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Poster 312: The Use of Photobiomodulation Therapy for a Pressure Ulcer: A Case Report
PM&R
Vol. 1, Iss. 9S, 2009
S239
This was followed by 3 inpatient rehabilitation admissions for functional decline. She demonstrated short-term improvement with FIM change of 46 (when metronidazole was held temporarily) and 10 points during 2 separate admissions but quickly regressed post-discharge. At her last acute care admission, MRI head was performed showing complex areas of both nuclear and deep white matter signal abnormality with ventricular signal abnormality consistent with possible immune-provoked or toxic process. Metronidazole was discontinued and she was again sent to inpatient rehabilitation where discharge FIM improved to 92. Six weeks post metronidazole discontinuation, repeat MRI head showed interval resolution of previously noted abnormal signals. At 8-week follow-up, cognitive function had returned to baseline, she had no reported falls, and has not been re-admitted all while off metronidazole. Conclusions: MIE is a reversible encephalopathy that can mimic common impairments seen within inpatient rehabilitation facilities. Given the increasing use of metronidazole for C. difficile related disorders, physiatrists should be aware of this clinical entity for patients using this medication. Keywords: Rehabilitation, MRI, Encephalopathy, Metronidazole.
Discussion: SPS is a very rare autoimmune disease characterized by increased muscle stiffness and rigidity, especially in axial muscles. This often leads to increased lumbar lordosis and difficulty with ambulation leading to frequent falls and decreased function with ADLs and quality of life. Sensory and motor function remain intact. Conclusions: SPS is a very rare disease with sparse amount of research seen in literature, especially in regards to the rehabilitative techniques. Therapy is crucial to the preservation of function and ROM in these patients. Our report showed mild improvements in ROM after 1 month of PT. SPS requires a multi-axial approach for management to optimize the quality of life in these patients. A continual therapy program is needed, along with other treatments, such as IVIG and muscle relaxants. Keywords: Rehabilitation, Stiff person syndrome.
Poster 311
Disclosures: H. Reddy, None. Patients or Programs: A 61-year-old man with long standing MS. Program Description: This patient fell suffering prolonged immobility. He subsequently developed a 22 ⫻12 cm pressure ulcer in the sacral area that was closed with flap surgery. Unfortunately, the skin broke down again in the center of the graft. He was treated with a wound vac, hyperbaric oxygen, and nutritional supplementation until the wound reduced to a 2.6 ⫻ 2.0 ⫻ 2.4 cm coccyx wound. The wound was irradiated with a 670 nm LED photobiomodulation device at a dose of 4 J/cm2 at the wound surface. The device was positioned 3 cm above the surface of the wound and was irradiated for 8 seconds (60 mW/cm2) twice a day. Results: After 2.5 months of photobiomodulation therapy the volume of the wound reduced in size by 90%. Discussion: Light in the far-red to near-infrared (630-1000 nm) modulates numerous cellular functions including fibroblast proliferation, attachment and synthesis of collagen and procollagen, promotion of angiogenesis, stimulation of macrophages and lymphocytes. Mechanistically these actions are attributed to the improvement of mitochondrial energy production and increased transcription of cytoprotective growth factors. Despite experimental and clinical reports of therapeutic efficacy, the use of photobiomodulation for wound healing remains controversial. The wide range of instrumentation, wavelengths, dosage and treatment parameters make the literature difficult to interpret. Clinical studies are even more complicated given the biologic variability and nutritional differences in the patients and the complex and dynamic nature of wound healing. Recently, photobiomodulation using light-emitting diode (LED) array technology (WARP 75 TM Quantum Devices Inc, Barneveld WI) has
The Effects of Various Rehabilitative Methods and Techniques to Enhance the Quality of Life and Function in a Patient with Stiff Person Syndrome: A Case Report. Amy Schneider, DO (Glen Cove Rehabilitation Center, Glen Cove, NY); Barry C. Root, MD. Disclosures: A. Schneider, None. Patients or Programs: A 54-year-old woman diagnosed with stiff person syndrome (SPS) approximately 3 years ago, who originally presented with recurrent frozen shoulder and significant axial stiffness, presents with continual decreased range of motion. Anti-GAD antibodies were found in high titer and EMG was done confirming SPS in 2006. Patient began therapy and was eventually treated with IVIG infusions with mild improvement in function but still restricted in hip and shoulder ROM. Program Description: Patient was prescribed a therapy program 3⫻ /week for 1 month. Each session lasted approximately 1 hour. Therapists focused on improving ROM through pulley systems, AROM/AAROM and PROM. Modalities such as ultrasound and hot packs were used to help decrease the restrictions present. Setting: Evaluation at outpatient rehabilatative center. Results: Initial assessment of patient showed decreased ROM especially in proximal muscles of hip and shoulder. Right shoulder abduction showed about 60% of FROM and Left 55% at initial evaluation. Follow-up visit in 1 month showed a slight improvement to 75% in R shoulder and 65% in L. R shoulder flexion improved from 65 to 75% and L from 60 to 65%. These results led the patient to function slightly better in her work environment and other activities.
Poster 312 The Use of Photobiomodulation Therapy for a Pressure Ulcer: A Case Report. Himabindu Reddy, MD (Medical College of Wisconsin/Milwaukee VA, Milwaukee, WI); Paula Benes, MD; Kevin T. White, MD.
S240
POSTER PRESENTATIONS
been shown to accelerate diabetic wound healing, prevent the development of chemo/radiation induced oral mucositis in pediatric bone marrow transplant patients and promote the healing of high intensity laser-induced retinal burns. The parameters developed from these recent investigations were used in this clinical case. Conclusions: Using the parameters described, this portable, easy-to-use modality that can be performed in the home by the patient offers a promising new treatment for pressure ulcers. Keywords: Rehabilitation, Light therapy, Pressure ulcers.
contractures can be assessed; spasticity can be reduced by chemodenervation or neurolytic blocks with the patient suffering a minimum of pain; contractures of joints (and their adjacent muscles) can be safely treated with manipulation under anesthesia by prolonged passive stretch followed by placement in a cast, splint, or other positioning device. It is especially helpful in treating the agitated brain injured patient or others with a low pain threshold for whom injections are intolerable. Keywords: Rehabilitation, Muscle spasticity, Brain injuries, Contracture.
Poster 313
PRACTICE MANAGEMENT
Treating Severe Muscle Spasticity and Contractures: Evaluation Under Anesthesia and Manipulation of Joints Combined with Chemodenervation or Neurolytic Blocks. Jeffrey S. Hecht, MD (University of Tennessee Graduate School of Medicine, Knoxville, TN); Jeffrey S. Hecht, MD.
Poster 314
Disclosures: J. S. Hecht, None. Objective: Clinically, sometimes it is difficult to distinguish between severe spasticity, muscle contractures, and joint contractures. The purpose of this study was to determine whether evaluation under anesthesia (EUA) combined with electromyography (EMG) is a useful assessment tool. Design: Retrospective, chart review. Setting: Tertiary medical center, outpatient surgery. Participants: Thirty-six patients with problematic spasticity and contractures due to spastic hemiplegia caused by brain injury, spinal cord injury (Brown-Sequard Syndrome), or stroke. Interventions: Review of patients and their treatments including EUA, manipulation under anesthesia, chemodenervation with botulinum A or B, and neurolytic blocks using phenol. Main Outcome Measures: Whether EUA yields useful information. Response of the contracted joints and muscles to treatment using manipulation under anesthesia. Complications of the procedures. Results: Most patients had both spasticity and fixed contractures involving muscle, joint, or both. The contracted joints most frequently manipulated were the shoulder (30 of 36 patients), knee (27), elbow (26), hip (22), wrist (20), and ankle (10). ROM gains were greatest in the shoulder followed next by the elbow and wrist. Responding least were severe knee extension and ankle flexion contractures. Most patients were taken to surgery once, but 14 returned two or more times. Occasionally patients had the unexpected finding of fibrillations and positive sharp waves on EMG. Conclusions: With evaluation under anesthesia, the physiatrist can assess and treat patients who have intractable contractures in the setting of severe spasticity. The contributions of severe spasticity, muscle contractures, and joint
Antioxidant Supplementation Effects on Insulin Sensitivity, Endothelial Adhesion Molecules and Oxidative Stress in Overweight Adults. Heather K. Vincent, PhD MS (University of Florida, Gainesville, FL); Eugene J. Barrett; Cheryl M. Bourguignon; Kim E. Innes; Ann G. Taylor; Kevin R. Vincent, MD, PhD; Arthur L. Weltman. Disclosures: H. K. Vincent, None. Objective: Antioxidant deficits are associated with disease development and subsequent disability; we sought to determine whether short-term antioxidant supplementation affects the early processes of disease development such as insulin sensitivity, endothelial adhesion molecule levels, and oxidative stress in overweight young adults. Design: A randomized, double-blind, controlled study tested the effects of antioxidants (AOX) on measures of insulin sensitivity, endothelial adhesion molecules and oxidative stress. Setting: A general clinical research center affiliated with an academic institution. Participants: Overweight and normal weight individuals (N ⫽ 48, body mass index ⬍ ⬎25 kg/m2). Interventions: Participants received either AOX (vitamin E 800 IU, vitamin C 500 mg, -carotene 10 mg) or placebo for 8 weeks. Main Outcome Measures: Homeostasis model assessment (HOMA and QUICKI), endothelial adhesion molecules soluble intercellular adhesion molecule (sICAM-1), soluble vascular cell adhesion molecule (sVCAM-1), soluble E-selectin), adiponectin and lipid hydroperoxides (PEROX). Results: HOMA values were initially higher in the overweight subjects and were lowered with AOX by week 8 (15% reduction, P ⫽ .020). Adiponectin increased in both AOX groups by week 8. sICAM-1 and sE-selectin levels decreased in overweight AOX treated groups by 6% and 13%, respectively (P ⬍ .05). Plasma PEROX levels were reduced by 0.31 and 0.70 nmol/mL in the normal weight and overweight AOX treated groups, respectively, by week 8 (P ⬍ .05).
Vol. 1, Iss. 9S, 2009
S239
This was followed by 3 inpatient rehabilitation admissions for functional decline. She demonstrated short-term improvement with FIM change of 46 (when metronidazole was held temporarily) and 10 points during 2 separate admissions but quickly regressed post-discharge. At her last acute care admission, MRI head was performed showing complex areas of both nuclear and deep white matter signal abnormality with ventricular signal abnormality consistent with possible immune-provoked or toxic process. Metronidazole was discontinued and she was again sent to inpatient rehabilitation where discharge FIM improved to 92. Six weeks post metronidazole discontinuation, repeat MRI head showed interval resolution of previously noted abnormal signals. At 8-week follow-up, cognitive function had returned to baseline, she had no reported falls, and has not been re-admitted all while off metronidazole. Conclusions: MIE is a reversible encephalopathy that can mimic common impairments seen within inpatient rehabilitation facilities. Given the increasing use of metronidazole for C. difficile related disorders, physiatrists should be aware of this clinical entity for patients using this medication. Keywords: Rehabilitation, MRI, Encephalopathy, Metronidazole.
Discussion: SPS is a very rare autoimmune disease characterized by increased muscle stiffness and rigidity, especially in axial muscles. This often leads to increased lumbar lordosis and difficulty with ambulation leading to frequent falls and decreased function with ADLs and quality of life. Sensory and motor function remain intact. Conclusions: SPS is a very rare disease with sparse amount of research seen in literature, especially in regards to the rehabilitative techniques. Therapy is crucial to the preservation of function and ROM in these patients. Our report showed mild improvements in ROM after 1 month of PT. SPS requires a multi-axial approach for management to optimize the quality of life in these patients. A continual therapy program is needed, along with other treatments, such as IVIG and muscle relaxants. Keywords: Rehabilitation, Stiff person syndrome.
Poster 311
Disclosures: H. Reddy, None. Patients or Programs: A 61-year-old man with long standing MS. Program Description: This patient fell suffering prolonged immobility. He subsequently developed a 22 ⫻12 cm pressure ulcer in the sacral area that was closed with flap surgery. Unfortunately, the skin broke down again in the center of the graft. He was treated with a wound vac, hyperbaric oxygen, and nutritional supplementation until the wound reduced to a 2.6 ⫻ 2.0 ⫻ 2.4 cm coccyx wound. The wound was irradiated with a 670 nm LED photobiomodulation device at a dose of 4 J/cm2 at the wound surface. The device was positioned 3 cm above the surface of the wound and was irradiated for 8 seconds (60 mW/cm2) twice a day. Results: After 2.5 months of photobiomodulation therapy the volume of the wound reduced in size by 90%. Discussion: Light in the far-red to near-infrared (630-1000 nm) modulates numerous cellular functions including fibroblast proliferation, attachment and synthesis of collagen and procollagen, promotion of angiogenesis, stimulation of macrophages and lymphocytes. Mechanistically these actions are attributed to the improvement of mitochondrial energy production and increased transcription of cytoprotective growth factors. Despite experimental and clinical reports of therapeutic efficacy, the use of photobiomodulation for wound healing remains controversial. The wide range of instrumentation, wavelengths, dosage and treatment parameters make the literature difficult to interpret. Clinical studies are even more complicated given the biologic variability and nutritional differences in the patients and the complex and dynamic nature of wound healing. Recently, photobiomodulation using light-emitting diode (LED) array technology (WARP 75 TM Quantum Devices Inc, Barneveld WI) has
The Effects of Various Rehabilitative Methods and Techniques to Enhance the Quality of Life and Function in a Patient with Stiff Person Syndrome: A Case Report. Amy Schneider, DO (Glen Cove Rehabilitation Center, Glen Cove, NY); Barry C. Root, MD. Disclosures: A. Schneider, None. Patients or Programs: A 54-year-old woman diagnosed with stiff person syndrome (SPS) approximately 3 years ago, who originally presented with recurrent frozen shoulder and significant axial stiffness, presents with continual decreased range of motion. Anti-GAD antibodies were found in high titer and EMG was done confirming SPS in 2006. Patient began therapy and was eventually treated with IVIG infusions with mild improvement in function but still restricted in hip and shoulder ROM. Program Description: Patient was prescribed a therapy program 3⫻ /week for 1 month. Each session lasted approximately 1 hour. Therapists focused on improving ROM through pulley systems, AROM/AAROM and PROM. Modalities such as ultrasound and hot packs were used to help decrease the restrictions present. Setting: Evaluation at outpatient rehabilatative center. Results: Initial assessment of patient showed decreased ROM especially in proximal muscles of hip and shoulder. Right shoulder abduction showed about 60% of FROM and Left 55% at initial evaluation. Follow-up visit in 1 month showed a slight improvement to 75% in R shoulder and 65% in L. R shoulder flexion improved from 65 to 75% and L from 60 to 65%. These results led the patient to function slightly better in her work environment and other activities.
Poster 312 The Use of Photobiomodulation Therapy for a Pressure Ulcer: A Case Report. Himabindu Reddy, MD (Medical College of Wisconsin/Milwaukee VA, Milwaukee, WI); Paula Benes, MD; Kevin T. White, MD.
S240
POSTER PRESENTATIONS
been shown to accelerate diabetic wound healing, prevent the development of chemo/radiation induced oral mucositis in pediatric bone marrow transplant patients and promote the healing of high intensity laser-induced retinal burns. The parameters developed from these recent investigations were used in this clinical case. Conclusions: Using the parameters described, this portable, easy-to-use modality that can be performed in the home by the patient offers a promising new treatment for pressure ulcers. Keywords: Rehabilitation, Light therapy, Pressure ulcers.
contractures can be assessed; spasticity can be reduced by chemodenervation or neurolytic blocks with the patient suffering a minimum of pain; contractures of joints (and their adjacent muscles) can be safely treated with manipulation under anesthesia by prolonged passive stretch followed by placement in a cast, splint, or other positioning device. It is especially helpful in treating the agitated brain injured patient or others with a low pain threshold for whom injections are intolerable. Keywords: Rehabilitation, Muscle spasticity, Brain injuries, Contracture.
Poster 313
PRACTICE MANAGEMENT
Treating Severe Muscle Spasticity and Contractures: Evaluation Under Anesthesia and Manipulation of Joints Combined with Chemodenervation or Neurolytic Blocks. Jeffrey S. Hecht, MD (University of Tennessee Graduate School of Medicine, Knoxville, TN); Jeffrey S. Hecht, MD.
Poster 314
Disclosures: J. S. Hecht, None. Objective: Clinically, sometimes it is difficult to distinguish between severe spasticity, muscle contractures, and joint contractures. The purpose of this study was to determine whether evaluation under anesthesia (EUA) combined with electromyography (EMG) is a useful assessment tool. Design: Retrospective, chart review. Setting: Tertiary medical center, outpatient surgery. Participants: Thirty-six patients with problematic spasticity and contractures due to spastic hemiplegia caused by brain injury, spinal cord injury (Brown-Sequard Syndrome), or stroke. Interventions: Review of patients and their treatments including EUA, manipulation under anesthesia, chemodenervation with botulinum A or B, and neurolytic blocks using phenol. Main Outcome Measures: Whether EUA yields useful information. Response of the contracted joints and muscles to treatment using manipulation under anesthesia. Complications of the procedures. Results: Most patients had both spasticity and fixed contractures involving muscle, joint, or both. The contracted joints most frequently manipulated were the shoulder (30 of 36 patients), knee (27), elbow (26), hip (22), wrist (20), and ankle (10). ROM gains were greatest in the shoulder followed next by the elbow and wrist. Responding least were severe knee extension and ankle flexion contractures. Most patients were taken to surgery once, but 14 returned two or more times. Occasionally patients had the unexpected finding of fibrillations and positive sharp waves on EMG. Conclusions: With evaluation under anesthesia, the physiatrist can assess and treat patients who have intractable contractures in the setting of severe spasticity. The contributions of severe spasticity, muscle contractures, and joint
Antioxidant Supplementation Effects on Insulin Sensitivity, Endothelial Adhesion Molecules and Oxidative Stress in Overweight Adults. Heather K. Vincent, PhD MS (University of Florida, Gainesville, FL); Eugene J. Barrett; Cheryl M. Bourguignon; Kim E. Innes; Ann G. Taylor; Kevin R. Vincent, MD, PhD; Arthur L. Weltman. Disclosures: H. K. Vincent, None. Objective: Antioxidant deficits are associated with disease development and subsequent disability; we sought to determine whether short-term antioxidant supplementation affects the early processes of disease development such as insulin sensitivity, endothelial adhesion molecule levels, and oxidative stress in overweight young adults. Design: A randomized, double-blind, controlled study tested the effects of antioxidants (AOX) on measures of insulin sensitivity, endothelial adhesion molecules and oxidative stress. Setting: A general clinical research center affiliated with an academic institution. Participants: Overweight and normal weight individuals (N ⫽ 48, body mass index ⬍ ⬎25 kg/m2). Interventions: Participants received either AOX (vitamin E 800 IU, vitamin C 500 mg, -carotene 10 mg) or placebo for 8 weeks. Main Outcome Measures: Homeostasis model assessment (HOMA and QUICKI), endothelial adhesion molecules soluble intercellular adhesion molecule (sICAM-1), soluble vascular cell adhesion molecule (sVCAM-1), soluble E-selectin), adiponectin and lipid hydroperoxides (PEROX). Results: HOMA values were initially higher in the overweight subjects and were lowered with AOX by week 8 (15% reduction, P ⫽ .020). Adiponectin increased in both AOX groups by week 8. sICAM-1 and sE-selectin levels decreased in overweight AOX treated groups by 6% and 13%, respectively (P ⬍ .05). Plasma PEROX levels were reduced by 0.31 and 0.70 nmol/mL in the normal weight and overweight AOX treated groups, respectively, by week 8 (P ⬍ .05).