- Email: [email protected]
Poster 9 Differences between Objective and Subjective Improvement in Facial Paralysis
S94
Abstracts / PM R 7 (2015) S83-S222
Conclusion: Genetic endowment can affect social integration after brain injury and should be considered as part of an individually tailored approach to rehabilitation intervention.
Poster 7 Plasmodium Falciparum Malaria and Stroke: A Case Report Hongmei Wang, MD (Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, United States), Mary Apiafi, MD, Jay M. Shah, MD, Stephen Erosa, DO, Michelle Stern Disclosures: H. Wang: I Have No Relevant Financial Relationships To Disclose. Case Description: A 71-year-old man, recent immigrant from Ghana, was admitted to acute inpatient rehabilitation for left middle cerebral artery infarct developed in Ghana and was found to have deep venous thrombosis (DVT). Comprehensive rehabilitation focusing on right hemiplegia and aphasia was interrupted by spiked fever with leucopenia not responding to empiric broad spectrum antibiotics. Parasitemia with Plasmodium falciparum (0.06%) was found on blood smear. On further questioning, patient recalled a history of malaria while in Ghana. He completed a 7-day course of quinine and doxycycline. Hypoglycemia secondary to quinine-induced hyperinsulinemia was managed with intravenous glucose. Setting: Acute inpatient rehabilitation unit at a university hospital. Results or Clinical Course: Patient remained afebrile with negative blood parasites and achieved improvement in mobility and active daily activities with intensive rehabilitation. Discussion: Malaria is a parasitic disease with high prevalence in several regions of the world. Cerebral malaria is the most severe complication of Plasmodium falciparum malaria and presents with various neurological manifestations including cerebral venous thrombosis and cerebral arterial occlusion. Postulated pathogenesis favors hypercoagulable state and mechanical plugging of cerebral venules by clumped, parasitized red cells. Malaria is known to cause activation of the coagulation cascade resulting in pulmonary embolism, peripheral gangrene and intracranial venous thrombosis. In our case, with the absence of risk factors of hypertension, diabetes mellitus, smoking, dyslipidemia and previous stroke, the possibility of this stroke being a chance occurrence with Plasmodium falciparum malaria is highly likely. The concomitance DVT can also be explained as a hypercoagulation complication of malaria. Physiatrist should be aware of the possible cause of stroke by malaria for patient with high risk so that proper treatment can be initiated in a timely manner. Conclusion: Although rare, cerebral malaria should be considered as a differential diagnosis for stroke patients from hyperendemic area. Prompt diagnosis and anti-malarial therapy are critical to prevent further complications.
Poster 8 First-Ever Reported Case of Anterior Spinal Artery Syndrome Caused by Penetrating Atherosclerotic Aortic Ulcers Catherine J. Yee (Schwab Rehabilitation Hospital/University of Chicago Medicine, Chicago, IL, United States), Annie Layno-Moses, MD, Nupur Saxena, MD, Raymond Lee, MD, David De Bruin, MD Disclosures: C. J. Yee: I Have No Relevant Financial Relationships To Disclose. Case Description: An independent 78-year-old black woman with PMHx of HTN, DM2, HLD presented to an acute hospital with sudden and rapid progression of bilateral lower extremity pain, weakness, and chest pain. Program Description: Patient had hypertensive emergency and paraplegia. She was transferred for MRI and intensive care for malignant hypertension. She was incontinent of urine and without rectal
tone. CTA Chest/Abdomen/Pelvis demonstrated tortuous aorta with ulcerations and thoracic aorta pseudoaneurysm. Cardiothoracic surgery and Neurosurgery deemed no acute surgical intervention in the absence of structural neural compression on MRI. Vascular Surgery consult for paraplegia due to cord infarction deemed no surgical intervention for penetrating distal thoracic aortic ulcers (AU); recommended aggressive BP control and outpatient surveillance. Neurology evaluation with CT head, vasculitis, and infectious work ups were negative; lumbar puncture was negative. Neurological physical examination of the lower extremities demonstrated intact proprioception and vibration, impaired pinprick and hot/cold, and flaccid paralysis with trace movement of right toes. Setting: Inpatient acute hospital; Inpatient acute rehabilitation hospital. Results or Clinical Course: Examination was consistent with anterior spinal artery (ASA) syndrome with impairments of corticospinal and spinothalamic tracts with preserved dorsal columns. The most likely etiology was her multiple AUs. She completed acute inpatient rehabilitation, improving to wheelchair level mobility, transfers, and selfcare. She was discharged home with family. Discussion: This is the first documented case of AU causing ASA syndrome. Vessels to the spinal cord (SC) originate from the aorta, branch to the artery of Adamkiewicz, and supply the lower two-thirds of the SC via the ASA, a crucial vessel of the SC grey matter. The most common causes of ASA syndromes include aortic clamping in surgery, dissection, hypotension, and arteriovenous malformation. Penetrating atherosclerotic ulcers are most commonly seen in elderly, atherosclerotic, hypertensive patients in the descending thoracic aorta. AUs must be followed closely. Conclusion: The prognosis of AUs may be more serious than aortic dissection. As ASA Syndrome is an uncommon complication of AUs and can cause profound disability, further research is warranted.
Poster 9 Differences between Objective and Subjective Improvement in Facial Paralysis Susana Moraleda, MD (Hospital La Paz, Madrid, Spain), Gara Dı´az, MD, Carlos Brin˜ez, MD, Mercedes Martı´nez-Moreno, MD, Carmen VilasVilla, MD, Luis Lassaletta, MD, Fermı´n Dı´az, MD Disclosures: S. Moraleda: I Have No Relevant Financial Relationships To Disclose. Objective: Our objectives were to evaluate if patients were able to assess subjectively the improvement after Botulinum Toxin A (BTA) injection, and if their sensation were related to both initial severity of the Facial Paralysis (FP) and the length of therapeutic effect. Design: Descriptive, retrospective study. Setting: University Tertiary Care Hospital. Participants: 179 patients with FP treated by BTA. Interventions: We held a telephone interview in order to quantify the degree of improvement and the length of therapeutic effect of BTA. Main Outcome Measures: All patients were evaluated before and after BTA injection by the Sunnybrook Facial Grading System (SFGS) scale. To evaluate the treatment global efficacy we used the Wilcoxon test. The relationship between objective and subjective improvement, and between initial severity of FP and length of therapeutic effect were evaluated by the Kruskal-Wallis test. Results or Clinical Course: We found statistically significant improvement after the BTA treatment (P¼.00) using the SFGS scale. Subjectively, from the 131 patients included (48 were excluded for different reasons), 89 improved significantly, 40 improved slightly, and 2 did not improve at all. There was no statistically significant relationship between objective and subjective improvement. We did not find any statistically significant relationship either between the subjective impression of shorter therapeutic effect of BTA injection and a previous worse SFGS score.
Abstracts / PM R 7 (2015) S83-S222 Conclusion: 1) Facial paralysis patients improve both subjectively and objectively after the botulinum toxin A treatment. 2) The subjective perception of improvement is not related to the initial severity of the facial paralysis. 3) The subjective perception of length of therapeutic effect is not related to the initial severity of the facial paralysis. 4) It would be advisable to add psychological impact and quality of life specific scales to the evaluation.
Poster 10 Progressive Myelopathy Mimicking Subacute Combined Degeneration After Intrathecal Methotrexate and Cytarabine Yinfei R. Xu, BS (Icahn School of Medicine at Mount Sinai, New York, NY, United States), Thomas N. Bryce, MD Disclosures: Y. R. Xu: I Have No Relevant Financial Relationships To Disclose. Objective: To describe a rare cause of myelopathy and discuss strategies for prevention and early recognition. Case Description: We present a 55-year-old man with acute myeloid leukemia and Burkitt’s lymphoma who underwent intrathecal (IT) chemotherapy and developed acute, progressive paraplegia. While undergoing Hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, dexamethasone), he developed urinary retention, bowel incontinence, and rapidly progressive lower extremity weakness several days after receiving IT cytarabine and IT methotrexate (MTX). MRI showed hyperintensity in T8-T12 dorsal columns. Multiple serum and CSF studies, nerve conduction studies and electromyography were all nondiagnostic. Setting: Acute inpatient rehabilitation. Results or Clinical Course: Despite empiric IVIG and pulsed methylprednisone, clinical status further declined. Patient was admitted to acute spinal cord injury unit with T8 complete paraplegia and started on comprehensive rehabilitation. He reached neurologic nadir at 1.5 months with flaccidity in both legs and significant sensory loss. By discharge, he regained trace movement but has remained nonambulatory. Discussion: This case demonstrates progressive myelopathy after IT chemotherapy, a rare but recognized complication. Whereas MRI findings from IT cytarabine may involve the entire cord, IT MTX is associated with isolated involvement of dorsal columns, mimicking findings in subacute combined degeneration. As there is no diagnostic test, other differentials must be excluded including transverse myelitis, radiation-induced myelopathy, infection, paraneoplastic syndrome, and nutritional deficiency. Recovery is uncommon and primary strategies lie in prevention to identify susceptible patients and prudent toxicity monitoring. There is however clinical significance in early recognition to withdraw treatment and initiate trials to reverse damage. Rather than dwelling on undiagnosed etiology, acceptance of this sequela can help patients better focus their efforts on interdisciplinary therapy. Conclusion: Progressive myelopathy attributed to IT chemotherapy is a rare complication and early recognition is clinically significant for intervention. Insight into diagnosis can help optimize a patient’s endeavor in rehabilitation to maximize potential for independence.
Poster 11 Management of Refractory Autonomic Abnormalities in a Tetraplegic with a Wound: A Case Report Lauren Del Prato, DO (SUNY Upstate Medical University, Syracuse, NY, United States), Casey Schoenlank, MD, Liju John, MD, Kristen Franklin, PharmD, Lori Hoffman, NP, Gizelda Casella, MD, Stephen Lebduska, MD Disclosures: L. Del Prato: I Have No Relevant Financial Relationships To Disclose.
S95
Objective: To present a symptom-based approach to severe autonomic abnormalities (AA), including autonomic dysreflexia, persistent sudoresis and symptomatic hypothermia, in a spinal cord injury (SCI) patient with a large decubitus wound. Case Description: A 60-year-old man with tetraplegia (C6 AIS B) due to traumatic C5 fracture in 1995. Nineteen years post-injury, he developed a large sacral wound with osteomyelitis requiring surgical debridement. One week post-admission, he developed severe autonomic dysreflexia (AD) when seated upright associated with “discomfort” in his buttocks. AD resolved upon repositioning supine. Imaging of the spine and pelvis was negative for deformities, occult fracture, and syrinx. The patient continued to display sudoresis and non-environmental hypothermia despite adequate blood pressure control. Setting: Inpatient SCI unit. Results or Clinical Course: Pain management was achieved with transdermal fentanyl patch (37.5 mcg/h) and gabapentin (1800 mg/ day). Terazosin (3mg/day) effectively controlled hypertension. The patient continued to complain of profuse sweating, which resolved with an anticholinergic (oxybutynin 20mg/day). Laboratory and radiographic workup for hypothermia was negative for infection, seizures, hormonal abnormalities, stroke, and brain tumor. Cyproheptadine (8mg/day), a potent serotonin antagonist used to treat spontaneous hypothermia with hyperhidrosis, prevented future episodes of hypothermia. Discussion: AA in SCI is a treatment challenge when associated with a trigger that cannot be immediately rectified, such as a large wound. Standard management for AD, sitting the patient upright, exacerbated pain and complicated treatment. The following systematic approach was beneficial: 1) in-depth investigation of the potential causes of AA including complete neuraxial imaging and determination of infectious or hormonal causes; 2) discontinuation of hypertensives (midodrine); 3) aggressive pain control; 4) use of sympathetic blockers (terazosin); 5) anticholinergic drug to manage sudoresis (oxybutynin); and 6) treatment of non-environmental hypothermia with an anti-serotonergic drug (cyproheptadine). Conclusion: Direct treatment of pain, in addition to targeting abnormal central and peripheral sympathetic responses, was successful in controlling AD, persistent sudoresis and non-environmental hypothermia.
Poster 12 Therapeutic Effects of Gait Training and Gait-Related Training with Functional Electrical Stimulation for Chronic Stroke Patients: Prospective Observational Study Koichiro Sota (Hyogo College of Medicine Hospital, Nishinomiya, Japan), Tatsushi Wakasugi, BSc, Yosuke Honda, Tetsuya Harada, bachelor, Shinichiro Morishita, Sayaka Adachi, BSc, Norihiko Kodama, PhD, Kazuhisa Domen, PhD, MD Disclosures: K. Sota: I Have No Relevant Financial Relationships To Disclose. Objective: To investigate the therapeutic effects of gait training and gait-related training with functional electrical stimulation (FES) for chronic stroke patients. Design: Prospective observational study. Setting: College hospital. Participants: Chronic stroke patients (N ¼ 12) with an average age of 59.3 8.6 years and average post stroke duration of 64.1 47.0 months. Interventions: We provided 4 weeks of gait training and gait-related training with FES for the patients. The patients underwent these trainings 3 times a week, at 1 h per session. We assessed patients without FES before intervention (baseline) and after the end of all interventions (4 weeks). Main Outcome Measures: Main outcome measurements were comfortable 10-m gait speed, 6 minutes walking test (6MWT), and Timed up & go test (TUG).
Abstracts / PM R 7 (2015) S83-S222
Conclusion: Genetic endowment can affect social integration after brain injury and should be considered as part of an individually tailored approach to rehabilitation intervention.
Poster 7 Plasmodium Falciparum Malaria and Stroke: A Case Report Hongmei Wang, MD (Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, United States), Mary Apiafi, MD, Jay M. Shah, MD, Stephen Erosa, DO, Michelle Stern Disclosures: H. Wang: I Have No Relevant Financial Relationships To Disclose. Case Description: A 71-year-old man, recent immigrant from Ghana, was admitted to acute inpatient rehabilitation for left middle cerebral artery infarct developed in Ghana and was found to have deep venous thrombosis (DVT). Comprehensive rehabilitation focusing on right hemiplegia and aphasia was interrupted by spiked fever with leucopenia not responding to empiric broad spectrum antibiotics. Parasitemia with Plasmodium falciparum (0.06%) was found on blood smear. On further questioning, patient recalled a history of malaria while in Ghana. He completed a 7-day course of quinine and doxycycline. Hypoglycemia secondary to quinine-induced hyperinsulinemia was managed with intravenous glucose. Setting: Acute inpatient rehabilitation unit at a university hospital. Results or Clinical Course: Patient remained afebrile with negative blood parasites and achieved improvement in mobility and active daily activities with intensive rehabilitation. Discussion: Malaria is a parasitic disease with high prevalence in several regions of the world. Cerebral malaria is the most severe complication of Plasmodium falciparum malaria and presents with various neurological manifestations including cerebral venous thrombosis and cerebral arterial occlusion. Postulated pathogenesis favors hypercoagulable state and mechanical plugging of cerebral venules by clumped, parasitized red cells. Malaria is known to cause activation of the coagulation cascade resulting in pulmonary embolism, peripheral gangrene and intracranial venous thrombosis. In our case, with the absence of risk factors of hypertension, diabetes mellitus, smoking, dyslipidemia and previous stroke, the possibility of this stroke being a chance occurrence with Plasmodium falciparum malaria is highly likely. The concomitance DVT can also be explained as a hypercoagulation complication of malaria. Physiatrist should be aware of the possible cause of stroke by malaria for patient with high risk so that proper treatment can be initiated in a timely manner. Conclusion: Although rare, cerebral malaria should be considered as a differential diagnosis for stroke patients from hyperendemic area. Prompt diagnosis and anti-malarial therapy are critical to prevent further complications.
Poster 8 First-Ever Reported Case of Anterior Spinal Artery Syndrome Caused by Penetrating Atherosclerotic Aortic Ulcers Catherine J. Yee (Schwab Rehabilitation Hospital/University of Chicago Medicine, Chicago, IL, United States), Annie Layno-Moses, MD, Nupur Saxena, MD, Raymond Lee, MD, David De Bruin, MD Disclosures: C. J. Yee: I Have No Relevant Financial Relationships To Disclose. Case Description: An independent 78-year-old black woman with PMHx of HTN, DM2, HLD presented to an acute hospital with sudden and rapid progression of bilateral lower extremity pain, weakness, and chest pain. Program Description: Patient had hypertensive emergency and paraplegia. She was transferred for MRI and intensive care for malignant hypertension. She was incontinent of urine and without rectal
tone. CTA Chest/Abdomen/Pelvis demonstrated tortuous aorta with ulcerations and thoracic aorta pseudoaneurysm. Cardiothoracic surgery and Neurosurgery deemed no acute surgical intervention in the absence of structural neural compression on MRI. Vascular Surgery consult for paraplegia due to cord infarction deemed no surgical intervention for penetrating distal thoracic aortic ulcers (AU); recommended aggressive BP control and outpatient surveillance. Neurology evaluation with CT head, vasculitis, and infectious work ups were negative; lumbar puncture was negative. Neurological physical examination of the lower extremities demonstrated intact proprioception and vibration, impaired pinprick and hot/cold, and flaccid paralysis with trace movement of right toes. Setting: Inpatient acute hospital; Inpatient acute rehabilitation hospital. Results or Clinical Course: Examination was consistent with anterior spinal artery (ASA) syndrome with impairments of corticospinal and spinothalamic tracts with preserved dorsal columns. The most likely etiology was her multiple AUs. She completed acute inpatient rehabilitation, improving to wheelchair level mobility, transfers, and selfcare. She was discharged home with family. Discussion: This is the first documented case of AU causing ASA syndrome. Vessels to the spinal cord (SC) originate from the aorta, branch to the artery of Adamkiewicz, and supply the lower two-thirds of the SC via the ASA, a crucial vessel of the SC grey matter. The most common causes of ASA syndromes include aortic clamping in surgery, dissection, hypotension, and arteriovenous malformation. Penetrating atherosclerotic ulcers are most commonly seen in elderly, atherosclerotic, hypertensive patients in the descending thoracic aorta. AUs must be followed closely. Conclusion: The prognosis of AUs may be more serious than aortic dissection. As ASA Syndrome is an uncommon complication of AUs and can cause profound disability, further research is warranted.
Poster 9 Differences between Objective and Subjective Improvement in Facial Paralysis Susana Moraleda, MD (Hospital La Paz, Madrid, Spain), Gara Dı´az, MD, Carlos Brin˜ez, MD, Mercedes Martı´nez-Moreno, MD, Carmen VilasVilla, MD, Luis Lassaletta, MD, Fermı´n Dı´az, MD Disclosures: S. Moraleda: I Have No Relevant Financial Relationships To Disclose. Objective: Our objectives were to evaluate if patients were able to assess subjectively the improvement after Botulinum Toxin A (BTA) injection, and if their sensation were related to both initial severity of the Facial Paralysis (FP) and the length of therapeutic effect. Design: Descriptive, retrospective study. Setting: University Tertiary Care Hospital. Participants: 179 patients with FP treated by BTA. Interventions: We held a telephone interview in order to quantify the degree of improvement and the length of therapeutic effect of BTA. Main Outcome Measures: All patients were evaluated before and after BTA injection by the Sunnybrook Facial Grading System (SFGS) scale. To evaluate the treatment global efficacy we used the Wilcoxon test. The relationship between objective and subjective improvement, and between initial severity of FP and length of therapeutic effect were evaluated by the Kruskal-Wallis test. Results or Clinical Course: We found statistically significant improvement after the BTA treatment (P¼.00) using the SFGS scale. Subjectively, from the 131 patients included (48 were excluded for different reasons), 89 improved significantly, 40 improved slightly, and 2 did not improve at all. There was no statistically significant relationship between objective and subjective improvement. We did not find any statistically significant relationship either between the subjective impression of shorter therapeutic effect of BTA injection and a previous worse SFGS score.
Abstracts / PM R 7 (2015) S83-S222 Conclusion: 1) Facial paralysis patients improve both subjectively and objectively after the botulinum toxin A treatment. 2) The subjective perception of improvement is not related to the initial severity of the facial paralysis. 3) The subjective perception of length of therapeutic effect is not related to the initial severity of the facial paralysis. 4) It would be advisable to add psychological impact and quality of life specific scales to the evaluation.
Poster 10 Progressive Myelopathy Mimicking Subacute Combined Degeneration After Intrathecal Methotrexate and Cytarabine Yinfei R. Xu, BS (Icahn School of Medicine at Mount Sinai, New York, NY, United States), Thomas N. Bryce, MD Disclosures: Y. R. Xu: I Have No Relevant Financial Relationships To Disclose. Objective: To describe a rare cause of myelopathy and discuss strategies for prevention and early recognition. Case Description: We present a 55-year-old man with acute myeloid leukemia and Burkitt’s lymphoma who underwent intrathecal (IT) chemotherapy and developed acute, progressive paraplegia. While undergoing Hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, dexamethasone), he developed urinary retention, bowel incontinence, and rapidly progressive lower extremity weakness several days after receiving IT cytarabine and IT methotrexate (MTX). MRI showed hyperintensity in T8-T12 dorsal columns. Multiple serum and CSF studies, nerve conduction studies and electromyography were all nondiagnostic. Setting: Acute inpatient rehabilitation. Results or Clinical Course: Despite empiric IVIG and pulsed methylprednisone, clinical status further declined. Patient was admitted to acute spinal cord injury unit with T8 complete paraplegia and started on comprehensive rehabilitation. He reached neurologic nadir at 1.5 months with flaccidity in both legs and significant sensory loss. By discharge, he regained trace movement but has remained nonambulatory. Discussion: This case demonstrates progressive myelopathy after IT chemotherapy, a rare but recognized complication. Whereas MRI findings from IT cytarabine may involve the entire cord, IT MTX is associated with isolated involvement of dorsal columns, mimicking findings in subacute combined degeneration. As there is no diagnostic test, other differentials must be excluded including transverse myelitis, radiation-induced myelopathy, infection, paraneoplastic syndrome, and nutritional deficiency. Recovery is uncommon and primary strategies lie in prevention to identify susceptible patients and prudent toxicity monitoring. There is however clinical significance in early recognition to withdraw treatment and initiate trials to reverse damage. Rather than dwelling on undiagnosed etiology, acceptance of this sequela can help patients better focus their efforts on interdisciplinary therapy. Conclusion: Progressive myelopathy attributed to IT chemotherapy is a rare complication and early recognition is clinically significant for intervention. Insight into diagnosis can help optimize a patient’s endeavor in rehabilitation to maximize potential for independence.
Poster 11 Management of Refractory Autonomic Abnormalities in a Tetraplegic with a Wound: A Case Report Lauren Del Prato, DO (SUNY Upstate Medical University, Syracuse, NY, United States), Casey Schoenlank, MD, Liju John, MD, Kristen Franklin, PharmD, Lori Hoffman, NP, Gizelda Casella, MD, Stephen Lebduska, MD Disclosures: L. Del Prato: I Have No Relevant Financial Relationships To Disclose.
S95
Objective: To present a symptom-based approach to severe autonomic abnormalities (AA), including autonomic dysreflexia, persistent sudoresis and symptomatic hypothermia, in a spinal cord injury (SCI) patient with a large decubitus wound. Case Description: A 60-year-old man with tetraplegia (C6 AIS B) due to traumatic C5 fracture in 1995. Nineteen years post-injury, he developed a large sacral wound with osteomyelitis requiring surgical debridement. One week post-admission, he developed severe autonomic dysreflexia (AD) when seated upright associated with “discomfort” in his buttocks. AD resolved upon repositioning supine. Imaging of the spine and pelvis was negative for deformities, occult fracture, and syrinx. The patient continued to display sudoresis and non-environmental hypothermia despite adequate blood pressure control. Setting: Inpatient SCI unit. Results or Clinical Course: Pain management was achieved with transdermal fentanyl patch (37.5 mcg/h) and gabapentin (1800 mg/ day). Terazosin (3mg/day) effectively controlled hypertension. The patient continued to complain of profuse sweating, which resolved with an anticholinergic (oxybutynin 20mg/day). Laboratory and radiographic workup for hypothermia was negative for infection, seizures, hormonal abnormalities, stroke, and brain tumor. Cyproheptadine (8mg/day), a potent serotonin antagonist used to treat spontaneous hypothermia with hyperhidrosis, prevented future episodes of hypothermia. Discussion: AA in SCI is a treatment challenge when associated with a trigger that cannot be immediately rectified, such as a large wound. Standard management for AD, sitting the patient upright, exacerbated pain and complicated treatment. The following systematic approach was beneficial: 1) in-depth investigation of the potential causes of AA including complete neuraxial imaging and determination of infectious or hormonal causes; 2) discontinuation of hypertensives (midodrine); 3) aggressive pain control; 4) use of sympathetic blockers (terazosin); 5) anticholinergic drug to manage sudoresis (oxybutynin); and 6) treatment of non-environmental hypothermia with an anti-serotonergic drug (cyproheptadine). Conclusion: Direct treatment of pain, in addition to targeting abnormal central and peripheral sympathetic responses, was successful in controlling AD, persistent sudoresis and non-environmental hypothermia.
Poster 12 Therapeutic Effects of Gait Training and Gait-Related Training with Functional Electrical Stimulation for Chronic Stroke Patients: Prospective Observational Study Koichiro Sota (Hyogo College of Medicine Hospital, Nishinomiya, Japan), Tatsushi Wakasugi, BSc, Yosuke Honda, Tetsuya Harada, bachelor, Shinichiro Morishita, Sayaka Adachi, BSc, Norihiko Kodama, PhD, Kazuhisa Domen, PhD, MD Disclosures: K. Sota: I Have No Relevant Financial Relationships To Disclose. Objective: To investigate the therapeutic effects of gait training and gait-related training with functional electrical stimulation (FES) for chronic stroke patients. Design: Prospective observational study. Setting: College hospital. Participants: Chronic stroke patients (N ¼ 12) with an average age of 59.3 8.6 years and average post stroke duration of 64.1 47.0 months. Interventions: We provided 4 weeks of gait training and gait-related training with FES for the patients. The patients underwent these trainings 3 times a week, at 1 h per session. We assessed patients without FES before intervention (baseline) and after the end of all interventions (4 weeks). Main Outcome Measures: Main outcome measurements were comfortable 10-m gait speed, 6 minutes walking test (6MWT), and Timed up & go test (TUG).