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Poster 89 Functional Outcomes with Acute Inpatient Prosthetic Gait Training for Lower Extremity Amputees
S190
Abstracts / PM R 8 (2016) S151-S332
Case/Program Description: An otherwise healthy 19-year-old male college student presented to the ED with nausea, vomiting, headache, photophobia, dizziness, slurred speech and unsteady gait two weeks after a febrile illness. Physical examination was notable for signs of cerebellar disease including dysmetria, gait ataxia and dysarthria. Initial vitals, labs and CT head were within normal limits. After admission to the medical floor, patient received amoxicillin and acyclovir. Subsequent brain and spine MRIs were unremarkable with the exception of disk protrusions in the thoracic spine. An LP with CSP analysis indicated a possible viral process, suggesting a diagnosis of Post-Infectious Cerebellar Ataxia. Patient showed minimal functional improvements with continued symptoms while on the medical floor and was then admitted to the acute inpatient rehabilitation unit. The initial admission assessment revealed that patient ambulated with moderate assistance using a rolling walker, required maximal to moderate assistance with most ADLs and had a dysarthric but fluent speech. A multidisciplinary approach was utilized to manage the patient and included PT, OT and SLP. Setting: Acute Rehabilitation Unit at a Tertiary Care Hospital. Results: At discharge, significant improvements in the patient’s FIM scores were noted. The patient was independent in ambulation and with the majority of his ADLs, had intact balance and made significant improvements in his speech. Discussion: Acute cerebellar ataxia is a rare syndrome characterized by the acute onset of gait disturbances with associated cerebellar symptoms. It often occurs in healthy individuals following an acute febrile illness, most commonly viral in etiology. The differential diagnoses in patients with acute ataxia can include brain tumors, autoimmune disorders, alcohol and drug toxicity and stroke. Treatment is primarily supportive with resolution of symptoms occurring within a few weeks to months. Conclusions: Acute post infectious cerebellar ataxia can result in significant functional impairments. Management with rehabilitation in an acute inpatient setting can help foster recovery. Level of Evidence: Level V Poster 88 Gait Analysis after Bilateral Quadriceps Tendon Rupture in a Patient Who Elected to be Conservatively Managed: A Case Report Marguerite Diab, MD, MSc (VA New York Harbour Health Care System, New York, NY, United States), Philip J. Poulos, MD, Evan C. Grant, MD, Mona Mirchandani, DO, Jason Maikos, PhD Disclosures: Marguerite Diab: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 63-year male presented with bilateral (b/l) knee pain after falling. On examination, b/l knees had palpable defects R>L superior to the patella. The left knee MRI revealed a near complete tear of the quadriceps tendon with evidence of retraction of the majority of the fibers; the right knee MRI revealed a complete quadriceps tendon rupture. He declined surgery and was treated conservatively. Seventeen months later he was evaluated in the Gait Laboratory, which consisted of level-ground walking along a 10 meter walkway at self-selected speed. Biomechanical data was collected. Setting: Veteran Affairs Medical Center. Results: The patient ambulated with b/l lofstrand crutches without knee braces and achieved a walking speed of 0.75 m/s. His gait pattern revealed symmetrical step length, increased stance time and bilateral stance. His pelvis remained anteriorly rotated throughout gait with excessive anterior pelvic tilt (200). There was hyperextension of the knees at heel strike through late stance with rapid knee flexion into swing phase and a lack of plantarflexion range of motion (ROM) bilaterally at push off. Discussion: Bilateral quadriceps tendon ruptures occur rarely, with poor outcomes reported without surgery. Formal gait analysis has not been reported. Biomechanical analysis indicated excessive pelvic rotation/tilt and knee extension, suggesting that the primary control of the knees in
stance is to maintain the ground reaction force in front of the knee to prevent knee buckling. The lack of motor control of the quadriceps was visualized as an uncontrolled swing phase, including rapidly reaching maximal knee flexion in swing and an unsteady limb during swing. Conclusions: Gait analysis of a patient with b/l quadriceps tendon ruptures revealed specific gait biomechanics. Future study using specialized orthotics such as a brace with a microprocessor controlled knee joint may be beneficial in addressing his particular gait abnormalities. Level of Evidence: Level V Poster 89 Functional Outcomes with Acute Inpatient Prosthetic Gait Training for Lower Extremity Amputees Prateek Grover, MD, PhD (Washington University/BJH/SLCH Consortium, St Louis, MO, United States), Oksana Volshteyn, MD, Amy Son, PT, DPT Disclosures: Prateek Grover: I Have No Relevant Financial Relationships To Disclose Objective: Acute inpatient prosthetic gait training improves function in lower extremity amputee, but has not been quantitatively well characterized in literature. The aim of this QI project was to evaluate functional outcomes in a small sample at our institution. Design: Retrospective chart review, from Sept-Dec 2015, of lower extremity amputee patients admitted for prosthetic gait training. Setting: Acute inpatient rehabilitation. Participants: 23 lower extremity amputees, 21 unilateral and 2 bilateral. The transtibial level (TTA, n¼15) was more common than the transfemoral level (TFA, n¼10). Demographic characteristics included middle age (5315 years) with male predominance (78%). Interventions: Not applicable. Main Outcome Measures: The functional independence measure (FIM) scale was utilized to derive FIM gain (discharge e admission FIM) and FIM efficiency (FIM gain divided by the length of stay, LOS), for ambulation, stairs, bed-to-chair transfer, and composite of cognition, ADLs, and Mobility (FIM-total). Achieving 75th percentile RCMG was used as an additional criterion of successful rehabilitation. Results: FIM-total gain and efficiency were 24.08.9 and 2.51.2, respectively. FIM gain and efficiency, respectively, were greatest for ambulation (4.11.4; 0.50.3), followed by stairs (3.52.2; 0.40.4), and then transfers (2.01.1; 0.20.1). A majority met or exceeded the RCMG goal for ambulation (78%), stairs (91%), and transfers (83%).Among FIM gain, only transfers reached statistical significance (TTA vs TFA: 6.00.7 vs 2.31.4, P value¼.00). On the other hand, FIM efficiency was significantly better for TTA compared with TFA for FIM-total (2.91.2 vs 0.51.2, P value¼.00), transfers (1.70.7 vs 0.20.1, P value¼.00), and ambulation (0.60.4 vs 0.30.2, P value¼.01). The average LOS was 11.55.7 days. All but 2 patients returned to the community at discharge. Conclusions: Inpatient rehabilitation for prosthetic gait training improved outcomes irrespective of the amputation level. The TTA level demonstrated superior FIM efficiency for transfers and ambulation, while FIM gains differed significantly only for transfers. Further study with larger sample size is planned to validate this data. Level of Evidence: Level III Poster 90 A Multidisciplinary Team Approach to Admitting Complex Patients to Inpatient Rehabilitation: A Quality Improvement Pilot Study Eric Morrison, MD, MSc (Vidant Rehabilitation Center/East Carolina Univ/Brod, Greenville, NC, United States), Abigail Morales, MD, Clinton E. Faulk, MD Disclosures: Eric Morrison: I Have No Relevant Financial Relationships To Disclose
Abstracts / PM R 8 (2016) S151-S332
Case/Program Description: An otherwise healthy 19-year-old male college student presented to the ED with nausea, vomiting, headache, photophobia, dizziness, slurred speech and unsteady gait two weeks after a febrile illness. Physical examination was notable for signs of cerebellar disease including dysmetria, gait ataxia and dysarthria. Initial vitals, labs and CT head were within normal limits. After admission to the medical floor, patient received amoxicillin and acyclovir. Subsequent brain and spine MRIs were unremarkable with the exception of disk protrusions in the thoracic spine. An LP with CSP analysis indicated a possible viral process, suggesting a diagnosis of Post-Infectious Cerebellar Ataxia. Patient showed minimal functional improvements with continued symptoms while on the medical floor and was then admitted to the acute inpatient rehabilitation unit. The initial admission assessment revealed that patient ambulated with moderate assistance using a rolling walker, required maximal to moderate assistance with most ADLs and had a dysarthric but fluent speech. A multidisciplinary approach was utilized to manage the patient and included PT, OT and SLP. Setting: Acute Rehabilitation Unit at a Tertiary Care Hospital. Results: At discharge, significant improvements in the patient’s FIM scores were noted. The patient was independent in ambulation and with the majority of his ADLs, had intact balance and made significant improvements in his speech. Discussion: Acute cerebellar ataxia is a rare syndrome characterized by the acute onset of gait disturbances with associated cerebellar symptoms. It often occurs in healthy individuals following an acute febrile illness, most commonly viral in etiology. The differential diagnoses in patients with acute ataxia can include brain tumors, autoimmune disorders, alcohol and drug toxicity and stroke. Treatment is primarily supportive with resolution of symptoms occurring within a few weeks to months. Conclusions: Acute post infectious cerebellar ataxia can result in significant functional impairments. Management with rehabilitation in an acute inpatient setting can help foster recovery. Level of Evidence: Level V Poster 88 Gait Analysis after Bilateral Quadriceps Tendon Rupture in a Patient Who Elected to be Conservatively Managed: A Case Report Marguerite Diab, MD, MSc (VA New York Harbour Health Care System, New York, NY, United States), Philip J. Poulos, MD, Evan C. Grant, MD, Mona Mirchandani, DO, Jason Maikos, PhD Disclosures: Marguerite Diab: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 63-year male presented with bilateral (b/l) knee pain after falling. On examination, b/l knees had palpable defects R>L superior to the patella. The left knee MRI revealed a near complete tear of the quadriceps tendon with evidence of retraction of the majority of the fibers; the right knee MRI revealed a complete quadriceps tendon rupture. He declined surgery and was treated conservatively. Seventeen months later he was evaluated in the Gait Laboratory, which consisted of level-ground walking along a 10 meter walkway at self-selected speed. Biomechanical data was collected. Setting: Veteran Affairs Medical Center. Results: The patient ambulated with b/l lofstrand crutches without knee braces and achieved a walking speed of 0.75 m/s. His gait pattern revealed symmetrical step length, increased stance time and bilateral stance. His pelvis remained anteriorly rotated throughout gait with excessive anterior pelvic tilt (200). There was hyperextension of the knees at heel strike through late stance with rapid knee flexion into swing phase and a lack of plantarflexion range of motion (ROM) bilaterally at push off. Discussion: Bilateral quadriceps tendon ruptures occur rarely, with poor outcomes reported without surgery. Formal gait analysis has not been reported. Biomechanical analysis indicated excessive pelvic rotation/tilt and knee extension, suggesting that the primary control of the knees in
stance is to maintain the ground reaction force in front of the knee to prevent knee buckling. The lack of motor control of the quadriceps was visualized as an uncontrolled swing phase, including rapidly reaching maximal knee flexion in swing and an unsteady limb during swing. Conclusions: Gait analysis of a patient with b/l quadriceps tendon ruptures revealed specific gait biomechanics. Future study using specialized orthotics such as a brace with a microprocessor controlled knee joint may be beneficial in addressing his particular gait abnormalities. Level of Evidence: Level V Poster 89 Functional Outcomes with Acute Inpatient Prosthetic Gait Training for Lower Extremity Amputees Prateek Grover, MD, PhD (Washington University/BJH/SLCH Consortium, St Louis, MO, United States), Oksana Volshteyn, MD, Amy Son, PT, DPT Disclosures: Prateek Grover: I Have No Relevant Financial Relationships To Disclose Objective: Acute inpatient prosthetic gait training improves function in lower extremity amputee, but has not been quantitatively well characterized in literature. The aim of this QI project was to evaluate functional outcomes in a small sample at our institution. Design: Retrospective chart review, from Sept-Dec 2015, of lower extremity amputee patients admitted for prosthetic gait training. Setting: Acute inpatient rehabilitation. Participants: 23 lower extremity amputees, 21 unilateral and 2 bilateral. The transtibial level (TTA, n¼15) was more common than the transfemoral level (TFA, n¼10). Demographic characteristics included middle age (5315 years) with male predominance (78%). Interventions: Not applicable. Main Outcome Measures: The functional independence measure (FIM) scale was utilized to derive FIM gain (discharge e admission FIM) and FIM efficiency (FIM gain divided by the length of stay, LOS), for ambulation, stairs, bed-to-chair transfer, and composite of cognition, ADLs, and Mobility (FIM-total). Achieving 75th percentile RCMG was used as an additional criterion of successful rehabilitation. Results: FIM-total gain and efficiency were 24.08.9 and 2.51.2, respectively. FIM gain and efficiency, respectively, were greatest for ambulation (4.11.4; 0.50.3), followed by stairs (3.52.2; 0.40.4), and then transfers (2.01.1; 0.20.1). A majority met or exceeded the RCMG goal for ambulation (78%), stairs (91%), and transfers (83%).Among FIM gain, only transfers reached statistical significance (TTA vs TFA: 6.00.7 vs 2.31.4, P value¼.00). On the other hand, FIM efficiency was significantly better for TTA compared with TFA for FIM-total (2.91.2 vs 0.51.2, P value¼.00), transfers (1.70.7 vs 0.20.1, P value¼.00), and ambulation (0.60.4 vs 0.30.2, P value¼.01). The average LOS was 11.55.7 days. All but 2 patients returned to the community at discharge. Conclusions: Inpatient rehabilitation for prosthetic gait training improved outcomes irrespective of the amputation level. The TTA level demonstrated superior FIM efficiency for transfers and ambulation, while FIM gains differed significantly only for transfers. Further study with larger sample size is planned to validate this data. Level of Evidence: Level III Poster 90 A Multidisciplinary Team Approach to Admitting Complex Patients to Inpatient Rehabilitation: A Quality Improvement Pilot Study Eric Morrison, MD, MSc (Vidant Rehabilitation Center/East Carolina Univ/Brod, Greenville, NC, United States), Abigail Morales, MD, Clinton E. Faulk, MD Disclosures: Eric Morrison: I Have No Relevant Financial Relationships To Disclose