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Developing an Ultrasound Course for a Physical Medicine & Rehabilitation Residency Program
PM&R
Conclusions: Although there is increasing popularity of barefoot running, this case highlights the need of medical discretion to guide patients with specific foot conditions. Poster 188 Insole-Pressure Distribution for Normal Children in Different Age Groups. Brian Curtin, DO (Loyola University, Chicago, IL, United States). Disclosures: B. Curtin, No Disclosures: I Have Nothing To Disclose. Objective: In measuring plantar pressures during gait, earlier methods have used a platform system that does not take into account the interactions feet have with orthotics and shoe wearing. The purpose of the study was to provide normal insole plantar pressure parameter data during stance phase using the Pedar pressure insole system. Design: Twenty-nine normal children, age 6 to 16 years, were recruited and walked along the 25 m walkway at self-selected speeds. Patients were divided into 2 separate groups for statistical analysis– juniors (< 12 y old) and teenagers (> 13 y old). The pressure map was divided into 8 regions (masks) determined by anatomic landmarks and a total of 7 pressure parameters were analyzed of each mask. Setting: The patients were evaluated at the musculoskeletal functional assessment center at Children’s Hospital of Wisconsin. Subjects walked along a 25m long walkway. Patients walked at a self-selected speed 3 separate times and then data was collected and analyzed. Participants: Twenty-nine normal male and female individuals were either current patients seen in the orthopedic clinic or patients recruited from local schools. Owing to an incorrect cable connection of the insole sensors, data were lost for 4 patients. The remaining 14 male patients and 11 female patients participated in the study, with a total of 49 individual feet examined. Patient age ranged from 6 to 16 years, with a mean age of 11.08 years. Main Outcome Measures: 7 parameters were analyzed of each mask: plantar contact area (cm2), maximum force (N), peak pressure (N/cm2), contact time for peak pressure occurrence as a function of stance phase(%), maximum mean pressure (N/cm2), pressure-timeintegral (NS/cm2), and force-time integral (NS). Results or Clinical Course: We did not detect significant differences in foot pressures between juniors and teenagers when regarding sex, or left and right feet for 7 parameters measured. Conclusions: This normative data will provide a basis with which to more accurately assess pediatric pathologic foot deformities and to distinguish dynamic foot deformities from anatomic foot deformities. Poster 190 Relief from Ultrasound-Guided Botulinum Toxin Injection after Failed Piriformis Release: A Case Report. Michael J. Ingraham, MD (Medstar Georgetown University Hospital & National Rehabilitation Hospital, Washington, DC, United States); Eric Wisotzky, MD; Cynthia G. Pineda, MD. Disclosures: M. J. Ingraham, No Disclosures: I Have Nothing To Disclose. Case Description: Patient is a 56-year-old woman with a 5-year history of right buttock pain radiating down to her foot and was diagnosed with piriformis syndrome on physical exam after an MRI failed to demonstrate nerve root compression. Patient had been
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previously treated with epidural steroid injections without relief and was referred to a pain specialist for chronic management. She had 2 ultrasound-guided steroid injections of the piriformis with shortterm relief and was referred for piriformis release. However pain persisted after the procedure. Her oral medications included: oxycodone extended- release (10 mg 5 times daily); duloxetine (60 mg daily) and oxycodone immediate-release (5 mg 2-4 times daily as needed). She completed a course of physical therapy without relief, and was unable to tolerate gabapentin or tizanidine due to excessive daytime somnolence. Patient then underwent ultrasound-guided visualization of the piriformis with injection of 200 units of botulinum toxin into the muscle body. The procedure was well tolerated. Setting: Outpatient Physiatry Clinic. Results or Clinical Course: Patient returned to clinic 6 weeks later to report a sustained 25% improvement in symptoms with pain control achieved with less oral medications. Patient noted no other procedure helped her with her pain for longer than 2 weeks and has been steadily titrating up her pain regimen over the past 5 years until this procedure. Patient was pleased with the outcome and wished to proceed with a repeat procedure at an increased dose of 300 units to attempt more complete symptom relief. Discussion: This case demonstrates the effectiveness of intramuscular botulinum toxin injection for the management of piriformis syndrome that had failed surgical, interventional, medical and physical therapeutic treatments. This treatment approach warrants further investigation with a larger patient sample size. Conclusions: Ultrasound-guided intramuscular botulinum toxin injection is an effective long-term treatment for recalcitrant piriformis syndrome, even after failure of piriformis release and other interventional procedures. Poster 191 Developing an Ultrasound Course for a Physical Medicine & Rehabilitation Residency Program. Jamil Bashir, MD (University of Miami Miller School of Medicine, Miami, FL, United States); Nitin Putcha, DO; Jackson Cohen, MD; Robert W. Irwin, MD. Disclosures: J. Bashir, No Disclosures: I Have Nothing To Disclose. Program Description: Resident interest in Ultrasound Training led to the creation of our Ultrasound training program. A literature review revealed a January 2010 publication in The American Journal of Physical Medicine & Rehabilitation by the Mayo Clinic outlining strategies used to generate a residency Ultrasound training course. A six session course covering the major joints: shoulder, elbow, hand, hip, knee and ankle/foot was prepared followed by a review session. The course for the first year was not mandatory. Ultrasound Phantom device was used familiarizing residents with injection techniques. Each session was led by a PGY-3 resident, under faculty guidance, beginning with a didactic. These lectures and hands on workshops were based on materials presented by The European Society for Musculoskeletal Radiology. Ultrasound technical skills and descriptive dialect were reviewed enabling residents to gain confidence in both imaging and presentation of findings. The course was concluded with an Objective Structured Clinical Examination (OSCE) and written examination. Setting: Tertiary care academic center. Results or Clinical Course: Of 18 residents involved with the program, 16 were evaluated with the written exam, and 9 participated in the OSCE. All 9 reported satisfaction with the training
S206
gained during the Ultrasound course. The overall written examination average was 69% and the average OSCE score was 77%. Discussion: Based on the interest in the voluntary course, this is now part of the regular didactics curriculum. Our first year of this course has served as a template upon which a recurring Ultrasound curriculum has been established at our Residency training program. Conclusions: There is significant interest amongst residents in Ultrasound training. The successful formation of an Ultrasound course demonstrates the possibility of training residents to become competent in this new modality. Poster 193 Comparison of Two Different Ultrasonographic Parameters for the Diagnosis of Carpal Tunnel Syndrome. Jason D. Curry, MD (East Carolina University Brody School of Medicine, Greenville, NC, United States); John W. Norbury, MD; Michael S. Cartwright, MD, MS; Andrada E. Ivanescu, PhD; Daniel Moore, MD. Disclosures: J. D. Curry, No Disclosures: I Have Nothing To Disclose. Objective: To compare the accuracy of two different ultrasonographic parameters for the diagnosis of carpal tunnel syndrome. Design: Prospective study. Setting: Hospital Based Electrodiagnostic Laboratory. Participants: 43 wrists on 28 patients who presented for an electrodiagnostic evaluation Interventions: We calculated the sensitivity and specificity of two different ultrasonographic parameters, with clinical signs and symptoms serving as the diagnostic gold standard. One parameter, as previously described by Hobson-Webb et al, was a ratio of the cross-sectional area of the median nerve at the wrist to the area of the median nerve 12cm proximal to the wrist. The other parameter, as previously described by Klauser et al, was the absolute difference between the area of the nerve at the wrist and the area of the nerve at the pronator quadratus. Main Outcome Measures: The sensitivity and specificity of the Hobson-Webb and Klauser et al criteria. Results or Clinical Course: Using cutoff values previously established in the literature by Hobson-Webb et al, a median nerve ratio of 1.4 wrist to forearm yielded a sensitivity of 52% and specificity of 39%. This compares to a previously reported value of 100% sensitivity. Using the criteria provided by Klauser et al of a 2mm2 absolute difference cutoff between median nerve measurement at the carpal tunnel and the median nerve measurement at the pronator quadratus yielded 78% sensitivity and 40% specificity. Previous values in the literature were 99% sensitive and 100% specific. Conclusions: Operator dependence, the type of ultrasound machine utilized, and the patient population studied may all have a profound effect on the sensitivities and specificities of ultrasound for the diagnosis of carpal tunnel syndrome. Also, it is possible that ultrasonography does not correlate as strongly with clinical carpal tunnel syndrome as it does with electrodiagnostically proven carpal tunnel syndrome. Poster 194 Tibial Tubercle Stress Fracture from Intensive Dancing in a Collegiate Dancer: A Case Report. Geraldine Dapul, MD (Wayne State University/Oakwood Hospital, Taylor, MI, United States); Michael Yoshida, MD, PhD.
PRESENTATIONS
Disclosures: G. Dapul, No Disclosures: I Have Nothing To Disclose. Case Description: A 20-year-old male dancer presented with a three-week history of right knee swelling. This was brought on by increasing intensity and frequency of dance classes and rehearsals, requiring extensive amount of repetitive knee drops and jumping combinations. He denied pain upon landing his jumps. Patient’s symptoms resolved with rest, ice and NSAIDs. However, patient returned to the dance studio to prepare for upcoming performance in which the swelling returned along with pitting edema tracking down his medial leg. He denied history of Osgood Schlatter’s disease. Palpation revealed point tenderness at the proximal aspect of the tibial tubercle. Ultrasound of right lower extremity was conducted. He was found to have a well-defined area below attachment of the patellar tendon to the tubercle of cortical irregularity consistent with stress fracture and diffuse hypoechoic layers signifying subcutaneous blood. Subsequently, he was able to complete the dance concert series with modifications in the choreography and extensive knee padding. Setting: Tertiary care outpatient setting. Results or Clinical Course: Upon completion of the dance season, patient rested his leg for four weeks. Patient’s symptomatology had significantly diminished. He slowly returned to dance activities without any difficulty and resumed full participation in the dance company. Discussion: Tibial stress fractures in young athletes are commonly found to occur in the proximal and middle thirds of the bone along the medial aspect. This is a unique case in which a stress fracture of the tibial tubercle in a skeletally mature dancer has been reported. Conclusions: Although tibial tuberosity stress fractures are infrequent fractures affecting highly active individuals, this diagnosis should be considered in skeletally mature individuals who present with insidious onset of focal tenderness and swelling. Poster 196 Ultrasound-Guided Platelet Rich Plasma (PRP) Injections for Greater Trochanteric Pain Syndrome (GTPS): A Retrospective Case Series. Stephen Massimi, MD (Hospital for Special Surgery, New York, NY, United States); Elizabeth LaSalle, BS; Joe Vongvorachoti, MD; Gregory E. Lutz, MD. Disclosures: S. Massimi, No Disclosures: I Have Nothing To Disclose. Objective: To evaluate the efficacy of ultrasound-guided PRP injections for patients with GTPS due to medius or minimus tear, tendinosis, or degeneration. Design: Retrospective case series. Setting: Outpatient physiatry practice. Participants: Patients aged 30-85 who were referred to an outpatient physiatry practice for GTPS and ultimately treated with an ultrasound-guided PRP injection into the diseased hip abductor tendon. Inclusion criteria were moderate to severe hip pain refractory to conservative treatment for greater than 12 weeks; right or left gluteus medius or minimus tear, tendinosis, or degeneration as determined by hip MRI. Interventions: The charts of patients who received a PRP injection for GTPS were reviewed by an independent observer. Then, MRIs from these patients were reviewed to confirm the presence of
Conclusions: Although there is increasing popularity of barefoot running, this case highlights the need of medical discretion to guide patients with specific foot conditions. Poster 188 Insole-Pressure Distribution for Normal Children in Different Age Groups. Brian Curtin, DO (Loyola University, Chicago, IL, United States). Disclosures: B. Curtin, No Disclosures: I Have Nothing To Disclose. Objective: In measuring plantar pressures during gait, earlier methods have used a platform system that does not take into account the interactions feet have with orthotics and shoe wearing. The purpose of the study was to provide normal insole plantar pressure parameter data during stance phase using the Pedar pressure insole system. Design: Twenty-nine normal children, age 6 to 16 years, were recruited and walked along the 25 m walkway at self-selected speeds. Patients were divided into 2 separate groups for statistical analysis– juniors (< 12 y old) and teenagers (> 13 y old). The pressure map was divided into 8 regions (masks) determined by anatomic landmarks and a total of 7 pressure parameters were analyzed of each mask. Setting: The patients were evaluated at the musculoskeletal functional assessment center at Children’s Hospital of Wisconsin. Subjects walked along a 25m long walkway. Patients walked at a self-selected speed 3 separate times and then data was collected and analyzed. Participants: Twenty-nine normal male and female individuals were either current patients seen in the orthopedic clinic or patients recruited from local schools. Owing to an incorrect cable connection of the insole sensors, data were lost for 4 patients. The remaining 14 male patients and 11 female patients participated in the study, with a total of 49 individual feet examined. Patient age ranged from 6 to 16 years, with a mean age of 11.08 years. Main Outcome Measures: 7 parameters were analyzed of each mask: plantar contact area (cm2), maximum force (N), peak pressure (N/cm2), contact time for peak pressure occurrence as a function of stance phase(%), maximum mean pressure (N/cm2), pressure-timeintegral (NS/cm2), and force-time integral (NS). Results or Clinical Course: We did not detect significant differences in foot pressures between juniors and teenagers when regarding sex, or left and right feet for 7 parameters measured. Conclusions: This normative data will provide a basis with which to more accurately assess pediatric pathologic foot deformities and to distinguish dynamic foot deformities from anatomic foot deformities. Poster 190 Relief from Ultrasound-Guided Botulinum Toxin Injection after Failed Piriformis Release: A Case Report. Michael J. Ingraham, MD (Medstar Georgetown University Hospital & National Rehabilitation Hospital, Washington, DC, United States); Eric Wisotzky, MD; Cynthia G. Pineda, MD. Disclosures: M. J. Ingraham, No Disclosures: I Have Nothing To Disclose. Case Description: Patient is a 56-year-old woman with a 5-year history of right buttock pain radiating down to her foot and was diagnosed with piriformis syndrome on physical exam after an MRI failed to demonstrate nerve root compression. Patient had been
Vol. 5, Iss. 9S, 2013
S205
previously treated with epidural steroid injections without relief and was referred to a pain specialist for chronic management. She had 2 ultrasound-guided steroid injections of the piriformis with shortterm relief and was referred for piriformis release. However pain persisted after the procedure. Her oral medications included: oxycodone extended- release (10 mg 5 times daily); duloxetine (60 mg daily) and oxycodone immediate-release (5 mg 2-4 times daily as needed). She completed a course of physical therapy without relief, and was unable to tolerate gabapentin or tizanidine due to excessive daytime somnolence. Patient then underwent ultrasound-guided visualization of the piriformis with injection of 200 units of botulinum toxin into the muscle body. The procedure was well tolerated. Setting: Outpatient Physiatry Clinic. Results or Clinical Course: Patient returned to clinic 6 weeks later to report a sustained 25% improvement in symptoms with pain control achieved with less oral medications. Patient noted no other procedure helped her with her pain for longer than 2 weeks and has been steadily titrating up her pain regimen over the past 5 years until this procedure. Patient was pleased with the outcome and wished to proceed with a repeat procedure at an increased dose of 300 units to attempt more complete symptom relief. Discussion: This case demonstrates the effectiveness of intramuscular botulinum toxin injection for the management of piriformis syndrome that had failed surgical, interventional, medical and physical therapeutic treatments. This treatment approach warrants further investigation with a larger patient sample size. Conclusions: Ultrasound-guided intramuscular botulinum toxin injection is an effective long-term treatment for recalcitrant piriformis syndrome, even after failure of piriformis release and other interventional procedures. Poster 191 Developing an Ultrasound Course for a Physical Medicine & Rehabilitation Residency Program. Jamil Bashir, MD (University of Miami Miller School of Medicine, Miami, FL, United States); Nitin Putcha, DO; Jackson Cohen, MD; Robert W. Irwin, MD. Disclosures: J. Bashir, No Disclosures: I Have Nothing To Disclose. Program Description: Resident interest in Ultrasound Training led to the creation of our Ultrasound training program. A literature review revealed a January 2010 publication in The American Journal of Physical Medicine & Rehabilitation by the Mayo Clinic outlining strategies used to generate a residency Ultrasound training course. A six session course covering the major joints: shoulder, elbow, hand, hip, knee and ankle/foot was prepared followed by a review session. The course for the first year was not mandatory. Ultrasound Phantom device was used familiarizing residents with injection techniques. Each session was led by a PGY-3 resident, under faculty guidance, beginning with a didactic. These lectures and hands on workshops were based on materials presented by The European Society for Musculoskeletal Radiology. Ultrasound technical skills and descriptive dialect were reviewed enabling residents to gain confidence in both imaging and presentation of findings. The course was concluded with an Objective Structured Clinical Examination (OSCE) and written examination. Setting: Tertiary care academic center. Results or Clinical Course: Of 18 residents involved with the program, 16 were evaluated with the written exam, and 9 participated in the OSCE. All 9 reported satisfaction with the training
S206
gained during the Ultrasound course. The overall written examination average was 69% and the average OSCE score was 77%. Discussion: Based on the interest in the voluntary course, this is now part of the regular didactics curriculum. Our first year of this course has served as a template upon which a recurring Ultrasound curriculum has been established at our Residency training program. Conclusions: There is significant interest amongst residents in Ultrasound training. The successful formation of an Ultrasound course demonstrates the possibility of training residents to become competent in this new modality. Poster 193 Comparison of Two Different Ultrasonographic Parameters for the Diagnosis of Carpal Tunnel Syndrome. Jason D. Curry, MD (East Carolina University Brody School of Medicine, Greenville, NC, United States); John W. Norbury, MD; Michael S. Cartwright, MD, MS; Andrada E. Ivanescu, PhD; Daniel Moore, MD. Disclosures: J. D. Curry, No Disclosures: I Have Nothing To Disclose. Objective: To compare the accuracy of two different ultrasonographic parameters for the diagnosis of carpal tunnel syndrome. Design: Prospective study. Setting: Hospital Based Electrodiagnostic Laboratory. Participants: 43 wrists on 28 patients who presented for an electrodiagnostic evaluation Interventions: We calculated the sensitivity and specificity of two different ultrasonographic parameters, with clinical signs and symptoms serving as the diagnostic gold standard. One parameter, as previously described by Hobson-Webb et al, was a ratio of the cross-sectional area of the median nerve at the wrist to the area of the median nerve 12cm proximal to the wrist. The other parameter, as previously described by Klauser et al, was the absolute difference between the area of the nerve at the wrist and the area of the nerve at the pronator quadratus. Main Outcome Measures: The sensitivity and specificity of the Hobson-Webb and Klauser et al criteria. Results or Clinical Course: Using cutoff values previously established in the literature by Hobson-Webb et al, a median nerve ratio of 1.4 wrist to forearm yielded a sensitivity of 52% and specificity of 39%. This compares to a previously reported value of 100% sensitivity. Using the criteria provided by Klauser et al of a 2mm2 absolute difference cutoff between median nerve measurement at the carpal tunnel and the median nerve measurement at the pronator quadratus yielded 78% sensitivity and 40% specificity. Previous values in the literature were 99% sensitive and 100% specific. Conclusions: Operator dependence, the type of ultrasound machine utilized, and the patient population studied may all have a profound effect on the sensitivities and specificities of ultrasound for the diagnosis of carpal tunnel syndrome. Also, it is possible that ultrasonography does not correlate as strongly with clinical carpal tunnel syndrome as it does with electrodiagnostically proven carpal tunnel syndrome. Poster 194 Tibial Tubercle Stress Fracture from Intensive Dancing in a Collegiate Dancer: A Case Report. Geraldine Dapul, MD (Wayne State University/Oakwood Hospital, Taylor, MI, United States); Michael Yoshida, MD, PhD.
PRESENTATIONS
Disclosures: G. Dapul, No Disclosures: I Have Nothing To Disclose. Case Description: A 20-year-old male dancer presented with a three-week history of right knee swelling. This was brought on by increasing intensity and frequency of dance classes and rehearsals, requiring extensive amount of repetitive knee drops and jumping combinations. He denied pain upon landing his jumps. Patient’s symptoms resolved with rest, ice and NSAIDs. However, patient returned to the dance studio to prepare for upcoming performance in which the swelling returned along with pitting edema tracking down his medial leg. He denied history of Osgood Schlatter’s disease. Palpation revealed point tenderness at the proximal aspect of the tibial tubercle. Ultrasound of right lower extremity was conducted. He was found to have a well-defined area below attachment of the patellar tendon to the tubercle of cortical irregularity consistent with stress fracture and diffuse hypoechoic layers signifying subcutaneous blood. Subsequently, he was able to complete the dance concert series with modifications in the choreography and extensive knee padding. Setting: Tertiary care outpatient setting. Results or Clinical Course: Upon completion of the dance season, patient rested his leg for four weeks. Patient’s symptomatology had significantly diminished. He slowly returned to dance activities without any difficulty and resumed full participation in the dance company. Discussion: Tibial stress fractures in young athletes are commonly found to occur in the proximal and middle thirds of the bone along the medial aspect. This is a unique case in which a stress fracture of the tibial tubercle in a skeletally mature dancer has been reported. Conclusions: Although tibial tuberosity stress fractures are infrequent fractures affecting highly active individuals, this diagnosis should be considered in skeletally mature individuals who present with insidious onset of focal tenderness and swelling. Poster 196 Ultrasound-Guided Platelet Rich Plasma (PRP) Injections for Greater Trochanteric Pain Syndrome (GTPS): A Retrospective Case Series. Stephen Massimi, MD (Hospital for Special Surgery, New York, NY, United States); Elizabeth LaSalle, BS; Joe Vongvorachoti, MD; Gregory E. Lutz, MD. Disclosures: S. Massimi, No Disclosures: I Have Nothing To Disclose. Objective: To evaluate the efficacy of ultrasound-guided PRP injections for patients with GTPS due to medius or minimus tear, tendinosis, or degeneration. Design: Retrospective case series. Setting: Outpatient physiatry practice. Participants: Patients aged 30-85 who were referred to an outpatient physiatry practice for GTPS and ultimately treated with an ultrasound-guided PRP injection into the diseased hip abductor tendon. Inclusion criteria were moderate to severe hip pain refractory to conservative treatment for greater than 12 weeks; right or left gluteus medius or minimus tear, tendinosis, or degeneration as determined by hip MRI. Interventions: The charts of patients who received a PRP injection for GTPS were reviewed by an independent observer. Then, MRIs from these patients were reviewed to confirm the presence of