- Email: [email protected]
Poster 152: Prevalence of 25-Hydroxy Vitamin D Deficiency in the Acute Inpatient Rehabilitation Population
PM&R
leg completed resolved. The patient’s lymphedema was treated with serial Unna boot applications. Discussion: Peroneal muscle and tendon disorders are relatively common but frequently under recognized. Diagnosis and treatment are based primarily on the history and physical examination. Our patient had left lower extremity lymphedema, which made this leg functionally longer than the right. This biomechanical imbalance put more stress on her right peroneal muscles during gait cycle due to compensatory attempt. Conclusions: Peroneal longus muscle overuse may cause pain in the lateral leg in a patient with contralateral lower extremity pathologies. Keywords: Rehabilitation, Cumulative trauma disorders, Lymphedema.
Poster 150 Plantar Fasciopathy Treated with Dynamic Splinting: A Randomized, Controlled Trial. Buck Willis, PhD (Landmark Medical, Austin, TX); Mathew M. John, DPM; Andres Perez, MD, DPM. Disclosures: B. Willis, Dynasplint Systems, Research grants. Objective: Plantar fasciopathy (or plantar fasciitis) is considered to be one of the most common foot pathologies affecting up to 2 million Americans each year, and the chief complaint is acute heel pain. Therapeutic protocols for this condition have included stretching exercises, corticosteroid injections, physical therapy, and foot orthoses, but a single modality has not been found to be universally effective. The purpose of this study is to determine the efficacy of stretching with dynamic splinting for treatment of plantar fasciitis. Design: Randomized, controlled trial. Participants: Sixty patients (76 feet) enrolled in this study from 4 different clinics across the U.S., and the duration of this study was 12 weeks. Interventions: All patients received NSAIDs, orthoses, and corticosteroid injections if needed. Thirty experimental patients also received dynamic splinting (ankle dorsiflexion) for nightly wear to obtain a low load, prolonged duration of stretch with dynamic tension. Main Outcome Measures: The dependent variable was change in the 100 point Plantar Fasciopathy Pain/Disability Scale which included a visual analog scale and questions regarding pain arising from ADLs. Results: A one-way analysis of variance with post-hoc ttests were performed, and there was a significant change in pain (Pre/Post) for the experimental patients (P ⬍ .0001, T ⫽ 13.6). The experimental patients displayed a 58% reduction in pain. There was not a significant difference in pain for the control patients, but there was a significant difference between the final (12-week) pain scores of experimental vs control patients (P ⬍ .0001). Conclusions: Dynamic splinting was effective for reducing the pain of plantar fasciopathy in this study.
Vol. 1, Iss. 9S, 2009
S169
Keywords: Rehabilitation, Pain, Dynasplint, Plantar fasciopathy.
Poster 151 Post-Arthroplasty Methylmethacrylate (PMMA) Hypersensitivity Reaction: A Case Report. Jignyasa Desai, (SBUH, Stony Brook, NY). Disclosures: J. Desai, None. Objective: Hypersensitivity reactions to implant componentry have been described with orthopedic surgical hardware, but cement sensitivity is relatively uncommon. Metals known as sensitizers are nickel, cobalt, and chromium, with the prevalence of metal sensitivity being 10-15%. All metals in vivo release ions that bind to proteins forming allergen complexes eliciting the hypersensitivity reaction. The nonbiodegradable polymeric biomaterial used for load bearing such as ultra high molecular weight polyethylene (UHMWPE) and methylmethacrylate cement (PMMA) are not easily chemically degraded in vivo and have rarely been investigated or even implicated as a source for immune hypersensitivity response. Patients or Programs: A 58-year-old woman with arthritis had a uni-compartmental knee replacement in 2002, followed by a total knee revision surgery in 2006. During her postoperative course, she developed inflammation, pain, and decreased range of motion. An extensive work-up ruled out hardware failure. Hypersensitivity testing for metallic ions was negative. This led to a subsequent investigation for a possible allergic reaction to cement products and polyethylene. She had sensitivity testing at Rush University Medical Center via lymphocyte proliferation assays. In vitro testing revealed a very strong proliferation response to PMMA and mild response to UHMWPE. Following these results, the patient had a non-cemented revision with removal of cement material on 10/08. She was then transferred to inpatient rehabilitation service. At 3-month follow-up, she had minimal pain and significant improvement in symptoms. Discussion: The rare potential of both metals and cement polymers to induce symptoms through allergy presents many problems for orthopedists. The specific laboratory tests such as the lymphokine macrophage inhibitor factor test (MIF) and lymphocyte transformation test (LTT) help to confirm these reactions. In patients who exhibit recurrent pain, inflammation, and aseptic loosening of implanted hardware, polymer cement, polyethylene, and metal hypersensitivity reactions should be considered in the differential diagnosis. Keywords: Methylmethacrylate, PMMA.
Poster 152 Prevalence of 25-Hydroxy Vitamin D Deficiency in the Acute Inpatient Rehabilitation Population. Anthony J. Pellicane, MD (Rehabilitation Institute of Chicago, Chicago, IL); Thomas Schnitzer, MD, PhD; Nicole M. Wysocki, MD.
S170
Disclosures: A. J. Pellicane, None. Objective: To assess the prevalence of 25-hydroxy vitamin D (25(OH)D) insufficiency and deficiency in the acute inpatient rehabilitation setting and to identify risk factors associated with low 25(OH)D levels Design: Retrospective cohort study. Setting: Academic acute rehabilitation hospital. Participants: 101 inpatients (36 consecutive from 9/1/ 2008 to 9/17/2008 and 65 convenience from 10/1/2008 to 12/1/2008) admitted to the 4th floor of an academic acute rehabilitation hospital. Interventions: None. Main Outcome Measures: 25(OH)D levels, patient demographics (age, sex, race), BMI, presenting diagnosis (fall with and without fracture), medication management on transfer. Results: 24.75% of subjects were 25(OH)D sufficient (32100 ng/mL) while the remainder of the population was as follows: mild insufficiency (20-32 ng/mL) 34.65%; moderate insufficiency (10-20 ng/mL) 34.65%; marked insufficiency (7-10 ng/mL) 4.95%; deficiency (⬍7 ng/mL) 0.99%. Blacks had significantly lower 25(OH)D levels compared to whites (27.86 ⫾ 12.74 vs 21.00 ⫾ 11.50; P ⫽ .03) while no significant difference was found between male and female 25(OH)D levels (24.23⫾11.20 vs 26.49 ⫾ 12.72; P ⫽ .29). 76.47% of subjects with the diagnosis of fracture were not transferred with 25(OH)D supplementation. Further, those subjects transferred with supplementation had a statistically higher 25(OH)D level compared to those not transferred with supplementation (33.48 ⫾ 12.81 vs 23.71 ⫾ 11.43; P ⫽ .0009). The 15 subjects sustaining fracture after fall had an insignificantly higher average 25(OH)D level than the 8 subjects sustaining no fracture after fall (25.56 ⫾ 14.18 vs 18.58 ⫾ 7.31; P ⫽ 0.18). Pearson’s correlation coefficient did not reveal a relationship between 25(OH)D levels and BMI, LOS, or age (r ⫽ -0.17, -0.14, 0.04, respectively). Conclusions: 75.24% of acute rehabilitation inpatients possessed insufficient or deficient 25(OH)D levels with blacks possibly being at higher risk for low 25(OH)D levels. A high percentage (76.47%) admitted to the acute rehabilitation setting with the primary diagnosis of fracture are transferred without 25(OH)D supplementation and those patients transferred without supplementation have a significantly lower average 25(OH)D level compared to those patients transferred with supplementation. Keywords: Rehabilitation, Musculoskeletal, Vitamin D, Bone.
Poster 153 Radiculopathy as a Manifestation of a Hamstring Tear: A Case Report. Halland Chen, MD (University of Miami Miller School of Medicine, Miami, FL); Andrew L. Sherman, MD. Disclosures: H. Chen, None. Patients or Programs: A 55-year-old woman with a
POSTER PRESENTATIONS
high-grade partial tear and severe tendinosis of the right hamstring, causing edema and compression of the sciatic neurovascular bundle leading to unremitting and disabling sciatic nerve pain in the right LE. Program Description: This patient presented with 1 year of right-sided buttock pain that radiated down the posterior leg and into the groin. The intensity was 6-8/10, with symptoms of intense burning, aching, and stabbing sensations. Examination revealed a positive SLR on the right, normal lower limb strength, sensation, and reflexes. Pain was reproduced on palpation in the posterior buttock and thigh. MRI of the lumbar spine was normal. Fluoroscopically guided combined right sacroiliac joint and piriformis trigger point injection resulted in no pain relief. Diagnostic MR-neurogram of the sciatic nerve through the piriformis area and posterior buttock and thigh was then performed. Setting: Tertiary academic medical center outpatient musculoskeletal clinic. Results: The MR-neurogram revealed a high-grade partial tear and severe tendinosis of the right hamstring muscletendon origin at the level of the ischial tuberosity. There was associated edema that extended into the medial portion of the right sciatic neurovascular bundle with nerve hyperintensity. Discussion: Hamstring injuries are frequently identified in sports, with typical damage resulting in localized and selflimited posterior thigh pain. There are 3 classifications to grade the severity of the strain, with 2nd and 3rd degree involving partial tears to complete rupture. It is rare for a hamstring tear to cause the type of sciatic nerve involvement seen in this case. The fact that this patient presented with symptoms of chronic leg pain without a known hamstring injury only to be found with such an injury is even more rare. Conclusions: An occult chronic hamstring tear can present with atypical radicular-like symptoms. If the more common causes of sciatica such as herniated disk, sacroiliac injury, or piriformis syndrome are ruled out then consider an occult hamstring tear where inflammation and swelling can invade and compress the neurovascular bundle. Keywords: Rehabilitation, Radiculopathy, Sciatica, Hamstring tear.
Poster 154 Radiculopathy with L6 Transitional Vertebra: A Case Report. Miguel A. Coba, MD (UMDNJ-NJMS/KMRREC, Livingston, NJ); Jeffrey L. Cole, MD. Disclosures: M. A. Coba, None. Patients or Programs: A 53-year-old woman with low back pain. Program Description: The patient presents with bilateral lower back pain that radiates from her back down her legs with prolonged walking, standing, and sitting. She has not had any significant evaluation or treatment. Examination shows full lumbosacral ROM. Palpation showed no significant tenderness. She had 5/5 strength throughout and no sensory deficit. Reflexes were 2⫹ at the patella; Achilles
leg completed resolved. The patient’s lymphedema was treated with serial Unna boot applications. Discussion: Peroneal muscle and tendon disorders are relatively common but frequently under recognized. Diagnosis and treatment are based primarily on the history and physical examination. Our patient had left lower extremity lymphedema, which made this leg functionally longer than the right. This biomechanical imbalance put more stress on her right peroneal muscles during gait cycle due to compensatory attempt. Conclusions: Peroneal longus muscle overuse may cause pain in the lateral leg in a patient with contralateral lower extremity pathologies. Keywords: Rehabilitation, Cumulative trauma disorders, Lymphedema.
Poster 150 Plantar Fasciopathy Treated with Dynamic Splinting: A Randomized, Controlled Trial. Buck Willis, PhD (Landmark Medical, Austin, TX); Mathew M. John, DPM; Andres Perez, MD, DPM. Disclosures: B. Willis, Dynasplint Systems, Research grants. Objective: Plantar fasciopathy (or plantar fasciitis) is considered to be one of the most common foot pathologies affecting up to 2 million Americans each year, and the chief complaint is acute heel pain. Therapeutic protocols for this condition have included stretching exercises, corticosteroid injections, physical therapy, and foot orthoses, but a single modality has not been found to be universally effective. The purpose of this study is to determine the efficacy of stretching with dynamic splinting for treatment of plantar fasciitis. Design: Randomized, controlled trial. Participants: Sixty patients (76 feet) enrolled in this study from 4 different clinics across the U.S., and the duration of this study was 12 weeks. Interventions: All patients received NSAIDs, orthoses, and corticosteroid injections if needed. Thirty experimental patients also received dynamic splinting (ankle dorsiflexion) for nightly wear to obtain a low load, prolonged duration of stretch with dynamic tension. Main Outcome Measures: The dependent variable was change in the 100 point Plantar Fasciopathy Pain/Disability Scale which included a visual analog scale and questions regarding pain arising from ADLs. Results: A one-way analysis of variance with post-hoc ttests were performed, and there was a significant change in pain (Pre/Post) for the experimental patients (P ⬍ .0001, T ⫽ 13.6). The experimental patients displayed a 58% reduction in pain. There was not a significant difference in pain for the control patients, but there was a significant difference between the final (12-week) pain scores of experimental vs control patients (P ⬍ .0001). Conclusions: Dynamic splinting was effective for reducing the pain of plantar fasciopathy in this study.
Vol. 1, Iss. 9S, 2009
S169
Keywords: Rehabilitation, Pain, Dynasplint, Plantar fasciopathy.
Poster 151 Post-Arthroplasty Methylmethacrylate (PMMA) Hypersensitivity Reaction: A Case Report. Jignyasa Desai, (SBUH, Stony Brook, NY). Disclosures: J. Desai, None. Objective: Hypersensitivity reactions to implant componentry have been described with orthopedic surgical hardware, but cement sensitivity is relatively uncommon. Metals known as sensitizers are nickel, cobalt, and chromium, with the prevalence of metal sensitivity being 10-15%. All metals in vivo release ions that bind to proteins forming allergen complexes eliciting the hypersensitivity reaction. The nonbiodegradable polymeric biomaterial used for load bearing such as ultra high molecular weight polyethylene (UHMWPE) and methylmethacrylate cement (PMMA) are not easily chemically degraded in vivo and have rarely been investigated or even implicated as a source for immune hypersensitivity response. Patients or Programs: A 58-year-old woman with arthritis had a uni-compartmental knee replacement in 2002, followed by a total knee revision surgery in 2006. During her postoperative course, she developed inflammation, pain, and decreased range of motion. An extensive work-up ruled out hardware failure. Hypersensitivity testing for metallic ions was negative. This led to a subsequent investigation for a possible allergic reaction to cement products and polyethylene. She had sensitivity testing at Rush University Medical Center via lymphocyte proliferation assays. In vitro testing revealed a very strong proliferation response to PMMA and mild response to UHMWPE. Following these results, the patient had a non-cemented revision with removal of cement material on 10/08. She was then transferred to inpatient rehabilitation service. At 3-month follow-up, she had minimal pain and significant improvement in symptoms. Discussion: The rare potential of both metals and cement polymers to induce symptoms through allergy presents many problems for orthopedists. The specific laboratory tests such as the lymphokine macrophage inhibitor factor test (MIF) and lymphocyte transformation test (LTT) help to confirm these reactions. In patients who exhibit recurrent pain, inflammation, and aseptic loosening of implanted hardware, polymer cement, polyethylene, and metal hypersensitivity reactions should be considered in the differential diagnosis. Keywords: Methylmethacrylate, PMMA.
Poster 152 Prevalence of 25-Hydroxy Vitamin D Deficiency in the Acute Inpatient Rehabilitation Population. Anthony J. Pellicane, MD (Rehabilitation Institute of Chicago, Chicago, IL); Thomas Schnitzer, MD, PhD; Nicole M. Wysocki, MD.
S170
Disclosures: A. J. Pellicane, None. Objective: To assess the prevalence of 25-hydroxy vitamin D (25(OH)D) insufficiency and deficiency in the acute inpatient rehabilitation setting and to identify risk factors associated with low 25(OH)D levels Design: Retrospective cohort study. Setting: Academic acute rehabilitation hospital. Participants: 101 inpatients (36 consecutive from 9/1/ 2008 to 9/17/2008 and 65 convenience from 10/1/2008 to 12/1/2008) admitted to the 4th floor of an academic acute rehabilitation hospital. Interventions: None. Main Outcome Measures: 25(OH)D levels, patient demographics (age, sex, race), BMI, presenting diagnosis (fall with and without fracture), medication management on transfer. Results: 24.75% of subjects were 25(OH)D sufficient (32100 ng/mL) while the remainder of the population was as follows: mild insufficiency (20-32 ng/mL) 34.65%; moderate insufficiency (10-20 ng/mL) 34.65%; marked insufficiency (7-10 ng/mL) 4.95%; deficiency (⬍7 ng/mL) 0.99%. Blacks had significantly lower 25(OH)D levels compared to whites (27.86 ⫾ 12.74 vs 21.00 ⫾ 11.50; P ⫽ .03) while no significant difference was found between male and female 25(OH)D levels (24.23⫾11.20 vs 26.49 ⫾ 12.72; P ⫽ .29). 76.47% of subjects with the diagnosis of fracture were not transferred with 25(OH)D supplementation. Further, those subjects transferred with supplementation had a statistically higher 25(OH)D level compared to those not transferred with supplementation (33.48 ⫾ 12.81 vs 23.71 ⫾ 11.43; P ⫽ .0009). The 15 subjects sustaining fracture after fall had an insignificantly higher average 25(OH)D level than the 8 subjects sustaining no fracture after fall (25.56 ⫾ 14.18 vs 18.58 ⫾ 7.31; P ⫽ 0.18). Pearson’s correlation coefficient did not reveal a relationship between 25(OH)D levels and BMI, LOS, or age (r ⫽ -0.17, -0.14, 0.04, respectively). Conclusions: 75.24% of acute rehabilitation inpatients possessed insufficient or deficient 25(OH)D levels with blacks possibly being at higher risk for low 25(OH)D levels. A high percentage (76.47%) admitted to the acute rehabilitation setting with the primary diagnosis of fracture are transferred without 25(OH)D supplementation and those patients transferred without supplementation have a significantly lower average 25(OH)D level compared to those patients transferred with supplementation. Keywords: Rehabilitation, Musculoskeletal, Vitamin D, Bone.
Poster 153 Radiculopathy as a Manifestation of a Hamstring Tear: A Case Report. Halland Chen, MD (University of Miami Miller School of Medicine, Miami, FL); Andrew L. Sherman, MD. Disclosures: H. Chen, None. Patients or Programs: A 55-year-old woman with a
POSTER PRESENTATIONS
high-grade partial tear and severe tendinosis of the right hamstring, causing edema and compression of the sciatic neurovascular bundle leading to unremitting and disabling sciatic nerve pain in the right LE. Program Description: This patient presented with 1 year of right-sided buttock pain that radiated down the posterior leg and into the groin. The intensity was 6-8/10, with symptoms of intense burning, aching, and stabbing sensations. Examination revealed a positive SLR on the right, normal lower limb strength, sensation, and reflexes. Pain was reproduced on palpation in the posterior buttock and thigh. MRI of the lumbar spine was normal. Fluoroscopically guided combined right sacroiliac joint and piriformis trigger point injection resulted in no pain relief. Diagnostic MR-neurogram of the sciatic nerve through the piriformis area and posterior buttock and thigh was then performed. Setting: Tertiary academic medical center outpatient musculoskeletal clinic. Results: The MR-neurogram revealed a high-grade partial tear and severe tendinosis of the right hamstring muscletendon origin at the level of the ischial tuberosity. There was associated edema that extended into the medial portion of the right sciatic neurovascular bundle with nerve hyperintensity. Discussion: Hamstring injuries are frequently identified in sports, with typical damage resulting in localized and selflimited posterior thigh pain. There are 3 classifications to grade the severity of the strain, with 2nd and 3rd degree involving partial tears to complete rupture. It is rare for a hamstring tear to cause the type of sciatic nerve involvement seen in this case. The fact that this patient presented with symptoms of chronic leg pain without a known hamstring injury only to be found with such an injury is even more rare. Conclusions: An occult chronic hamstring tear can present with atypical radicular-like symptoms. If the more common causes of sciatica such as herniated disk, sacroiliac injury, or piriformis syndrome are ruled out then consider an occult hamstring tear where inflammation and swelling can invade and compress the neurovascular bundle. Keywords: Rehabilitation, Radiculopathy, Sciatica, Hamstring tear.
Poster 154 Radiculopathy with L6 Transitional Vertebra: A Case Report. Miguel A. Coba, MD (UMDNJ-NJMS/KMRREC, Livingston, NJ); Jeffrey L. Cole, MD. Disclosures: M. A. Coba, None. Patients or Programs: A 53-year-old woman with low back pain. Program Description: The patient presents with bilateral lower back pain that radiates from her back down her legs with prolonged walking, standing, and sitting. She has not had any significant evaluation or treatment. Examination shows full lumbosacral ROM. Palpation showed no significant tenderness. She had 5/5 strength throughout and no sensory deficit. Reflexes were 2⫹ at the patella; Achilles