- Email: [email protected]
Poster 152 Safety of ‘high dose’ botulinum toxin injection for spasticity in adults
ACADEMY .ANNUAL ASSEMBLY ABSTRACTS
thrombosis and pulmonary embolism, and was later found to have a lung mass. Physiatrists will care for increasing numbers of debilitated, disabled cancer patients, at great risk for thromboembolic disease. Other patients will present with recurrent thromboembolism, recalcitrant to warfarin therapy, in whom early diagnosis and treatment of both thromboembolism and malignancy will potentially decrease morbidity and mortality. Our favorable results with LMWH are encouraging. Further study to evaluate the efficacy of LMWH for prophylaxis and treatment of thromboembolism will lead to improved quality of life for patients with Trousseau's syndrome.
Poster 147 "Patient Self-Medication: Another Step Towards Independence." William P. Hedrick, MD (Riverside Medical Center, Kankakee, IL); Barbara A. Hamilton, RN, CRRN. The ability to self-medicate is a critical function for successful independent living. Failure to maintain a strict regimen at home often produces significant morbidity and mortality. Thirty patients on a general rehabilitation unit were included in a self-medication program that allowed each patient to progress through 3 levels characterized by increasing independence in this activity. Patients were selected for this program on the basis of cognitive and/or physical deficits present that would possibly prevent self-medication. This program was initiated at least 72 hours before discharge. A physical and neuropsychological screen was administered on the same day that the self-medication program was initiated. The physical component contained an assessment of the patient's ability to perform six identifiable steps involved in the process of taking medication. The psychological component was comprised of an assessment of cognitive tasks such as memory and executive functions found to be essential for self-medication. This study and its discussion will demonstrate how the resulting screen can be use to: (1) make more appropriate recommendations for inpatient self-medication training and education, home health assistance, additional family/social support, and altered disposition; and (2) isolate the cause for medication noncompliance in outpatients.
Poster 148 "Side Effects of Methylphenidate in Inpatient Rehabilitation," Karen P. Barr, MD (University of Cincinnati, Cincinnati, OH); Mark J. Goddard, MD; Michael O'DeH, MD. Studies have suggested that methylphenidate (MP) may be effective in the treatment of inattention and poor initiation in traumatically brain injured (TBI) and stroke patients. It is unclear, however, if side effects, particularly hypertension, limit the use of MP in these populations. We performed a retrospective chart review of 59 consecutive patients receiving MP during an inpatient rehabilitation stay; 35 (59%) were stroke patients, 20 (33%) were TBI patients, and 4 (8%) had other neurological diagnoses. The median age was 58 years (range 15 to 88.) Patients received doses from 5 to 30mg/day. MP was discontinued during the inpatient rehabilitation stay in 50% of the patients, but in only 7 patients because of side effects; in 6 patients because of increased impulsivity or agitation, and in one because of a very mild increase in hypertension (169/80). Other reasons for discontinuing the medication included questionable efficacy in 15, improvement beyond needing the medication in 4, and no identifiable reason in 2 patients. Furthermore, 34•59 (54%) patients in the study had a diagnosis of hypertension listed in the admission history or discharge summary. Of these patients, only 1 required an increase in antihypertensive medication while taking MP. In conclusion, these results suggest that MP is associated with few and relatively mild side effects in the setting of inpatient rehabilitation. Although monitoring is warranted, MP appears to be safe even in persons with a history of hypertension. Further research should address the risk benefit ratio of MP in CNS injury with little risk to patients.
Poster 149 "Efficacy of Amantidine in Olivopontocerebellar Atrophy Documented by Gait Analysis: A Case Report." Alasdair M. Goldstein, MD (University of Texas Health Science Center, San Antonio, TX); Robert D. McAnelly, MD; Douglas B. Barber, MD; Susan J. Rogers, Pharm.D.; Nicolas E. Walsh, MD. Olivopontocerebellar atrophy (OPCA) is a degenerative disease characterized by neuronal loss in the inferior olives, ventral pons, and cerebellar cortex, and is manifested by cerebellar ataxia with slow, chronic
1069
progression. The typical patient has a parkinsonian gait with flexed posture, hesitancy, slowness, short steps, and balance impairment. However, unlike the parkinsonian gait, the base is widened from ataxia. Efficacy of drug therapy for OPCA has relied on clinical observation, not on objective gait assessment. We present the case of a 40-year-old man with OPCA confirmed by magnetic resonance imaging. All central nervous system acting medications were discontinued. The patient was treated with amantidine hydrochloride titrated to a dose of 300rag/day without formal gait therapy. Vicon kinematic gait analysis was obtained immediately before and after the patient became theraputic on amantidine. Pre-amantidine and post-amantidine gait analysis demonstrated a more upright posture by joint angles and body center of mass closer to his base of support. There were minimal changes in velocity, cadence, percent of double support, stride length, lateral and vertical displacement of center of mass, and base of support. We conclude that our gait analysis data demonstrate objective improvement in parkinsonian features, but not in base of support from ataxia.
Poster 150 "Complications Among Patients Receiving Botulinum Toxin Injection for Spastic Hypertonia." William J. Hogan, MD (Baylor College of Medicine, Houston, TX); Stuart A. Yablon, MD. We investigated the rate of complications among patients receiving intramuscular botulinum toxin (BTXA) injection for spastic hypertonia. We treated 356 muscle groups in 106 consecutive patients. They included 59 elbow fexors, 95 wrist and finger flexors, 54 hip adductors, 42 hamstrings, 53 ankle plantarflexors, 33 ankle inverters, and 20 others. Among the patients treated, 4 encountered unanticipated adverse effects, including localized swelling in three patients and weakness impairing function in 1 patient (1.1%). Onset of swelling was noted within the first week after injection, and did not persist longer than 2 weeks. Weakness lasted approximately I month. These findings confirm that botulinum toxin injection in the treatment of dystonia appears safe.
Poster 151 "Successful Treatment of Bruxism Following Brain Injury with Botulinum Toxin-A." Jenny M. Lai, MD (Baylor College of Medicine, Houston, TX); Cindy H. Ivanhoe, MD. Bruxism, the rhythmic grinding of teeth usually seen during sleep, is often seen in traumatic brain injury patients. Its prevalence in the general population is 21%, but its incidence after brain injury is unknown. Untreated, bruxism causes masseter hypertrophy, headaches, temporal mandibular joint destructions, and total dental wear. We report complete resolution of bruxism treated with botulinum toxin-A. The patient is a 28-year-old man with no previous history of bruxism who sustained an anoxic brain injury secondary to cardiac arrest. Two months after the injury, the patient, demonstrating severe bruxism, was admitted to rehabilitation. On examination, there was heavy dental wear. The patient was injected with a total of 200 units of botulinum toxin-A to each masseter and temporalis. Total resolution of bruxism was seen 2 days postinjection. No complications were noted after the injections. On follow-up 3 months after injection, the patient remains free of bruxism. This case illustrates successful treatment of bruxism, and we propose that botulinum toxin be considered as a treatment for bruxism secondary to CNS injury. Further studies regarding muscle selection and dosages are warranted to elucidate the toxin's efficacy in this condition.
Poster 152 "Safety of 'High Dose' Botulinum Toxin Injection for Spasticity in Adults." Donna J. Roggenbuck, MD (Bayior College of Medicine, Houston, TX); Stuart A. Yablon, MD. Botulinum toxin A (BTXA) has been approved for treatment of blepharospasm, hemifacial spasm, and strabismus. Recent open-labeled and controlled studies suggest utility among patients with spastic hypertonia. The manufacturer has recommended a maximum dosage of 300 units, although clinical experience suggests that selected patients with severe spasticity and dystonia may require higher doses to achieve functional improvement. We reviewed the safety of "high-dose" (-->400 units) BTXA intramuscular injection among patients with severe spasticity. Ten patients, who previously tolerated 300 units or less of BTXA, subsequently underwent treatment with ->400 units (range: 400 to 530 units). Diagnoses among these patients included traumatic brain injury, stroke, cerebral palsy, anoxic encephalopathy, and transverse myelitis.
Arch Phys Med Rehabil Vol 76, November 1995
1070
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Dosage was determined by number of muscles treated and spasticity severity. Following treatment, no decline in functional status (ie, impairment in mobility, self-care task performance, or swallowing), was noted. Significant improvement in spasticity severity was observed among 8 patients. These findings suggest that BTXA dosage >-400 units may be safely administered in selected patients with spasticity. Implications of treatment with "higher" doses, including antibody formation and secondary nonresponsiveness, will be discussed.
Poster 153 "Suboptimal Response of Index Distal Phalanx Spastieity Following Treatment with Botulinum Toxin A: Indications for Precise Muscle Localization with Needle Stimulation." Donna J. Roggenbuck, MD (Baylor College of Medicine, Houston, TX); Stuart A. Yablon, MD. We reviewed the outcome of botulinum toxin A (BTXA) injections Ibr treatment of spasticity involving 95 wrist and finger flexor muscle groups among adults with acquired brain injury. Most demonstrated marked improvement in spasticity in all muscle groups treated. However, we have observed a suboptimal response in the index finger distal phalanx, as compared with adjacent digits, in four patients. Suboptimal treatment response was defined as no improvement in modified Ashworth Scale, or recurrence of pretreatment degree of spasticity in less than two months. In each patient, the FDP was identified as described by Delagi (1982), with electromyography employed for confirmation of intramuscular injection. Recent introduction of monopolar needle stimulation techniques, however, enhanced anatomic identification of the index FDP. This resulted in sustained reduction of spasticity in a patient who previously demonstrated suboptimal response at an identical BTXA dose. We propose that electrical stimulation be considered to improve precision with administration of intramuscular BTXA in the distal upper extremity musculature.
Prosthetic/Orthotic/Assistive Devices Poster 154 "Decreased Balance Performance in Cowboy Boots Compared With Tennis Shoes." J. Stephen Brecht (University of Washington, Seattie, WA); Michael W. Chang, MD, PhD; Robert Price, MSME; Justus F. Lehmann, MD. Footwear serves as a support for the body, providing static and dynamic stability. Improperly designed footwear can contribute to falls by altering the biomechanics of balance. This study was done to examine the relative balance performance of subjects wearing cowboy boots versus wearing tennis shoes when challenged with different accelerations. The end point was the highest acceleration at which the subject could maintain full foot contact with the platform. Twenty-seven healthy women, 18 to 40 years old, with shoe sizes between 6 to 9, were selected for a crossover trial. The subjects were challenged with various magnitudes of anterior acceleration on a MotionspecT M balance platform. Success was defined as keeping one's feet fiat for 2 of 3 tests at each level. The highest sustainable acceleration found for subjects in boots was 10.66 ± 6.20crrds 2 lower than those in tennis shoes (p < .001). A period effect was found that improved the results of the second footwear tested by 7.2 _+ 6.20cm/s 2 (p = .025). We conclude that cowboy boots produce a decreased balance performance compared with tennis shoes, and thus pose a risk for posterior fall. More work should be done to examine the specific features in the boot that contribute to this imbalance, and to find the body's kinematic adaptations to cowboy boots.
Poster 155 "Rehabilitation after Sacrectomy." David C. Thomas, MD (Mount Sinai Medical Center, New York, NY); Adam B. Stein, MD; Narayan Sundaresan, MD; Kristjan T. Ragnarsson, MD. The purpose of this study was to examine the functional outcomes of individuals after sacrum surgery. This is a population that is not well studied because survival rates are low and they are not traditional recipients of rehabilitation services. A total of 13 patients (7 men, 6 women) underwent this procedure in the period between 1990 and 1994; 6 patients survived and were interviewed for this study. The following findings emerged from this interview: (1) Three patients were seen by a physiatrist; (2) three patients had outpatient physical therapy; (3) four individuals had unimpaired Functional Independence Measure, ie, scores above 125, and the rest were minimally impaired, ie, scores = 118
Arch Phys Med Rehabil Vol 76, November 1995
and 115; (4) all patients reported a loss of sensation; (5) two patients experienced distal leg weakness; (6) two patients were incontinent of urine; (7) four patients require a bowel regimen; (8) four patients experienced a change in their sexual functioning. (9) Finally, 3 patients have pain of sufficient severity to interfere with function. This study indicates that the survivors of this surgery are left with diverse functional impairments that could be ameliorated with rehabilitation services. Unfortunately, these needed services are often not provided because the appropriate referrals are not made.
Poster 156 "Successful Use of Nonarticulating Lower Extremity Prostheses in a Geriatric Woman: A Case Report." Nelson V. Valena, MD (Baylor College of Medicine, Houston, TX); Susan J. Garrison, MD. Successful use of short, nonarticulating lower extremity prostheses (stubbles) has previously been reported in bilateral lower extremity amputees, typically adult men or children. This case report is of a 71year-old woman with a bilateral above knee amputation (AKA) secondary to peripheral vascular disease, who has achieved independent living by using stubbles. After initial inpatient rehabilitation she was independent with wheelchair mobility; however, she required moderate assistance for transfers and lower extremity dressing. She chose to be discharged to a family member's house because her house's bathroom was not wheelchair accessible. Over the next 4 months she gradually improved in upper extremity strength and endurance but continued to have difficulty with commode transfers and dressing after toileting. She was then readmitted to inpatient rehabilitation for stubby training with a personal goal of improving toileting activities. Significant gains were made; at discharge she was at supervision level for commode transfers and was independent with clothing management after toileting using a bodysuit with a front snap crotch. She could ambulate 100 feet using a pediatric walker. The patient then returned to her own house. The advantages of stubby use include improved balance and safety as well as more efficient energy expenditure. In this case, use of stubbles by a geriatric woman gave her bathroom accessibility and ease in independence in toileting activities and made it possible for to return to her own home.
Poster 157 "Functional Outcome of Quad Amputee Patients with End-Stage Renal Disease: A Review of Three Cases." Bradley S. Merritt, MD (Baylor College of Medicine, Houston, TX); Pare Glazener, OTR; Susan J. Garrison, MD. A rare but catastrophic complication of end-stage renal disease (ESRD) is amputation of all 4 limbs secondary to gangrene. We present 3 patients with ESRD who underwent quadruple amputation. The purpose of this case study is to investigate the functional benefit of inpatient rehabilitation for such amputee patients. Our large, tertiary acute care hospital admitted 497 patients with ESRD over a 5-year period. Of these, 36 underwent 51 amputation procedures, 41 involving the lower limbs, and 10 involving the upper limbs. Three patients had all 4 limbs amputated and were subsequently admitted to our acute inpatient rehabilitation center. Their mean functional independence measurement (FIM) scores on admission were 52 ___4 and on discharge 76 ___ 2. At discharge all 3 patients were able to perform sliding board transfers and self-propel wheelchairs modified with quad knobs and brake extenders. Each continued hemodialysis 3 times a week. All were independent with feeding using adaptive equipment, although 1 required cues. Two patients were able to write using dorsal wrist splints and pencil holders, and the third patient was able to use a speaker phone and lift lightweight objects with a left below-the-elbow hook type prosthesis. Our review of these 3 cases demonstrates that inpatient rehabilitation can improve functional scores in quadruple amputee patients with ESRD. A large multicenter study is warranted to obtain adequate sample size and generate a randomized controlled study.
Poster 158 "A New Dynamic Triceps Driven Orthosis: Achieving Elbow Flexion in Patients with Central Cord Syndrome with C5 Deficits." Brett D. Lawlor, MD (Mayo Clinic, Rochester, MN); Kathryn A. Stolp-Smith, MD. We present a unique orthosis developed for a 68-year-old man with traumatic central cord syndrome following a skiing accident. Motor examination demonstrated normal elbow extensors, wrist flexors and
thrombosis and pulmonary embolism, and was later found to have a lung mass. Physiatrists will care for increasing numbers of debilitated, disabled cancer patients, at great risk for thromboembolic disease. Other patients will present with recurrent thromboembolism, recalcitrant to warfarin therapy, in whom early diagnosis and treatment of both thromboembolism and malignancy will potentially decrease morbidity and mortality. Our favorable results with LMWH are encouraging. Further study to evaluate the efficacy of LMWH for prophylaxis and treatment of thromboembolism will lead to improved quality of life for patients with Trousseau's syndrome.
Poster 147 "Patient Self-Medication: Another Step Towards Independence." William P. Hedrick, MD (Riverside Medical Center, Kankakee, IL); Barbara A. Hamilton, RN, CRRN. The ability to self-medicate is a critical function for successful independent living. Failure to maintain a strict regimen at home often produces significant morbidity and mortality. Thirty patients on a general rehabilitation unit were included in a self-medication program that allowed each patient to progress through 3 levels characterized by increasing independence in this activity. Patients were selected for this program on the basis of cognitive and/or physical deficits present that would possibly prevent self-medication. This program was initiated at least 72 hours before discharge. A physical and neuropsychological screen was administered on the same day that the self-medication program was initiated. The physical component contained an assessment of the patient's ability to perform six identifiable steps involved in the process of taking medication. The psychological component was comprised of an assessment of cognitive tasks such as memory and executive functions found to be essential for self-medication. This study and its discussion will demonstrate how the resulting screen can be use to: (1) make more appropriate recommendations for inpatient self-medication training and education, home health assistance, additional family/social support, and altered disposition; and (2) isolate the cause for medication noncompliance in outpatients.
Poster 148 "Side Effects of Methylphenidate in Inpatient Rehabilitation," Karen P. Barr, MD (University of Cincinnati, Cincinnati, OH); Mark J. Goddard, MD; Michael O'DeH, MD. Studies have suggested that methylphenidate (MP) may be effective in the treatment of inattention and poor initiation in traumatically brain injured (TBI) and stroke patients. It is unclear, however, if side effects, particularly hypertension, limit the use of MP in these populations. We performed a retrospective chart review of 59 consecutive patients receiving MP during an inpatient rehabilitation stay; 35 (59%) were stroke patients, 20 (33%) were TBI patients, and 4 (8%) had other neurological diagnoses. The median age was 58 years (range 15 to 88.) Patients received doses from 5 to 30mg/day. MP was discontinued during the inpatient rehabilitation stay in 50% of the patients, but in only 7 patients because of side effects; in 6 patients because of increased impulsivity or agitation, and in one because of a very mild increase in hypertension (169/80). Other reasons for discontinuing the medication included questionable efficacy in 15, improvement beyond needing the medication in 4, and no identifiable reason in 2 patients. Furthermore, 34•59 (54%) patients in the study had a diagnosis of hypertension listed in the admission history or discharge summary. Of these patients, only 1 required an increase in antihypertensive medication while taking MP. In conclusion, these results suggest that MP is associated with few and relatively mild side effects in the setting of inpatient rehabilitation. Although monitoring is warranted, MP appears to be safe even in persons with a history of hypertension. Further research should address the risk benefit ratio of MP in CNS injury with little risk to patients.
Poster 149 "Efficacy of Amantidine in Olivopontocerebellar Atrophy Documented by Gait Analysis: A Case Report." Alasdair M. Goldstein, MD (University of Texas Health Science Center, San Antonio, TX); Robert D. McAnelly, MD; Douglas B. Barber, MD; Susan J. Rogers, Pharm.D.; Nicolas E. Walsh, MD. Olivopontocerebellar atrophy (OPCA) is a degenerative disease characterized by neuronal loss in the inferior olives, ventral pons, and cerebellar cortex, and is manifested by cerebellar ataxia with slow, chronic
1069
progression. The typical patient has a parkinsonian gait with flexed posture, hesitancy, slowness, short steps, and balance impairment. However, unlike the parkinsonian gait, the base is widened from ataxia. Efficacy of drug therapy for OPCA has relied on clinical observation, not on objective gait assessment. We present the case of a 40-year-old man with OPCA confirmed by magnetic resonance imaging. All central nervous system acting medications were discontinued. The patient was treated with amantidine hydrochloride titrated to a dose of 300rag/day without formal gait therapy. Vicon kinematic gait analysis was obtained immediately before and after the patient became theraputic on amantidine. Pre-amantidine and post-amantidine gait analysis demonstrated a more upright posture by joint angles and body center of mass closer to his base of support. There were minimal changes in velocity, cadence, percent of double support, stride length, lateral and vertical displacement of center of mass, and base of support. We conclude that our gait analysis data demonstrate objective improvement in parkinsonian features, but not in base of support from ataxia.
Poster 150 "Complications Among Patients Receiving Botulinum Toxin Injection for Spastic Hypertonia." William J. Hogan, MD (Baylor College of Medicine, Houston, TX); Stuart A. Yablon, MD. We investigated the rate of complications among patients receiving intramuscular botulinum toxin (BTXA) injection for spastic hypertonia. We treated 356 muscle groups in 106 consecutive patients. They included 59 elbow fexors, 95 wrist and finger flexors, 54 hip adductors, 42 hamstrings, 53 ankle plantarflexors, 33 ankle inverters, and 20 others. Among the patients treated, 4 encountered unanticipated adverse effects, including localized swelling in three patients and weakness impairing function in 1 patient (1.1%). Onset of swelling was noted within the first week after injection, and did not persist longer than 2 weeks. Weakness lasted approximately I month. These findings confirm that botulinum toxin injection in the treatment of dystonia appears safe.
Poster 151 "Successful Treatment of Bruxism Following Brain Injury with Botulinum Toxin-A." Jenny M. Lai, MD (Baylor College of Medicine, Houston, TX); Cindy H. Ivanhoe, MD. Bruxism, the rhythmic grinding of teeth usually seen during sleep, is often seen in traumatic brain injury patients. Its prevalence in the general population is 21%, but its incidence after brain injury is unknown. Untreated, bruxism causes masseter hypertrophy, headaches, temporal mandibular joint destructions, and total dental wear. We report complete resolution of bruxism treated with botulinum toxin-A. The patient is a 28-year-old man with no previous history of bruxism who sustained an anoxic brain injury secondary to cardiac arrest. Two months after the injury, the patient, demonstrating severe bruxism, was admitted to rehabilitation. On examination, there was heavy dental wear. The patient was injected with a total of 200 units of botulinum toxin-A to each masseter and temporalis. Total resolution of bruxism was seen 2 days postinjection. No complications were noted after the injections. On follow-up 3 months after injection, the patient remains free of bruxism. This case illustrates successful treatment of bruxism, and we propose that botulinum toxin be considered as a treatment for bruxism secondary to CNS injury. Further studies regarding muscle selection and dosages are warranted to elucidate the toxin's efficacy in this condition.
Poster 152 "Safety of 'High Dose' Botulinum Toxin Injection for Spasticity in Adults." Donna J. Roggenbuck, MD (Bayior College of Medicine, Houston, TX); Stuart A. Yablon, MD. Botulinum toxin A (BTXA) has been approved for treatment of blepharospasm, hemifacial spasm, and strabismus. Recent open-labeled and controlled studies suggest utility among patients with spastic hypertonia. The manufacturer has recommended a maximum dosage of 300 units, although clinical experience suggests that selected patients with severe spasticity and dystonia may require higher doses to achieve functional improvement. We reviewed the safety of "high-dose" (-->400 units) BTXA intramuscular injection among patients with severe spasticity. Ten patients, who previously tolerated 300 units or less of BTXA, subsequently underwent treatment with ->400 units (range: 400 to 530 units). Diagnoses among these patients included traumatic brain injury, stroke, cerebral palsy, anoxic encephalopathy, and transverse myelitis.
Arch Phys Med Rehabil Vol 76, November 1995
1070
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Dosage was determined by number of muscles treated and spasticity severity. Following treatment, no decline in functional status (ie, impairment in mobility, self-care task performance, or swallowing), was noted. Significant improvement in spasticity severity was observed among 8 patients. These findings suggest that BTXA dosage >-400 units may be safely administered in selected patients with spasticity. Implications of treatment with "higher" doses, including antibody formation and secondary nonresponsiveness, will be discussed.
Poster 153 "Suboptimal Response of Index Distal Phalanx Spastieity Following Treatment with Botulinum Toxin A: Indications for Precise Muscle Localization with Needle Stimulation." Donna J. Roggenbuck, MD (Baylor College of Medicine, Houston, TX); Stuart A. Yablon, MD. We reviewed the outcome of botulinum toxin A (BTXA) injections Ibr treatment of spasticity involving 95 wrist and finger flexor muscle groups among adults with acquired brain injury. Most demonstrated marked improvement in spasticity in all muscle groups treated. However, we have observed a suboptimal response in the index finger distal phalanx, as compared with adjacent digits, in four patients. Suboptimal treatment response was defined as no improvement in modified Ashworth Scale, or recurrence of pretreatment degree of spasticity in less than two months. In each patient, the FDP was identified as described by Delagi (1982), with electromyography employed for confirmation of intramuscular injection. Recent introduction of monopolar needle stimulation techniques, however, enhanced anatomic identification of the index FDP. This resulted in sustained reduction of spasticity in a patient who previously demonstrated suboptimal response at an identical BTXA dose. We propose that electrical stimulation be considered to improve precision with administration of intramuscular BTXA in the distal upper extremity musculature.
Prosthetic/Orthotic/Assistive Devices Poster 154 "Decreased Balance Performance in Cowboy Boots Compared With Tennis Shoes." J. Stephen Brecht (University of Washington, Seattie, WA); Michael W. Chang, MD, PhD; Robert Price, MSME; Justus F. Lehmann, MD. Footwear serves as a support for the body, providing static and dynamic stability. Improperly designed footwear can contribute to falls by altering the biomechanics of balance. This study was done to examine the relative balance performance of subjects wearing cowboy boots versus wearing tennis shoes when challenged with different accelerations. The end point was the highest acceleration at which the subject could maintain full foot contact with the platform. Twenty-seven healthy women, 18 to 40 years old, with shoe sizes between 6 to 9, were selected for a crossover trial. The subjects were challenged with various magnitudes of anterior acceleration on a MotionspecT M balance platform. Success was defined as keeping one's feet fiat for 2 of 3 tests at each level. The highest sustainable acceleration found for subjects in boots was 10.66 ± 6.20crrds 2 lower than those in tennis shoes (p < .001). A period effect was found that improved the results of the second footwear tested by 7.2 _+ 6.20cm/s 2 (p = .025). We conclude that cowboy boots produce a decreased balance performance compared with tennis shoes, and thus pose a risk for posterior fall. More work should be done to examine the specific features in the boot that contribute to this imbalance, and to find the body's kinematic adaptations to cowboy boots.
Poster 155 "Rehabilitation after Sacrectomy." David C. Thomas, MD (Mount Sinai Medical Center, New York, NY); Adam B. Stein, MD; Narayan Sundaresan, MD; Kristjan T. Ragnarsson, MD. The purpose of this study was to examine the functional outcomes of individuals after sacrum surgery. This is a population that is not well studied because survival rates are low and they are not traditional recipients of rehabilitation services. A total of 13 patients (7 men, 6 women) underwent this procedure in the period between 1990 and 1994; 6 patients survived and were interviewed for this study. The following findings emerged from this interview: (1) Three patients were seen by a physiatrist; (2) three patients had outpatient physical therapy; (3) four individuals had unimpaired Functional Independence Measure, ie, scores above 125, and the rest were minimally impaired, ie, scores = 118
Arch Phys Med Rehabil Vol 76, November 1995
and 115; (4) all patients reported a loss of sensation; (5) two patients experienced distal leg weakness; (6) two patients were incontinent of urine; (7) four patients require a bowel regimen; (8) four patients experienced a change in their sexual functioning. (9) Finally, 3 patients have pain of sufficient severity to interfere with function. This study indicates that the survivors of this surgery are left with diverse functional impairments that could be ameliorated with rehabilitation services. Unfortunately, these needed services are often not provided because the appropriate referrals are not made.
Poster 156 "Successful Use of Nonarticulating Lower Extremity Prostheses in a Geriatric Woman: A Case Report." Nelson V. Valena, MD (Baylor College of Medicine, Houston, TX); Susan J. Garrison, MD. Successful use of short, nonarticulating lower extremity prostheses (stubbles) has previously been reported in bilateral lower extremity amputees, typically adult men or children. This case report is of a 71year-old woman with a bilateral above knee amputation (AKA) secondary to peripheral vascular disease, who has achieved independent living by using stubbles. After initial inpatient rehabilitation she was independent with wheelchair mobility; however, she required moderate assistance for transfers and lower extremity dressing. She chose to be discharged to a family member's house because her house's bathroom was not wheelchair accessible. Over the next 4 months she gradually improved in upper extremity strength and endurance but continued to have difficulty with commode transfers and dressing after toileting. She was then readmitted to inpatient rehabilitation for stubby training with a personal goal of improving toileting activities. Significant gains were made; at discharge she was at supervision level for commode transfers and was independent with clothing management after toileting using a bodysuit with a front snap crotch. She could ambulate 100 feet using a pediatric walker. The patient then returned to her own house. The advantages of stubby use include improved balance and safety as well as more efficient energy expenditure. In this case, use of stubbles by a geriatric woman gave her bathroom accessibility and ease in independence in toileting activities and made it possible for to return to her own home.
Poster 157 "Functional Outcome of Quad Amputee Patients with End-Stage Renal Disease: A Review of Three Cases." Bradley S. Merritt, MD (Baylor College of Medicine, Houston, TX); Pare Glazener, OTR; Susan J. Garrison, MD. A rare but catastrophic complication of end-stage renal disease (ESRD) is amputation of all 4 limbs secondary to gangrene. We present 3 patients with ESRD who underwent quadruple amputation. The purpose of this case study is to investigate the functional benefit of inpatient rehabilitation for such amputee patients. Our large, tertiary acute care hospital admitted 497 patients with ESRD over a 5-year period. Of these, 36 underwent 51 amputation procedures, 41 involving the lower limbs, and 10 involving the upper limbs. Three patients had all 4 limbs amputated and were subsequently admitted to our acute inpatient rehabilitation center. Their mean functional independence measurement (FIM) scores on admission were 52 ___4 and on discharge 76 ___ 2. At discharge all 3 patients were able to perform sliding board transfers and self-propel wheelchairs modified with quad knobs and brake extenders. Each continued hemodialysis 3 times a week. All were independent with feeding using adaptive equipment, although 1 required cues. Two patients were able to write using dorsal wrist splints and pencil holders, and the third patient was able to use a speaker phone and lift lightweight objects with a left below-the-elbow hook type prosthesis. Our review of these 3 cases demonstrates that inpatient rehabilitation can improve functional scores in quadruple amputee patients with ESRD. A large multicenter study is warranted to obtain adequate sample size and generate a randomized controlled study.
Poster 158 "A New Dynamic Triceps Driven Orthosis: Achieving Elbow Flexion in Patients with Central Cord Syndrome with C5 Deficits." Brett D. Lawlor, MD (Mayo Clinic, Rochester, MN); Kathryn A. Stolp-Smith, MD. We present a unique orthosis developed for a 68-year-old man with traumatic central cord syndrome following a skiing accident. Motor examination demonstrated normal elbow extensors, wrist flexors and