- Email: [email protected]
Poster 96 persistent hip pain after gunshot wound: A case report. Jay S. Patel, MD (Univ Virginia, Charlottesville, VA); David S. Rubendall, DO, e-mail: [email protected]
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2004 Academy Annual Assembly Abstracts
research grant from the Ministry of Science & Technology, Republic of Korea; Y. Kim, research grant from the Ministry of Science & Technology, Republic of Korea; P.K. Lee, research grant from the Ministry of Science & Technology, Republic of Korea; N. Kim, research grant from the Technologic Development Program for Intelligent Robotics, Ministry of Science & Technology, Republic of Korea. Objective: To determine the stability parameters in posturography that can assess more sensitively age-related changes in posture control. Design: Descriptive study with repeated measures. Setting: Complex continuing care facility for geriatric population in Korea. Participants: 39 healthy geriatric people aged 60y and older who were free of neurologic and medical conditions that cause motor weakness, visual disturbance, and vestibular dysfunction. Interventions: Not applicable. Mean Outcome Measures: Subjects were divided into 3 groups by age (aged 60 – 69y, 70 –79y, ⱖ80y). Center of pressure (COP) parameters were obtained as total path distance, integration of total path, and mean frequency of sway in comfortable standing with eyes open and closed in each group. A visual feedback system (VFS) was added to posturography and then subjects were asked to move their COP into the target circle on a CRT monitor with active movement on forceplate. Clinical COP parameters (moving time to get in the circle, total path of deviation, elapsed time in the circle) were obtained with the VFS. Results: There was no difference in COP parameters in static posturography between age groups. Total path of deviation assessed by posturography with the VFS showed a significant difference between age groups (P⬍.05); significant correlations with a clinical balance test (Berg Balance Scale) were also found (correlation coefficient⫽⫺.471, P⫽.002). Conclusions: A posturographic balance assessment system with visual feedback was clinically useful in more sensitive evaluation of age-related change of balance control in healthy geriatric people. The therapeutic use of visual feedback as a tool of balance training may be a valuable subject of further study. Key Words: Feedback; Geriatrics; Posture; Rehabilitation. Poster 90 Modified Arnis de Mano as a Tool to Improve Balance in the Elderly: A Randomized Controlled Trial. Maria Luisa P. Santos, MD (Univ Santo Tomas Hosp, Manila, Philippines); Consuelo G. Suarez, MD; Joven Christopher T. Cerdenia, PTRP; Michael Jorge N. Peralta, PTRP, e-mail: [email protected]. Disclosure: M.P. Santos, None; C.G. Suarez, None; J.T. Cerdenia, None; M.N. Peralta, None. Objective: To determine the effectiveness of the Modified Arnis de Mano, a Filipino form of martial arts adopted as a form of exercise, in improving balance among the elderly. Design: Randomized controlled, single-blinded trial. Setting: A government-run home-for-the-aged community in the Philippines. Participants: Elderly men and women aged 60 to 84y. Interventions: The Modified Arnis de Mano and a standardized strengthening exercise protocol for the lower extremities geared toward improving balance. Main Outcome Measures: Functional performance measures done pre- and postintervention were the Timed Up & Go (TUG) test, Functional Reach Test (FRT), and 10-meter speed test (10MST). Results: 22 participants were randomly grouped into 2: 11 participants (mean age, 72.73⫾8.34y) were assigned in the Arnis group and the other 11 participants (mean age, 70.45⫾6.88y) were placed in the structured exercise group. 9 participants completed the 4-wk strengthening exercise protocols and another 9 completed the 4-wk Arnis protocol. No participants were injured during the program. The overall dropout rate was 39%. Outcome measures showed improvement in the Arnis group on the FRT and a reduction in time on the 10MST and TUG test. Although the strengthening group also showed similar changes on the 3 outcome measures, 10MST times differed significantly between the 2 groups. Conclusions: Exercise programs done regularly improved balance among the elderly. Both the standard strengthening exercise protocol and the Modified Arnis de Mano exercise showed absolute change in clinical measurements but only the latter showed a positive effect in dynamic balance. Key Words: Balance; Elderly; Rehabilitation. Poster 91: Refer to Abstract 53 in the Rehabilitation II Poster Grand Rounds for the full abstract. e-mail: [email protected]. Poster 92: Refer to Abstract 54 in the Rehabilitation II Poster Grand Rounds for the full abstract. e-mail: [email protected]. Poster 93 Clinical Balance Test More Sensitive to Age-Related Changes and Correlation With Joint Motion. Juha An, MD (Samsung Med Ctr, Seoul, Republic of Korea); JiHye Hwang, MD, PhD; Young-keun Woo, MSPT; Yun-Hee Kim, MD, PhD; Peter K. Lee, MD, PhD; Nam-Gyun Kim, PhD, e-mail: [email protected]. Disclosure: J. An, None; J. Hwang, research grant from Technologic Development Program for Intelligent Robotics, Ministry of Science & Technology, Republic of Korea; Y. Woo, research grant from Technologic Development Program for Intelligent Robotics, Ministry of Science & Technology, Republic of Korea; Y. Kim, research grant from Technologic Development Program for Intelligent Robotics, Ministry of Science & Technology, Republic of Korea; P.K. Lee, None; N. Kim, research grant from Technologic Development Program for Intelligent Robotics, Ministry of Science & Technology, Republic of Korea. Objectives: To identify a balance test that can reflect more sensitively changes according to age and to investigate the test’s correlation with flexibility of joint. Design: Descriptive survey with repeated measures. Setting: Complex continuing care facility for a geriatric population in Korea. Participants: 39 healthy geriatric people aged 60y and older who were free of neurologic and medical conditions that cause motor weakness, visual disturbance, and vestibular dysfunction. Intervention: Not applicable. Main Outcome Measures: Subjects were divided into 3 groups by age (aged 60 – 69y, 70 –79y, ⱖ80y) and each group was evaluated with clinical balance tests (Berg Balance Scale [BBS], Functional Reach Test, Tinetti Performance Oriented Mobility Assessment [POMA]). Bilateral lower-extremity range of motion (ROM) was measured with goniometry to quantify the flexibility of whole joints. Results: The BBS was the most sensitive clinical balance test reflecting the changes by age (P⫽.002) and the POMA balance subtest was also more sensitive test than others (P⫽.022). Correlations between clinical balance tests and joint flexibility were found.
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The strongest correlation existed between the BBS and bilateral ankle ROM inversion and eversion (correlation coefficient⫽.565, P⫽.000). Conclusions: Among the clinically validated balance tests, the BBS was the most sensitive test at reflecting the decline of balance performance related to aging. A correlation exists between ankle ROM and balance in healthy elderly people. Additional research is needed to determine whether treatment directed at increasing ankle ROM can improve balance. Key Words: Geriatrics; Posture; Range of motion, articular; Rehabilitation. Poster 94 Improvement in Lumbar Extensor Strength in Overweight Elderly Adults After 6 Months of Resistance Training. Kevin R. Vincent, MD, PhD (Univ Virginia, Charlottesville, VA); Heather K. Vincent, PhD; Randy W. Braith, PhD, e-mail: [email protected]. Disclosure: K.R. Vincent, None; H.K. Vincent, None; R.W. Braith, None. Objective: To measure lumbar extensor strength in overweight and nonoverweight (control) elderly adults before and after chronic resistance exercise. Design: Randomized controlled trial. Setting: Spine care center. Participants: Elderly adults 60 to 72y (N⫽62), grouped based on body mass index (BMI): control group (mean, 22.5kg/m2) and overweight group (mean, 29.2kg/m2). Interventions: 6mo of lumbar extensor resistance exercise using MedX equipment. Main Outcome Measures: Body fat and fat free mass, and isometric lumbar extensor strength in 12° increments in the 0° to 72° range of back flexion. Results: At baseline, the overweight group had 45% to 73% greater back extensor strength at positions 12° to 72° compared with the control group (P⬍.05). When expressed per unit of BMI, the overweight group had lower lumbar extensor strength compared with the control group at 12° to 48° (P⬍.05). After resistance exercise training, the increase in isometric lumbar extensor strength was greater in the overweight compared with the control group at positions 0° (46 vs 16Nm) and 12° (52 vs 20Nm) of flexion (P⬍.05). The differences in lumbar extensor strength per unit BMI were not present after training. Conclusions: Low back pain (LBP) was associated with excess body mass and decreased lumbar extensor strength. These study results showed that overweight adults have greater baseline lumbar extensor strength when compared with nonobese adults and displayed greater strength gains with lumbar extensor training. However, although their lumbar extensor strength was greater, it may be inadequate to prevent LBP caused by the increased mechanical demands associated with excess body mass. Despite greater absolute force production, the lumbar extensor may not have the endurance to counteract the mechanical strain of excess body mass throughout an entire day. Improvements in lumbar extensor strength, particularly in the obese group, after resistance exercise indicate that this form of rehabilitation may be used to enhance lumbar support and attenuate weight-related complications such as LBP and lordosis. Key Words: Elderly; Lumbar region; Rehabilitation. Poster 95 Efficacy of Acute Inpatient Stroke Rehabilitation in an Asian Geriatric Population. Swee Long Chong, MD (Singapore Gen Hosp, Singapore, Singapore); Yee Sien Ng, MD; Peter A. Lim, MD, e-mail: [email protected]. Disclosure: S. Chong, None; Y. Ng, None; P. Lim, None. Objective: To determine if geriatric patients can benefit from an acute inpatient stroke rehabilitation program. Design: Database review. Setting: Rehabilitation unit in a tertiary teaching hospital. Participants: 140 geriatric (defined as age ⬎64y) and 166 nongeriatric patients admitted consecutively for stroke rehabilitation. Interventions: Not applicable. Main Outcome Measures: FIM instrument, length of stay (LOS), and discharge disposition. Results: Mean ages were 73.3⫾5.8y and 52.0⫾13.3y for the geriatric and nongeriatric groups, respectively. There were no significant differences in gender distribution (P⫽.220) or ethnicity with Chinese being the largest proportion (P⫽.198), followed by Malays and Indians. Geriatric FIM scores were lower than nongeriatric scores in all categories at admission and discharge, but there was no significant difference in quantum of overall FIM gains (19.88⫾12.74 vs 22.14⫾14.64; P⫽.156). Mean rehabilitation LOS was 21.9⫾10.2d in the geriatric group and 22.7⫾13.5d in the nongeriatric group (P⫽.60). 127 (90.7%) of the geriatric patients and 157 (94.6%) of the nongeriatric patients were discharged home (P⫽0192). Only 7 (5 geriatric, 2 nongeriatric) patients were discharged to nursing homes. Although family members remained the main caregivers in both groups, there was greater reliance on hired live-in caregivers in the geriatric group (28.6%, P⬍.001). Conclusions: The benefits of a rehabilitation program have comparable benefits for both geriatric and nongeriatric patients in an Asian setting. Age per se should not be the sole determinant for inpatient rehabilitation. Home discharge rate was not significantly lower in geriatric patients, although there was a significantly higher demand for assistance from hired live-in caregivers. Key Words: Geriatrics; Rehabilitation; Stroke.
Musculoskeletal Poster 96 Persistent Hip Pain After Gunshot Wound: A Case Report. Jay S. Patel, MD (Univ Virginia, Charlottesville, VA); David S. Rubendall, DO, e-mail: [email protected]. Disclosure: J.S. Patel, None; D.S. Rubendall, None. Setting: Community hospital and university-based outpatient clinic. Patient: A 43-yo AfricanAmerican woman with persistent hip pain after gunshot wound. Case Description: The patient suffered from a gunshot wound to her right hip. At admission, no evidence of trauma to bones, major vessels, or nerves was noted. She underwent bullet excision 2d after the injury. 2wk later in clinic, findings included right hip pain, hip flexion weakness, and a healed incision. Examination was otherwise unremarkable. Thereafter, the pain in her right hip persisted and worsened. However, she did not see a physician until 6mo later. At that time, she demonstrated an antalgic gait on the right. Palpation around the incision revealed an area of nodularity. Hip flexion was significantly decreased, and external rotation was also decreased. No neurologic deficits were noted. Pulses were palpable, and there was no evidence of adenopathy, venous insufficiency, or peripheral edema. Assessment/ Results: Plain radiographs revealed heterotopic bone surrounding the proximal right femur. Com-
2004 Academy Annual Assembly Abstracts puted tomography scan of the pelvis showed mature calcification in the right vastus lateralis and iliopsoas without involvement of the hip joint. Triple-phase bone scan revealed active heterotopic ossification (HO). Management included indomethacin, tramadol (Ultram) and acetaminophen as needed, physical therapy, and osteopathic manipulation. Further developments will be discussed. A follow-up bone scan is planned to evaluate the activity of the lesion and consideration for surgery. Discussion: This is the first reported case, to our knowledge, of periarticular HO after gunshot wound without evidence of trauma to bone. HO has been known to occur after fractures of various etiology. Conclusions: HO should be considered in the differential diagnosis of persistent pain after gunshot wound. Key Words: Ossification, heterotopic; Rehabilitation; Wounds, gunshot. Poster 97 Upper-Limb Pain and Weakness Secondary to Pancoast Tumor: A Case Report. Kevin A. Miles, DO, MS (Mayo Clin, Rochester, MN); Robert Yang, MD, e-mail: miles.kevin@ mayo.edu. Disclosure: K.A. Miles, None; R. Yang, None. Setting: Academic tertiary care multispecialty group practice. Patient: A 75-yo woman. Case Description: The patient presented on referral from her internist with approximately 7mo of slowly progressive right-sided upper back and shoulder pain with intermittent radiation into the posterior aspect of the arm, which had not resolved with conservative treatment. Initial radiographs showed degenerative changes in the cervical spine with normal shoulder findings. On evaluation, her symptoms were attributed to rotator cuff dysfunction. She was provided with an injection and rotator cuff rehabilitation program. At 1-mo follow-up, she complained of significant pain radiating down the medial aspect of her right arm, forearm, and into the fingers, with weakness in her finger extensors and interosseus muscles. Assessment/Results: Cervical and thoracic spine magnetic resonance imaging (MRI) was essentially normal. Electromyography revealed a chronic right C8-T1 radiculopathy. She continued to have worsening pain and weakness over the ensuing 2- to 3-wk period. Cervical and thoracic spine MRI was repeated along with a chest computed tomography scan, which demonstrated an abnormal soft tissue mass in the right lung apex with some destructive changes in the first rib. A needle biopsy revealed adenocarcinoma and aggressive radiation was provided. She subsequently had invasion of the tumor into the neck, which involved the brachial plexus and caused ulnar nerve involvement resulting in claw hand deformity and fixed contractures. Surgical services were consulted regarding further treatment, but she was uninterested in a forequarter amputation or any chemotherapy. The patient died 6mo after presentation to her physiatrist. Discussion: The presentation of a Pancoast tumor can mimic more common shoulder or cervical radicular complaints. Conclusions: This case emphasizes the importance of continued investigation when conservative treatments and initial studies fail to aid in symptom relief and definitive diagnosis. Key Words: Pain; Pancoast’s tumor; Rehabilitation. Poster 98 Avascular Necrosis as a Source of Knee Pain in a Patient With Multiple Sclerosis: A Case Report. Yvette Ju, DO (Univ of Maryland/James Lawrence Kernan Hosp, Baltimore, MD); Peter H. Gorman, MD, e-mail: [email protected]. Disclosure: Y. Ju, None; P.H. Gorman, None Setting: A comprehensive inpatient rehabilitation unit. Patient: A 37-yo woman with 9-y history of multiple sclerosis (MS) exacerbations treated with both intravenous (IV) and oral steroids; she had had chronic bilateral knee pain for 5 to 6y. The patient at baseline was ambulatory with a cane until several weeks before admission. Case Description: The patient was admitted to the acute care hospital with the new onset of double vision, bilateral facial and upper-extremity numbness, tremors, and worsening bilateral lower-extremity weakness. Magnetic resonance imaging (MRI) of the brain was consistent with active MS involving the cerebellum, medulla, and pons. Lowerextremity radiographs revealed a right lateral condyle effusion. Lower-extremity MRI demonstrated bilateral avascular necrosis (AVN) of the distal femur, proximal tibia, and proximal fibula. Nonetheless, the patient was treated with IV dexamethasone. Moderate improvement in strength and tremor was noted by day 5. Inpatient rehabilitation was initiated 22d after admission. The patient was weight bearing as tolerated but required narcotic analgesia for knee pain and high-dose antispasmotics. Ultimately, right total knee arthroplasty (TKA) was performed for pain management. Assessment/Results: The patient had temporary pain relief after surgery. She was discharged to home with analgesia at a wheelchair level, despite her leg strength being otherwise considered adequate for ambulation. Left TKA was under consideration. Discussion: Steroid use is a common cause of AVN of the hip; but AVN is an unusual cause of knee pain in patients with MS. The combination of weakness, spasticity, and AVN-related joint pain could adversely affect rehabilitation outcomes. Conclusions: AVN of the knee can occur in patients with MS who are treated with steroids. Further studies are needed to assess the incidence of AVN in this population. Key Words: Avascular necrosis of bone; Multiple sclerosis; Rehabilitation; Steroids. Poster 99: Cancelled. Poster 100 Low Back Pain and Bilateral Pure Motor Paraparesis Induced by Retroperitoneal Hematoma. Leon Margolin, MD, PhD (AECOM, Bronx, NY); Miriam Segal, MD; Avital Fast, MD, e-mail: [email protected]. Disclosure: L. Margolin, None; M. Segal, None; A. Fast, None. Setting: Tertiary care hospital. Patient: A 65-yo white woman. Case Description: The patient was hospitalized because of severe low back pain and lower-extremity weakness that developed gradually over 3 to 4wk prior to admission. She was started on low dose of warfarin (Coumadin) because of deep vein thrombosis that developed after a surgical procedure 3mo prior to the admission. Her international normalized ratio was 3.1 on admission. Computed tomography scan of the retroperitoneum was compatible with a chronic retroperitoneal and left perinephric hematoma. Physical exam showed proximal lower-extremity weakness 3⫺/5 without any sensory findings; femoral and ankle jerk were 1⫹ bilaterally. Coumadin was stopped and the patient was treated with vitamin K; the hematoma gradually resolved, with significant improvement of the weakness on
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physical therapy program. Assessment/Results: The clinical presentation of bilateral pure motor paraparesis is very uncommon and, to the best of our knowledge, has not been reported in connection with retroperitoneal and perinephric hematoma. Discussion: This unusual finding might be related to the difference of myelinization ratio of the motor versus sensory fibers that makes them more vulnerable to the oxidative and free radical damage associated with the chronic rebleeding process that caused the hematoma formation. Conclusions: Vigilance of the syndrome and with use of Coumadin is advocated. Key Words: Hematoma; Paraparesis; Rehabilitation. Poster 101: Refer to Abstract 48 in the Musculoskeletal Poster Grand Rounds for full abstract. e-mail: [email protected]. Poster 102 Interspinous Bursitis: An Unusual Etiology of Low Back Pain. Sheryl L. Oleski, MD; Michael J. DePalma, MD (Penn Spine Ctr, Hosp Univ Pennsylvania, Philadelphia, PA); Amit Bhargava, MD; Kingsley R. Chin, MD; Larry H. Chou, MD; Curtis W. Slipman, MD, e-mail: [email protected]. Disclosure: S.L. Oleski, None; M.J. DePalma, None; A. Bhargava, None; K.R. Chin, None; L.H. Chou, None; C.W. Slipman, None. Setting: Academic spine center. Patients: 2 subjects presenting with symptoms consistent with lumbar spondylolysis. Case Descriptions: Each subject presented with midline lumbar pain and lumbar extension sensitivity. Conservative management including 2mo of physical therapy, avoidance of provocative activities, and use of oral anti-inflammatory agents provided no symptom amelioration. Neither single-photon emission tomography nor magnetic resonance imaging (MRI) of the lumbar spine demonstrated an osseous abnormality. However, in both instances, the T2weighted sagittal images revealed a single focal area of increased uptake localized in the potential space between the 2 spinous processes. Each patient underwent a fluoroscopically guided diagnostic interspinous injection in which a firm end point was reached while observing a cotton ball appearing collection of contrast. An adjacent control level was injected in the first case, which exhibited the expected fascial spread and a soft end point. After infusion of 1mL of 2% lidocaine into the suspected bursa, complete symptom relief was reported; there was no change in the visual analog scale (VAS) rating after local anesthetic injection into the control level. The first subject received 2 steroid injections and the second received 4. Assessment/Results: Both subjects returned for follow-up at 2mo. The first subject returned at 1y and the second at 4.5mo. At 2mo, the VAS score decreased from 6 to 2 in the first subject and from 9 to 3 in the second. The 2 subjects remained pain free at 1y and 4.5mo, respectively. Discussion: To our knowledge, this is the first reported use of fluoroscopically guided diagnostic and therapeutic injections to evaluate and treat lumbar interspinous bursitis. Conclusions: Younger patients with refractory lumbar pain provoked by extension may be experiencing symptoms of interspinous bursitis that can be specifically diagnosed and treated with a spinal injection procedure. Key Words: Bursitis; Fluoroscopy; Rehabilitation. Poster 103: Refer to Abstract 46 in the Musculoskeletal Poster Grand Rounds for full abstract. e-mail: [email protected]. Poster 104 An Unusual Case of Radicular Pain Secondary to a Mucinois Cystadenoma: A Case Report. Kenneth Botwin, MD (Florida Spine Inst, Clearwater, FL); Robert Savarese, DO; Robert Gruber, DO; C.P. Shah, MD, e-mail: [email protected]. Disclosure: K. Botwin, None; R. Savarese, None; R. Gruber, None; C. Shah, None. Setting: Multidisciplinary spine care center. Patient: A 41-yo woman. Case Description: The woman presented with a 3-mo history of left-sided buttock pain radiating into her left calf and lateral foot. This pain was associated with some numbness in her left popliteal fossa, extending to the dorsum of the left foot. On physical examination, palpation revealed tenderness over the left sciatic notch. Range of motion of the lumbar spine was normal, but did reproduce the patient’s left leg symptoms. Neurologic examination was significant for decreased sensation in the L5 and S1 dermatomes and a positive left straight-leg raising test. Assessment/Results: The pain continued to worsen over 2wk despite anti-inflammatory medications and physical therapy. Magnetic resonance imaging (MRI) of the lumbar spine was negative. The patient refused electromyography and nerve conduction study, therefore an MRI of the pelvis and sacrum was ordered. The MRI of the pelvis and sacrum demonstrated a cystic benign appearing intrapelvic mass on the left measuring 6⫻5⫻4cm, with mass effect on the left lumbosacral plexus. The patient was referred to her gynecologist for definitive diagnosis and possible excision. Subsequently, the patient underwent surgical excision; biopsy revealed an ovarian mucinous cystadenoma. 3mo postoperatively, the patient’s pain had decreased by approximately 80%. Discussion: This is the first published report of a mucinous cystadenoma presenting as buttock pain radiating into the foot. Lumbosacral plexopathy is an infrequent cause of gluteal pain with radicular symptoms. It is difficult to diagnose because its symptoms are similar to those of more frequent causes of sciatica. Conclusions: To our knowledge, this is also the first reported case on lumbosacral plexus compression as a result of ovarian neoplasm. Key Words: Lumbosacral plexus; Ovarian neoplasms; Rehabilitation.
Poster 105 Radiculopathy as a Complication of Vertebroplasty With Polymethylmethacrylate: A Case Report. Maria A. Bastien, MD (Temple Univ Hosp, Philadelphia, PA); Richard Rosenstein, DO, e-mail: [email protected]. Disclosure: M.A. Bastien, None; R. Rosenstein, None. Setting: Acute inpatient rehabilitation unit in a community hospital. Patient: 82-yo woman, with a history of osteoporosis and recurrent lumbar compression fractures, was admitted to a community hospital after a fall, with severe back pain described as 9/10 on the visual analog scale. She also complained of right buttock and right leg pain. Workup including magnetic resonance imaging of the lumbosacral spine, which revealed old compression fractures at L1-3 and new compression fractures at L4-5. Physiatry was consulted and recommended vertebroplasty. Neuro-
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2004 Academy Annual Assembly Abstracts
research grant from the Ministry of Science & Technology, Republic of Korea; Y. Kim, research grant from the Ministry of Science & Technology, Republic of Korea; P.K. Lee, research grant from the Ministry of Science & Technology, Republic of Korea; N. Kim, research grant from the Technologic Development Program for Intelligent Robotics, Ministry of Science & Technology, Republic of Korea. Objective: To determine the stability parameters in posturography that can assess more sensitively age-related changes in posture control. Design: Descriptive study with repeated measures. Setting: Complex continuing care facility for geriatric population in Korea. Participants: 39 healthy geriatric people aged 60y and older who were free of neurologic and medical conditions that cause motor weakness, visual disturbance, and vestibular dysfunction. Interventions: Not applicable. Mean Outcome Measures: Subjects were divided into 3 groups by age (aged 60 – 69y, 70 –79y, ⱖ80y). Center of pressure (COP) parameters were obtained as total path distance, integration of total path, and mean frequency of sway in comfortable standing with eyes open and closed in each group. A visual feedback system (VFS) was added to posturography and then subjects were asked to move their COP into the target circle on a CRT monitor with active movement on forceplate. Clinical COP parameters (moving time to get in the circle, total path of deviation, elapsed time in the circle) were obtained with the VFS. Results: There was no difference in COP parameters in static posturography between age groups. Total path of deviation assessed by posturography with the VFS showed a significant difference between age groups (P⬍.05); significant correlations with a clinical balance test (Berg Balance Scale) were also found (correlation coefficient⫽⫺.471, P⫽.002). Conclusions: A posturographic balance assessment system with visual feedback was clinically useful in more sensitive evaluation of age-related change of balance control in healthy geriatric people. The therapeutic use of visual feedback as a tool of balance training may be a valuable subject of further study. Key Words: Feedback; Geriatrics; Posture; Rehabilitation. Poster 90 Modified Arnis de Mano as a Tool to Improve Balance in the Elderly: A Randomized Controlled Trial. Maria Luisa P. Santos, MD (Univ Santo Tomas Hosp, Manila, Philippines); Consuelo G. Suarez, MD; Joven Christopher T. Cerdenia, PTRP; Michael Jorge N. Peralta, PTRP, e-mail: [email protected]. Disclosure: M.P. Santos, None; C.G. Suarez, None; J.T. Cerdenia, None; M.N. Peralta, None. Objective: To determine the effectiveness of the Modified Arnis de Mano, a Filipino form of martial arts adopted as a form of exercise, in improving balance among the elderly. Design: Randomized controlled, single-blinded trial. Setting: A government-run home-for-the-aged community in the Philippines. Participants: Elderly men and women aged 60 to 84y. Interventions: The Modified Arnis de Mano and a standardized strengthening exercise protocol for the lower extremities geared toward improving balance. Main Outcome Measures: Functional performance measures done pre- and postintervention were the Timed Up & Go (TUG) test, Functional Reach Test (FRT), and 10-meter speed test (10MST). Results: 22 participants were randomly grouped into 2: 11 participants (mean age, 72.73⫾8.34y) were assigned in the Arnis group and the other 11 participants (mean age, 70.45⫾6.88y) were placed in the structured exercise group. 9 participants completed the 4-wk strengthening exercise protocols and another 9 completed the 4-wk Arnis protocol. No participants were injured during the program. The overall dropout rate was 39%. Outcome measures showed improvement in the Arnis group on the FRT and a reduction in time on the 10MST and TUG test. Although the strengthening group also showed similar changes on the 3 outcome measures, 10MST times differed significantly between the 2 groups. Conclusions: Exercise programs done regularly improved balance among the elderly. Both the standard strengthening exercise protocol and the Modified Arnis de Mano exercise showed absolute change in clinical measurements but only the latter showed a positive effect in dynamic balance. Key Words: Balance; Elderly; Rehabilitation. Poster 91: Refer to Abstract 53 in the Rehabilitation II Poster Grand Rounds for the full abstract. e-mail: [email protected]. Poster 92: Refer to Abstract 54 in the Rehabilitation II Poster Grand Rounds for the full abstract. e-mail: [email protected]. Poster 93 Clinical Balance Test More Sensitive to Age-Related Changes and Correlation With Joint Motion. Juha An, MD (Samsung Med Ctr, Seoul, Republic of Korea); JiHye Hwang, MD, PhD; Young-keun Woo, MSPT; Yun-Hee Kim, MD, PhD; Peter K. Lee, MD, PhD; Nam-Gyun Kim, PhD, e-mail: [email protected]. Disclosure: J. An, None; J. Hwang, research grant from Technologic Development Program for Intelligent Robotics, Ministry of Science & Technology, Republic of Korea; Y. Woo, research grant from Technologic Development Program for Intelligent Robotics, Ministry of Science & Technology, Republic of Korea; Y. Kim, research grant from Technologic Development Program for Intelligent Robotics, Ministry of Science & Technology, Republic of Korea; P.K. Lee, None; N. Kim, research grant from Technologic Development Program for Intelligent Robotics, Ministry of Science & Technology, Republic of Korea. Objectives: To identify a balance test that can reflect more sensitively changes according to age and to investigate the test’s correlation with flexibility of joint. Design: Descriptive survey with repeated measures. Setting: Complex continuing care facility for a geriatric population in Korea. Participants: 39 healthy geriatric people aged 60y and older who were free of neurologic and medical conditions that cause motor weakness, visual disturbance, and vestibular dysfunction. Intervention: Not applicable. Main Outcome Measures: Subjects were divided into 3 groups by age (aged 60 – 69y, 70 –79y, ⱖ80y) and each group was evaluated with clinical balance tests (Berg Balance Scale [BBS], Functional Reach Test, Tinetti Performance Oriented Mobility Assessment [POMA]). Bilateral lower-extremity range of motion (ROM) was measured with goniometry to quantify the flexibility of whole joints. Results: The BBS was the most sensitive clinical balance test reflecting the changes by age (P⫽.002) and the POMA balance subtest was also more sensitive test than others (P⫽.022). Correlations between clinical balance tests and joint flexibility were found.
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The strongest correlation existed between the BBS and bilateral ankle ROM inversion and eversion (correlation coefficient⫽.565, P⫽.000). Conclusions: Among the clinically validated balance tests, the BBS was the most sensitive test at reflecting the decline of balance performance related to aging. A correlation exists between ankle ROM and balance in healthy elderly people. Additional research is needed to determine whether treatment directed at increasing ankle ROM can improve balance. Key Words: Geriatrics; Posture; Range of motion, articular; Rehabilitation. Poster 94 Improvement in Lumbar Extensor Strength in Overweight Elderly Adults After 6 Months of Resistance Training. Kevin R. Vincent, MD, PhD (Univ Virginia, Charlottesville, VA); Heather K. Vincent, PhD; Randy W. Braith, PhD, e-mail: [email protected]. Disclosure: K.R. Vincent, None; H.K. Vincent, None; R.W. Braith, None. Objective: To measure lumbar extensor strength in overweight and nonoverweight (control) elderly adults before and after chronic resistance exercise. Design: Randomized controlled trial. Setting: Spine care center. Participants: Elderly adults 60 to 72y (N⫽62), grouped based on body mass index (BMI): control group (mean, 22.5kg/m2) and overweight group (mean, 29.2kg/m2). Interventions: 6mo of lumbar extensor resistance exercise using MedX equipment. Main Outcome Measures: Body fat and fat free mass, and isometric lumbar extensor strength in 12° increments in the 0° to 72° range of back flexion. Results: At baseline, the overweight group had 45% to 73% greater back extensor strength at positions 12° to 72° compared with the control group (P⬍.05). When expressed per unit of BMI, the overweight group had lower lumbar extensor strength compared with the control group at 12° to 48° (P⬍.05). After resistance exercise training, the increase in isometric lumbar extensor strength was greater in the overweight compared with the control group at positions 0° (46 vs 16Nm) and 12° (52 vs 20Nm) of flexion (P⬍.05). The differences in lumbar extensor strength per unit BMI were not present after training. Conclusions: Low back pain (LBP) was associated with excess body mass and decreased lumbar extensor strength. These study results showed that overweight adults have greater baseline lumbar extensor strength when compared with nonobese adults and displayed greater strength gains with lumbar extensor training. However, although their lumbar extensor strength was greater, it may be inadequate to prevent LBP caused by the increased mechanical demands associated with excess body mass. Despite greater absolute force production, the lumbar extensor may not have the endurance to counteract the mechanical strain of excess body mass throughout an entire day. Improvements in lumbar extensor strength, particularly in the obese group, after resistance exercise indicate that this form of rehabilitation may be used to enhance lumbar support and attenuate weight-related complications such as LBP and lordosis. Key Words: Elderly; Lumbar region; Rehabilitation. Poster 95 Efficacy of Acute Inpatient Stroke Rehabilitation in an Asian Geriatric Population. Swee Long Chong, MD (Singapore Gen Hosp, Singapore, Singapore); Yee Sien Ng, MD; Peter A. Lim, MD, e-mail: [email protected]. Disclosure: S. Chong, None; Y. Ng, None; P. Lim, None. Objective: To determine if geriatric patients can benefit from an acute inpatient stroke rehabilitation program. Design: Database review. Setting: Rehabilitation unit in a tertiary teaching hospital. Participants: 140 geriatric (defined as age ⬎64y) and 166 nongeriatric patients admitted consecutively for stroke rehabilitation. Interventions: Not applicable. Main Outcome Measures: FIM instrument, length of stay (LOS), and discharge disposition. Results: Mean ages were 73.3⫾5.8y and 52.0⫾13.3y for the geriatric and nongeriatric groups, respectively. There were no significant differences in gender distribution (P⫽.220) or ethnicity with Chinese being the largest proportion (P⫽.198), followed by Malays and Indians. Geriatric FIM scores were lower than nongeriatric scores in all categories at admission and discharge, but there was no significant difference in quantum of overall FIM gains (19.88⫾12.74 vs 22.14⫾14.64; P⫽.156). Mean rehabilitation LOS was 21.9⫾10.2d in the geriatric group and 22.7⫾13.5d in the nongeriatric group (P⫽.60). 127 (90.7%) of the geriatric patients and 157 (94.6%) of the nongeriatric patients were discharged home (P⫽0192). Only 7 (5 geriatric, 2 nongeriatric) patients were discharged to nursing homes. Although family members remained the main caregivers in both groups, there was greater reliance on hired live-in caregivers in the geriatric group (28.6%, P⬍.001). Conclusions: The benefits of a rehabilitation program have comparable benefits for both geriatric and nongeriatric patients in an Asian setting. Age per se should not be the sole determinant for inpatient rehabilitation. Home discharge rate was not significantly lower in geriatric patients, although there was a significantly higher demand for assistance from hired live-in caregivers. Key Words: Geriatrics; Rehabilitation; Stroke.
Musculoskeletal Poster 96 Persistent Hip Pain After Gunshot Wound: A Case Report. Jay S. Patel, MD (Univ Virginia, Charlottesville, VA); David S. Rubendall, DO, e-mail: [email protected]. Disclosure: J.S. Patel, None; D.S. Rubendall, None. Setting: Community hospital and university-based outpatient clinic. Patient: A 43-yo AfricanAmerican woman with persistent hip pain after gunshot wound. Case Description: The patient suffered from a gunshot wound to her right hip. At admission, no evidence of trauma to bones, major vessels, or nerves was noted. She underwent bullet excision 2d after the injury. 2wk later in clinic, findings included right hip pain, hip flexion weakness, and a healed incision. Examination was otherwise unremarkable. Thereafter, the pain in her right hip persisted and worsened. However, she did not see a physician until 6mo later. At that time, she demonstrated an antalgic gait on the right. Palpation around the incision revealed an area of nodularity. Hip flexion was significantly decreased, and external rotation was also decreased. No neurologic deficits were noted. Pulses were palpable, and there was no evidence of adenopathy, venous insufficiency, or peripheral edema. Assessment/ Results: Plain radiographs revealed heterotopic bone surrounding the proximal right femur. Com-
2004 Academy Annual Assembly Abstracts puted tomography scan of the pelvis showed mature calcification in the right vastus lateralis and iliopsoas without involvement of the hip joint. Triple-phase bone scan revealed active heterotopic ossification (HO). Management included indomethacin, tramadol (Ultram) and acetaminophen as needed, physical therapy, and osteopathic manipulation. Further developments will be discussed. A follow-up bone scan is planned to evaluate the activity of the lesion and consideration for surgery. Discussion: This is the first reported case, to our knowledge, of periarticular HO after gunshot wound without evidence of trauma to bone. HO has been known to occur after fractures of various etiology. Conclusions: HO should be considered in the differential diagnosis of persistent pain after gunshot wound. Key Words: Ossification, heterotopic; Rehabilitation; Wounds, gunshot. Poster 97 Upper-Limb Pain and Weakness Secondary to Pancoast Tumor: A Case Report. Kevin A. Miles, DO, MS (Mayo Clin, Rochester, MN); Robert Yang, MD, e-mail: miles.kevin@ mayo.edu. Disclosure: K.A. Miles, None; R. Yang, None. Setting: Academic tertiary care multispecialty group practice. Patient: A 75-yo woman. Case Description: The patient presented on referral from her internist with approximately 7mo of slowly progressive right-sided upper back and shoulder pain with intermittent radiation into the posterior aspect of the arm, which had not resolved with conservative treatment. Initial radiographs showed degenerative changes in the cervical spine with normal shoulder findings. On evaluation, her symptoms were attributed to rotator cuff dysfunction. She was provided with an injection and rotator cuff rehabilitation program. At 1-mo follow-up, she complained of significant pain radiating down the medial aspect of her right arm, forearm, and into the fingers, with weakness in her finger extensors and interosseus muscles. Assessment/Results: Cervical and thoracic spine magnetic resonance imaging (MRI) was essentially normal. Electromyography revealed a chronic right C8-T1 radiculopathy. She continued to have worsening pain and weakness over the ensuing 2- to 3-wk period. Cervical and thoracic spine MRI was repeated along with a chest computed tomography scan, which demonstrated an abnormal soft tissue mass in the right lung apex with some destructive changes in the first rib. A needle biopsy revealed adenocarcinoma and aggressive radiation was provided. She subsequently had invasion of the tumor into the neck, which involved the brachial plexus and caused ulnar nerve involvement resulting in claw hand deformity and fixed contractures. Surgical services were consulted regarding further treatment, but she was uninterested in a forequarter amputation or any chemotherapy. The patient died 6mo after presentation to her physiatrist. Discussion: The presentation of a Pancoast tumor can mimic more common shoulder or cervical radicular complaints. Conclusions: This case emphasizes the importance of continued investigation when conservative treatments and initial studies fail to aid in symptom relief and definitive diagnosis. Key Words: Pain; Pancoast’s tumor; Rehabilitation. Poster 98 Avascular Necrosis as a Source of Knee Pain in a Patient With Multiple Sclerosis: A Case Report. Yvette Ju, DO (Univ of Maryland/James Lawrence Kernan Hosp, Baltimore, MD); Peter H. Gorman, MD, e-mail: [email protected]. Disclosure: Y. Ju, None; P.H. Gorman, None Setting: A comprehensive inpatient rehabilitation unit. Patient: A 37-yo woman with 9-y history of multiple sclerosis (MS) exacerbations treated with both intravenous (IV) and oral steroids; she had had chronic bilateral knee pain for 5 to 6y. The patient at baseline was ambulatory with a cane until several weeks before admission. Case Description: The patient was admitted to the acute care hospital with the new onset of double vision, bilateral facial and upper-extremity numbness, tremors, and worsening bilateral lower-extremity weakness. Magnetic resonance imaging (MRI) of the brain was consistent with active MS involving the cerebellum, medulla, and pons. Lowerextremity radiographs revealed a right lateral condyle effusion. Lower-extremity MRI demonstrated bilateral avascular necrosis (AVN) of the distal femur, proximal tibia, and proximal fibula. Nonetheless, the patient was treated with IV dexamethasone. Moderate improvement in strength and tremor was noted by day 5. Inpatient rehabilitation was initiated 22d after admission. The patient was weight bearing as tolerated but required narcotic analgesia for knee pain and high-dose antispasmotics. Ultimately, right total knee arthroplasty (TKA) was performed for pain management. Assessment/Results: The patient had temporary pain relief after surgery. She was discharged to home with analgesia at a wheelchair level, despite her leg strength being otherwise considered adequate for ambulation. Left TKA was under consideration. Discussion: Steroid use is a common cause of AVN of the hip; but AVN is an unusual cause of knee pain in patients with MS. The combination of weakness, spasticity, and AVN-related joint pain could adversely affect rehabilitation outcomes. Conclusions: AVN of the knee can occur in patients with MS who are treated with steroids. Further studies are needed to assess the incidence of AVN in this population. Key Words: Avascular necrosis of bone; Multiple sclerosis; Rehabilitation; Steroids. Poster 99: Cancelled. Poster 100 Low Back Pain and Bilateral Pure Motor Paraparesis Induced by Retroperitoneal Hematoma. Leon Margolin, MD, PhD (AECOM, Bronx, NY); Miriam Segal, MD; Avital Fast, MD, e-mail: [email protected]. Disclosure: L. Margolin, None; M. Segal, None; A. Fast, None. Setting: Tertiary care hospital. Patient: A 65-yo white woman. Case Description: The patient was hospitalized because of severe low back pain and lower-extremity weakness that developed gradually over 3 to 4wk prior to admission. She was started on low dose of warfarin (Coumadin) because of deep vein thrombosis that developed after a surgical procedure 3mo prior to the admission. Her international normalized ratio was 3.1 on admission. Computed tomography scan of the retroperitoneum was compatible with a chronic retroperitoneal and left perinephric hematoma. Physical exam showed proximal lower-extremity weakness 3⫺/5 without any sensory findings; femoral and ankle jerk were 1⫹ bilaterally. Coumadin was stopped and the patient was treated with vitamin K; the hematoma gradually resolved, with significant improvement of the weakness on
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physical therapy program. Assessment/Results: The clinical presentation of bilateral pure motor paraparesis is very uncommon and, to the best of our knowledge, has not been reported in connection with retroperitoneal and perinephric hematoma. Discussion: This unusual finding might be related to the difference of myelinization ratio of the motor versus sensory fibers that makes them more vulnerable to the oxidative and free radical damage associated with the chronic rebleeding process that caused the hematoma formation. Conclusions: Vigilance of the syndrome and with use of Coumadin is advocated. Key Words: Hematoma; Paraparesis; Rehabilitation. Poster 101: Refer to Abstract 48 in the Musculoskeletal Poster Grand Rounds for full abstract. e-mail: [email protected]. Poster 102 Interspinous Bursitis: An Unusual Etiology of Low Back Pain. Sheryl L. Oleski, MD; Michael J. DePalma, MD (Penn Spine Ctr, Hosp Univ Pennsylvania, Philadelphia, PA); Amit Bhargava, MD; Kingsley R. Chin, MD; Larry H. Chou, MD; Curtis W. Slipman, MD, e-mail: [email protected]. Disclosure: S.L. Oleski, None; M.J. DePalma, None; A. Bhargava, None; K.R. Chin, None; L.H. Chou, None; C.W. Slipman, None. Setting: Academic spine center. Patients: 2 subjects presenting with symptoms consistent with lumbar spondylolysis. Case Descriptions: Each subject presented with midline lumbar pain and lumbar extension sensitivity. Conservative management including 2mo of physical therapy, avoidance of provocative activities, and use of oral anti-inflammatory agents provided no symptom amelioration. Neither single-photon emission tomography nor magnetic resonance imaging (MRI) of the lumbar spine demonstrated an osseous abnormality. However, in both instances, the T2weighted sagittal images revealed a single focal area of increased uptake localized in the potential space between the 2 spinous processes. Each patient underwent a fluoroscopically guided diagnostic interspinous injection in which a firm end point was reached while observing a cotton ball appearing collection of contrast. An adjacent control level was injected in the first case, which exhibited the expected fascial spread and a soft end point. After infusion of 1mL of 2% lidocaine into the suspected bursa, complete symptom relief was reported; there was no change in the visual analog scale (VAS) rating after local anesthetic injection into the control level. The first subject received 2 steroid injections and the second received 4. Assessment/Results: Both subjects returned for follow-up at 2mo. The first subject returned at 1y and the second at 4.5mo. At 2mo, the VAS score decreased from 6 to 2 in the first subject and from 9 to 3 in the second. The 2 subjects remained pain free at 1y and 4.5mo, respectively. Discussion: To our knowledge, this is the first reported use of fluoroscopically guided diagnostic and therapeutic injections to evaluate and treat lumbar interspinous bursitis. Conclusions: Younger patients with refractory lumbar pain provoked by extension may be experiencing symptoms of interspinous bursitis that can be specifically diagnosed and treated with a spinal injection procedure. Key Words: Bursitis; Fluoroscopy; Rehabilitation. Poster 103: Refer to Abstract 46 in the Musculoskeletal Poster Grand Rounds for full abstract. e-mail: [email protected]. Poster 104 An Unusual Case of Radicular Pain Secondary to a Mucinois Cystadenoma: A Case Report. Kenneth Botwin, MD (Florida Spine Inst, Clearwater, FL); Robert Savarese, DO; Robert Gruber, DO; C.P. Shah, MD, e-mail: [email protected]. Disclosure: K. Botwin, None; R. Savarese, None; R. Gruber, None; C. Shah, None. Setting: Multidisciplinary spine care center. Patient: A 41-yo woman. Case Description: The woman presented with a 3-mo history of left-sided buttock pain radiating into her left calf and lateral foot. This pain was associated with some numbness in her left popliteal fossa, extending to the dorsum of the left foot. On physical examination, palpation revealed tenderness over the left sciatic notch. Range of motion of the lumbar spine was normal, but did reproduce the patient’s left leg symptoms. Neurologic examination was significant for decreased sensation in the L5 and S1 dermatomes and a positive left straight-leg raising test. Assessment/Results: The pain continued to worsen over 2wk despite anti-inflammatory medications and physical therapy. Magnetic resonance imaging (MRI) of the lumbar spine was negative. The patient refused electromyography and nerve conduction study, therefore an MRI of the pelvis and sacrum was ordered. The MRI of the pelvis and sacrum demonstrated a cystic benign appearing intrapelvic mass on the left measuring 6⫻5⫻4cm, with mass effect on the left lumbosacral plexus. The patient was referred to her gynecologist for definitive diagnosis and possible excision. Subsequently, the patient underwent surgical excision; biopsy revealed an ovarian mucinous cystadenoma. 3mo postoperatively, the patient’s pain had decreased by approximately 80%. Discussion: This is the first published report of a mucinous cystadenoma presenting as buttock pain radiating into the foot. Lumbosacral plexopathy is an infrequent cause of gluteal pain with radicular symptoms. It is difficult to diagnose because its symptoms are similar to those of more frequent causes of sciatica. Conclusions: To our knowledge, this is also the first reported case on lumbosacral plexus compression as a result of ovarian neoplasm. Key Words: Lumbosacral plexus; Ovarian neoplasms; Rehabilitation.
Poster 105 Radiculopathy as a Complication of Vertebroplasty With Polymethylmethacrylate: A Case Report. Maria A. Bastien, MD (Temple Univ Hosp, Philadelphia, PA); Richard Rosenstein, DO, e-mail: [email protected]. Disclosure: M.A. Bastien, None; R. Rosenstein, None. Setting: Acute inpatient rehabilitation unit in a community hospital. Patient: 82-yo woman, with a history of osteoporosis and recurrent lumbar compression fractures, was admitted to a community hospital after a fall, with severe back pain described as 9/10 on the visual analog scale. She also complained of right buttock and right leg pain. Workup including magnetic resonance imaging of the lumbosacral spine, which revealed old compression fractures at L1-3 and new compression fractures at L4-5. Physiatry was consulted and recommended vertebroplasty. Neuro-
Arch Phys Med Rehabil Vol 85, September 2004