48 per year. Post-MIE hospitalization rate determination is ongoing. Conclusions: Approximately 5% of persons with SCI followed at the study center have received MIE units for outpatient use. Subsequent analyses will determine whether respiratory complication rates decreased following prescription of MIE units. Key Words: Pneumonia; Rehabilitation; Respiratory therapy; Spinal cord injuries. Poster 295 Botulinum Toxin Type A to Improve Sitting Ability in a Patient With Tetraplegia and Hip Dislocation: A Case Report. Adam Berliner, DO (Jackson Memorial Hospital, Miami, FL); Suzanne Duncan, MD; Ronald Tolchin, DO. Disclosure: A. Berliner, None; S. Duncan, None; R. Tolchin, None. Setting: University-based multidisciplinary tertiary care center. Patient: A 24-year-old man with tetraplegia and left hip dislocation. Case Description: The patient, who was involved in a motor vehicle collision resulting in C5 complete tetraplegia, later developed difficulty in lying supine and propelling his wheelchair. Left hip imaging revealed a dislocation with sclerosis superiorly. Orthopedic evaluation determined that relocation was not possible. On examination, he was found to have severe lower-extremity spasticity. The left hip was internally rotated and the greater trochanter was superior to the right. An initial trial of 500U of botulinum toxin type A (BTX-A) was administered to reduce spasticity in the muscles surrounding the left hip. 3 months later, another 500U of BTX-A was administered in conjunction with dehydrated alcohol motor point blocks. Both sets of injections were followed by comprehensive physical therapy to reduce tone in the hip. Assessment/Results: Within 2 weeks of the initial treatment, the patient reported improved sitting posture and ability to operate his wheelchair. He noted significantly more improvement following the second procedure. Discussion: The use of neurotoxin injections for the management of spasticity is supported by several studies. Several case reports describe the use of BTX-A for dislocation of the temporomandibular or cricoarytenoid joints with favorable results. However, there are currently no studies addressing the use of neurotoxin injections for hip dislocation in spinal cord injury. A comprehensive review of the literature revealed 1 retrospective study looking at combining botulinum toxin with phenol to treat spasticity in children with cerebral palsy. Conclusions: The use of injected neurotoxins may be beneficial in treating patients with hip dislocation associated with lower-extremity spasticity and should be further investigated. Additional studies should address the safety and efficacy of combining neurotoxins to achieve greater spasticity reduction. Key Words: Botulinum toxin type A; Hip dislocation; Rehabilitation; Spinal cord injuries.