- Email: [email protected]
Poster 155
ACADEMY ANNUAL ASSEMBLY ABSTRACTS wall). After reinnervation occurred a myoelectric prosthesis that used these electromyographic control sites was fit on the patient. Main Outcome Measures: Number of independent electromyographic control sites obtained and prosthetic function. Results: After reinnervation occurred, 4 separate electromyographic sites could be identified and 3 were usable for the control of the prosthesis. The musculocutaneous nerve-muscle graft was used to control elbow flexion. 2 independent sites were recordable from the median nerve-muscle graft and were used to control terminal device opening and closing. A radial nerve-muscle graft had a recordable signal, but it was small, had large electromyographic interference, and was difficult to use for controlling a prosthesis. The ulnar nerve to pectoralis muscle graft was nonviable. The patient was able to operate his terminal device, elbow, and, with cocontraction switching, a powered wrist. He reported that the control was much easier and better than with his previous externally powered prosthesis, which used shoulder touch-pad control. Conclusion: Nerve-muscle grafts can be used to develop additional myoelectric control signals for improved prosthesis control in high level upper-limb amputees. Key Words: Control; Electromyography; Myoelectric; Prosthesis; Rehabilitation. Poster 150 Vertical Movement of Center of Gravity in the Gait of Transfemoral Amputees. Sun G. Chung, MD, PhD (Seoul National University College of Medicine, Seoul, Republic of Korea); TaiRyoon Han, MD, PhD, e-mail: [email protected]. Disclosure: None. Objective: To evaluate whether vertical movement of center of gravity (COG) depends on stance-phase knee flexion in transfemoral prosthetic walking. Design: Case-control series. Setting: Hospital gait laboratory. Participants: 6 fully rehabilitated transfemoral amputees (5 men, 1 woman; age, 32.1⫾9.7y) and 10 healthy subjects (6 men, 4 women; age, 35.4⫾4.3y). Interventions: 3-dimensional gait analysis was done for each subject using an optoelectronic system. 13 reflective markers for walking trial at comfortable speed and 15 markers for static standing trial were used. Main Outcome Measures: COG was estimated from the 3 pelvic markers. Vertical movement of COG during the walking trial was expressed as the deviation from the vertical position of COG in the standing trial. 3-dimensional joint angles were calculated based on Cardan angles. Results: The COG moved in a sinusoidal pathway in both amputee and control groups. However, the amputee group showed asymmetric movement of COG at each limb stance phase. The vertical COG of the healthy limb stance phase (nadir, – 0.82⫾1.20cm; zenith, 2.30⫾1.53cm) was higher than that of the prosthetic limb stance phase (nadir, – 0.45⫾2.01cm; zenith, 0.21⫾1.94cm) (P⬍.05), even though the healthy limb showed much higher peak knee flexion (13.2°⫾5.3°) than the prosthetic limb (0.74°⫾0.7°) (P⬍.01) during the stance phase. The vertical COG of the prosthetic, as well as the healthy limb stance phase was higher than that of the normal control (nadir, –3.84⫾1.13cm; zenith, – 0.59⫾1.19cm) (P⬍.05). The excursion (zenith-nadir) of vertical COG in the prosthetic stance phase, was smaller than that of the healthy group (P⬍.05). Conclusions: Contrary to general belief, the knee flexion motion in stance phase may not contribute to drop the highest point of COG or to decrease the range of vertical excursion of COG in the gait of transfemoral amputees. Key Words: Artificial limbs; Gait; Rehabilitation. Poster 151 A New Prosthetic Arm and Terminal Device for Sports, Work, and Activities of Daily Living. William H. Craig, MD, MSc (University of Utah, Salt Lake City, UT), e-mail: [email protected]. Disclosure: None. Objective: To develop a new prosthetic arm and terminal device that is durable enough to withstand high-intensity sports, while being easily adapted for activities requiring a high degree of dexterity. Design: Basic research and development, prototype construction and testing. Setting: Outpatient prosthetic clinics. Participants: 5 unilateral above-elbow amputees. Intervention: Construction of prototype prosthetic components compatible with amputees’ current prostheses. Main Outcome Measure: Ability to participate in high-intensity sport; functional comparison to other currently available components. Results: This new prosthesis has several unique features. The elbow incorporates a shock absorber to combat the high impacts associated with sports, such as mountain biking and motocross. Elbow flexion and extension and internal and external rotation are adjustable. The terminal device consists of a flexion wrist, quick connect coupling, and a terminal bracket. The quick connect coupling allows voluntary release in the event of a crash, but the device will not release accidentally. The terminal device has 4 degrees of freedom, permitting a high degree of adjustability. The terminal bracket is easily exchanged and, in stock form, can accept tools, utensils, and other objects that have had a 1.5-in handle molded around them. A large contact area provides a secure grip. Conclusions: This new prosthesis has significant advantages over currently available componentry. To our knowledge, these are the only upper-extremity components durable enough to withstand very high-intensity activities. The flexion wrist and terminal bracket offer twice the degrees of freedom of other terminal devices, while providing a much stronger grip. Tools and other objects are easily modified to be compatible with the terminal device. Key Words: Amputee; Artificial Limbs; Rehabilitation.
Poster 152 Sagittal Plane Biomechanics and Low Back Pain in Transfemoral Amputees. Ali Shakir, MD (University of Washington, Seattle, WA); Karen Barr, MD; Ava Segal, BAS; Michael Orendurff, MS; Janice Pecoraro, RN; Joseph Czerniecki, MD, MS, e-mail: [email protected]. Disclosure: None. Objectives: To document the extent of static lumbar lordosis and dynamic lumbar spine motion in the sagittal plane in transfemoral amputees and to determine whether excessive lumbar lordosis and excessive sagittal plane spine motion are related to low back pain (LBP) in transfemoral amputees. Design: A cross-sectional observational study. Setting: Motion analysis laboratory at a Veterans Affairs tertiary care facility. Participants: 6 ambulatory transfemoral amputees with a history of significant chronic LBP (CLBP) beginning after amputation and 3 ambulatory transfemoral amputees without history of CLBP since amputation. Interventions: Not applicable. Main
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Outcome Measures: L1-S1 Cobb angle from a lateral upright radiograph. Peak lumbar sagittal plane flexion and extension measured by a video-based motion analysis system. Results: The mean L1-S1 Cobb angle ⫾ SD (range) were 62°⫾10° (44°–77°) for transfemoral amputees with LBP and 58°⫾3° (54°– 61°) for transfemoral amputees without LBP. The mean maximum degrees of flexion (range) were 4.2°⫾5.9° (– 8.0° to 13.7°) for transfemoral amputees with LBP and 3.0°⫾3.4° (–2.7° to 8.8°) for transfemoral amputees without LBP. The mean maximum degrees of extension (range) were –5.7°⫾6.4° (–21.0° to 2.3°) for transfemoral amputees with LBP and –5.9°⫾4.1° (–12.1° to 1.0°) for transfemoral amputees without LBP. Conclusions: The L1-S1 Cobb angle showed a significant relationship with LBP in transfemoral amputees (P⬍.0313). The most extreme L1-S1 Cobb angles were seen in transfemoral amputees with LBP. There was no difference between the groups in either maximum lumbar flexion or extension (P⬍0.3). From this data, static lumbar angles appear to be more related to LBP than the sagittal flexion and extension range of dynamic lumbar motion during gait; perhaps it is not the extremes of sagittal plane lumbar motion that place this population at risk. However, type II error cannot be excluded. Key Words: Amputation; Gait; Low back pain; Rehabilitation. Poster 153 Knee Disarticulation in a Patient With an Ipsilateral Girdlestone Hip: A Case Report. Erasmus G. Morfe, DO (Mayo Clinic, Rochester, MN); Jeff Thompson, MD; Steve Amundson, CPO, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care medical center. Patient: A 66-year-old man with spindle cell sarcoma of the right lower-extremity requiring amputation. Case Description: The patient presented for preoperative consultation to an outpatient amputee clinic on an appropriate level of amputation to achieve best functional outcome. He had a Girdlestone hip on the ipsilateral side of the sarcoma. Due to the proximity of the sarcoma to the knee, a below-knee amputation was not an option. The patient suffered from multiple comorbidities, including diabetes, peripheral vascular disease, and degenerative joint disease. Preoperatively, the patient was an independent household ambulator, but used a wheelchair for longer distances. He was independent with transfers, toileting, and activities of daily living. The patient’s goal was to continue ambulation after the amputation. We recommended a knee disarticulation for the following reasons: a longer residual limb provides a better base of support for sitting, a longer lever arm is better for transfers, and less energy is expended during gait as compared with hip disarticulation or above-knee amputation. Regarding prosthetic fitting issues, the knee disarticulation would provide greater stability with the longer residual limb and partial distribution of weight bearing at the femoral condyles. Assessment/Results: The patient underwent a knee disarticulation without complication. The prosthesis included an ischial containment socket with a manual locking knee. Inpatient rehabilitation was planned for gait training. Discussion: This is the first reported case, to our knowledge, of a knee disarticulation with an ipsilateral Girdlestone hip. Conclusion: This exemplifies the importance of physiatric preoperative functional assessment, with attention to patient goals and consideration of prosthetic-fitting issues. Key Words: Amputee; Orthopedics; Rehabilitation. Poster 154 Quantitative Electromyographic Analysis of Disk Unloader Brace. Vijay Vad, MD; Michael S. Lee, MD (Hospital for Special Surgery, New York, NY), e-mail: [email protected]. Disclosure: None. Objective: To determine if the Disk Unloader brace is effective in reducing intradiskal pressure because there is a strong correlation between lumbar paraspinal activity and intradiskal pressure. Design: Descriptive crossover study. Setting: Academic-affiliated private physiatry practice. Participants: 10 healthy volunteers (7 women; 3 men; avg age, 39y; range, 26 – 46y). Interventions: We used 10 healthy volunteers to measure lumbar paraspinal activity at L5 using a Cadwell quantitative electromyography system. After completing reliability and reproducibility testing, which showed a margin of error of 7%, 10 volunteers were measure for quantitative electromyographic activity at the L5 paraspinal level in full lumbar flexion without the Disk Unloader brace 3 times and the results were averaged. The same quantitative electromyographic testing was done in full flexion with the Disk Unloader brace on at the L5 paraspinal level 3 times and the results were also averaged. For 5 of the 10 patients, we performed the test first with the Disk Unloader brace on whereas for the rest, the test was performed first without the brace. Main Outcome Measure: Quantitative electromyographic activity at the L5 paraspinal level in full lumbar flexion. Results: The average area under the curve (AUC) score was 173⫾27.1mV at the L5 paraspinal for the 10 healthy subjects without the Disk Unloader brace. The average AUC score was 102⫾19.6mV at the L5 paraspinal for 10 healthy subjects with the Disk Unloader brace. There was a statistically significant (P⬍.05) reduction in quantitative paraspinal activity of 41% with the Disk Unloader brace on. Conclusions: We conclude that the Disk Unloader brace is effective in reducing quantitative electromyographic lumbar paraspinal activity and therefore intradiskal pressures. Key Words: Brace; Electromyography; Rehabilitation.
Poster 155 Prosthetic Fitting for a Patient With a Traumatic Above-Knee Amputation Complicated by Sacroiliac Joint Dysfunction: A Case Report. Darren C. Rosenberg, DO (Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, MA); Dorothy D. Aiello, PT, MS, e-mail: [email protected]. Disclosure: None. Setting: Outpatient rehabilitation center. Patient: A 32-year-old woman after left traumatic above-knee amputation. This patient had been a pedestrian who was struck by a car and was thrown through a store window. Case Description: The patient presented 10 weeks after amputation with a complaint of inability to use her prosthesis because of severe groin pain. She reported that her prior therapist had the prosthetist adjust the prosthesis multiple times, but the groin pain did not abate. Her pain did not appear to relate to a prosthetic fitting issue. The patient’s pelvis was assessed and her left posterior superior iliac spine was 11/2in higher than the right side. Her left anterior superior iliac spine was lower and outflared excessively. She had a positive standing forward flexion test. Her left
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quadratus lumborum had markedly increased tissue density and was shortened. Assessment/ Results: These findings were consistent with left anterior ilial rotation, out-flare, and up-slip. Intervention: To test the whether the pain was due to the pelvic dysfunction and not the prosthetic fitting, prosthetic modifications were held and the pelvis was treated with manual medicine techniques. Treatment included inferior mobilization with traction, muscle energy, strain and counterstrain, and posterior mobilization. Results: The patient’s anterior groin pain resolved after manual medicine treatment. No further prosthetic modifications were needed. Discussion: To our knowledge, this is the first published case of treatment of sacroiliac dysfunction after posttraumatic amputation. For this patient, proper prosthetic fitting was impaired because of pelvic dysfunction. We also noted some minor pelvic issues in other patients after traumatic amputations. Conclusion: A pelvic assessment should be done in all patients who have had traumatic amputations to optimize prosthetic fit and function. Key Words: Amputation; Pelvic pain; Rehabilitation. Poster 156 Ambulation After Bilateral Below-Knee Amputations Secondary to Necrotizing Fasciitis: A Case Report. Krishna P. Bhat, MD (Rush-Presbyterian-St. Luke’s Medical Center, Chicago, IL); Christopher Reger, MD; Henry R. Caoili, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care hospital. Patient: A 57-year-old woman with bilateral below-knee amputations secondary to necrotizing fasciitis. Case Description: This patient was initially admitted with respiratory distress, and she eventually developed bilateral lower-extremity open wounds caused by disseminated intravascular coagulation. Subsequently, she underwent bilateral belowknee amputations secondary to necrotizing fasciitis. Multiple skin grafts were done, with 100% grafting of both amputation stumps. She was informed that she would never be able to ambulate again. At a later date, she had right elbow capsular release surgery for flexion contracture. Her right index to ring proximal interphalangeal joints had a 30° to 40° contracture, however, she was able to make a partial fist. 10 months after her amputations, she commenced comprehensive inpatient prosthetic gait training and skin care education. A total-surface bearing hydrostatic socket prosthesis with extra-thick silicone gel liners was issued for optimal shear force reduction and suspension. A single-axis dynamic foot with soft heel describes the foot component. Assessment/Results: 3 weeks after admission, the patient was able to transfer and ambulate 50ft with supervision, and she required minimal to moderate assist for donning and doffing her prosthesis. Only 1 incident of skin breakdown occurred since surgery. The patient followed up regularly in clinic and she continued to improve. Currently, the patient is ambulating independently with a cane, and she manages her prosthesis with complete independence. Discussion: This is the first reported case, to our knowledge, of successful ambulation after bilateral below-knee amputations secondary to necrotizing fasciitis requiring complete skin grafting of residual limbs. Conclusions: This case illustrates that meticulous skin care in combination with an effective prosthetic device in skin grafted amputation stumps can lead to results that exceed expectation. Key Words: Fasciitis, necrotizing; Leg prosthesis; Rehabilitation. Poster 157 The Validity and Reliability of the SENSERite System: A Preliminary Evaluation. Joshua H. You, PT, PhD (University of Virginia, Hampton, VA), e-mail: [email protected]. Disclosure: None. Objectives: To establish the concurrent validity and reliability of the SENSERite computerized ankle proprioception analysis system and to determine and compare proprioceptive acuity (thresholds). Design: Within-groups, repeated-measures design with randomized sequence and control group. Setting: A university research laboratory. Participants: 10 healthy younger adults; 41 older adults (22 nonfallers, 14 fallers, 3 adults with stroke, 1 with peripheral neuropathy [PN], 1 with Parkinson’s disease [PD]). Interventions: Instrument validity was determined by comparing the system’s performance with a validated goniometer measure. Instrument reliability was determined by repeatedly measuring the established angles for the 5 different positions: neutral, inversion, eversion, plantarflexion, and dorsiflexion. In addition, proprioceptive acuities of the participants were measured by the SENSERite system. Data were analyzed using descriptive statistics, intraclass correlation coefficients (ICCs), and independent t tests. Main Outcome Measures: Composite proprioceptive acuity thresholds from the 5 position sense tests. Results: Excellent clinical goniometer and SENSERite correlation (ICC⫽.99, P⬍.0001) was found. The SENSERite system was reliable (ICC⫽1.0, P⬍.0001). A significant difference in proprioceptive acuity threshold was found between the younger adults and the older adults. No significant difference in proprioceptive acuity threshold was observed between nonfallers and fallers. The nonfallers’ proprioceptive acuity threshold was similar to that of stroke patients, whereas both the adult with PD and the adult with PN showed substantially increased thresholds. Conclusions: The SENSERite system is a valid and reliable instrument to measure ankle proprioception in the normal and pathologic populations. Persons with either a history of falls or neurologic impairments may or may not show diminished ankle proprioception. Key Words: Proprioception; Rehabilitation; Reproducibility of results.
Rehabilitation Topics Poster 158 Teaching Residents in Rehabilitation to Communicate Bad News to Their Patients. Thomas S. Kiser, MD, MPH (University of Arkansas for Medical Sciences, Little Rock, AR); Florian S. Keplinger, MD; Patricia O’Sullivan, PhD; Jeanne Heard, MD, e-mail: [email protected]. Disclosure: None. Objective: To determine if an educational program can improve a physical medicine and rehabilitation resident’s ability to deliver bad news to patients. Design: Preeducation and posteducation assessment of residents’ communication ability with a standardized patient. Setting: Clinical skills center. Participants: 10 rehabilitation residents (PGY-2 to PGY-4). Intervention: Preeducation experience with a standardized patient with a simulated C6 complete spinal cord injury
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followed by a 1-hour educational lecture using the American Medical Association’s (AMA) Education for Physicians on End-of-Life Care (EPEC) program on communicating bad news to patients. This was followed by a posteducation experience with the original standardized patient. The person monitoring the session then provided feedback to the resident before a novel standardized patient, who simulated a mother of a patient who had been in a persistent vegetative state for over a year. The monitor and the standardized patient used a standardized checklist to assess the resident’s performance. Main Outcome Measures: Monitor checklist of 8 items: score 1 if done and 0 if not done (max⫽8, min⫽0). Standardized patient checklist of 7 items rated on a Likert scale: excellent, 5; very good, 4; good, 3; fair, 2; poor, 1 (max⫽35, min⫽7). Results: Monitor checklist: the preeducation mean was 2.9 (95% confidence interval [CI], 1.81–3.99); the posteducation mean was 5.4 (95% CI, 4.377– 6.423); and the novel case mean was 5.9 (95% CI, 5.044 – 6.756) (multivariate test [Hotelling trace], P⫽.002). Standardized patient checklist: the preeducation mean was 31.4 (95% CI, 29.609 –33.191); the posteducation mean was 34.2 (95% CI, 33.636 –34.764); and the novel case mean was 27.9 (95% CI, 25.577–30.223) (multivariate test [Hotelling trace], P⫽.001). Resident survey (5-point scale): worthwhile educational experience was 4.9; I will use what I learned in the future was 4.7; and I would participate again if not compensated was 4.4. Conclusions: A 1-hour lecture on delivering bad news to patients using the AMA’s EPEC program produced a significant change in resident behavior in interaction with a standardized patient. Residents felt that it was a worthwhile educational experience that would help them in their future practice. Key Words: Communication; Education; Rehabilitation.
Poster 159 Contact Precautions in a Rehabilitation Hospital. Steven Lewis, MD (Marianjoy Rehabilitation Hospital, Wheaton, IL); Barbara Lewis, MS; Estelle Zanotti, RN; Jan Jensen, RN; Cara Coomer, RN; Nelson Escobar, MD, e-mail: [email protected]. Disclosure: None. Objectives: To develop a modification of the US Centers for Disease Control and Prevention (CDC) contact precautions applicable to the rehabilitation environment and to determine its impact on implementation and nosocomial infection rates of specific pathogens. Design: Descriptive epidemiologic study. Setting: 110-bed free-standing comprehensive inpatient rehabilitation teaching hospital. Participants: All hospital staff and inpatients. Interventions: An infection prevention program, based on CDC contact precautions directed at Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE), was implemented. This program incorporated the following elements: new definitions for stop and start of precautions; establishment of criteria for private rooms and protective equipment utilization; institution of precautions within therapy departments; emphasis on housekeeping for prevention of environmental contamination; initiation of door-mounted isolation supplies; implementation of alcohol-based waterless hand hygiene; staff education; computer tracking of patients in isolation; surveillance of isolation implementation and compliance; and selective use of eradication therapy. Main Outcome Measures: The ability of staff to comprehend, implement, and adhere to the prevention program; efficiency in isolation resource utilization; and nosocomial rates for Clostridium difficile, MRSA, and VRE. Results: Staff demonstrated better understanding of precaution implementation and improved compliance with more reliable private room and protective equipment use. There was less disruption of the rehabilitation process. During the first year of program phase-in, the percentage of nosocomial infections decreased as follows: Clostridium difficile, 48.7%; MRSA, 69.5%; and VRE, 64.1%. Conclusion: We present a modification of the CDC contact precautions implementation specific for the rehabilitation environment that is more easily understood, more consistently and effectively implemented by staff, and that effectively prevents nosocomial transmission of epidemiologically important pathogens. Key Words: Epidemiology; Infection control; Nosocomial infections; Rehabilitation.
Poster 160 Dysphagia After West Nile Virus: A Report of 5 Cases. Nelson Escobar, MD (Marianjoy Rehabilitation Hospital, Wheaton, IL); Norman Aliga, MD; Richard Krieger, MD; Vasilios Stambolis, MD; Susan L. Brady, MS, e-mail: [email protected]. Disclosure: None. Setting: Free-standing rehabilitation hospital. Patients: 5 consecutive patients (3 men, 2 women; mean age, 57.20y; range, 34 –72y) who presented with dysphagia after West Nile virus (WNV) infection. Case Descriptions: All patients presented with their initial symptoms in August and September 2002. All diagnoses were confirmed by lumbar puncture. 3 patients were initially not eating by mouth and required nonoral nutritional support. 3 patients experienced pneumonia; 2 patients required mechanical ventilation; and 1 patient required a tracheotomy tube. Assessment/ Results: Swallowing therapy focused on compensatory swallowing safety strategies and swallowing rehabilitation and strengthening exercises. Videofluoroscopy was completed in 4 of the patients, with aspiration being present in 3 patients. Days from onset to discharge ranged from 24 to 183 (mean ⫾ SD, 85.8⫾69.1d). The patient who required mechanical ventilation, a tracheotomy tube, and a gastrostomy tube had the longest length of stay. All patients were eventually able to return to oral feedings after swallowing therapy during their inpatient rehabilitation stay without requiring any supplemental tube feedings. All patients were weaned from the ventilators and tracheotomy tube. 4 of the 5 patients were receiving a regular diet of thin liquids and bread at discharge. Discussion: Physicians should recognize that dysphagia is a potential complication after WNV infection and should provide appropriate direction for the team management of dysphagia with these patients. Conclusion: Functional gains can be made for dysphagia after WNV infection. Key Words: Dysphagia; Rehabilitation; West Nile virus.
Poster 161 Axonal Neuropathy of the Extremities After West Nile Virus: A Case Report. Vasilios Stambolis, MD (Marianjoy Rehabilitation Hospital, Wheaton, IL); Colleen Peterson, MPT; Deepthi Saxena, MD, e-mail: [email protected]. Disclosure: None.
Poster 152 Sagittal Plane Biomechanics and Low Back Pain in Transfemoral Amputees. Ali Shakir, MD (University of Washington, Seattle, WA); Karen Barr, MD; Ava Segal, BAS; Michael Orendurff, MS; Janice Pecoraro, RN; Joseph Czerniecki, MD, MS, e-mail: [email protected]. Disclosure: None. Objectives: To document the extent of static lumbar lordosis and dynamic lumbar spine motion in the sagittal plane in transfemoral amputees and to determine whether excessive lumbar lordosis and excessive sagittal plane spine motion are related to low back pain (LBP) in transfemoral amputees. Design: A cross-sectional observational study. Setting: Motion analysis laboratory at a Veterans Affairs tertiary care facility. Participants: 6 ambulatory transfemoral amputees with a history of significant chronic LBP (CLBP) beginning after amputation and 3 ambulatory transfemoral amputees without history of CLBP since amputation. Interventions: Not applicable. Main
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Outcome Measures: L1-S1 Cobb angle from a lateral upright radiograph. Peak lumbar sagittal plane flexion and extension measured by a video-based motion analysis system. Results: The mean L1-S1 Cobb angle ⫾ SD (range) were 62°⫾10° (44°–77°) for transfemoral amputees with LBP and 58°⫾3° (54°– 61°) for transfemoral amputees without LBP. The mean maximum degrees of flexion (range) were 4.2°⫾5.9° (– 8.0° to 13.7°) for transfemoral amputees with LBP and 3.0°⫾3.4° (–2.7° to 8.8°) for transfemoral amputees without LBP. The mean maximum degrees of extension (range) were –5.7°⫾6.4° (–21.0° to 2.3°) for transfemoral amputees with LBP and –5.9°⫾4.1° (–12.1° to 1.0°) for transfemoral amputees without LBP. Conclusions: The L1-S1 Cobb angle showed a significant relationship with LBP in transfemoral amputees (P⬍.0313). The most extreme L1-S1 Cobb angles were seen in transfemoral amputees with LBP. There was no difference between the groups in either maximum lumbar flexion or extension (P⬍0.3). From this data, static lumbar angles appear to be more related to LBP than the sagittal flexion and extension range of dynamic lumbar motion during gait; perhaps it is not the extremes of sagittal plane lumbar motion that place this population at risk. However, type II error cannot be excluded. Key Words: Amputation; Gait; Low back pain; Rehabilitation. Poster 153 Knee Disarticulation in a Patient With an Ipsilateral Girdlestone Hip: A Case Report. Erasmus G. Morfe, DO (Mayo Clinic, Rochester, MN); Jeff Thompson, MD; Steve Amundson, CPO, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care medical center. Patient: A 66-year-old man with spindle cell sarcoma of the right lower-extremity requiring amputation. Case Description: The patient presented for preoperative consultation to an outpatient amputee clinic on an appropriate level of amputation to achieve best functional outcome. He had a Girdlestone hip on the ipsilateral side of the sarcoma. Due to the proximity of the sarcoma to the knee, a below-knee amputation was not an option. The patient suffered from multiple comorbidities, including diabetes, peripheral vascular disease, and degenerative joint disease. Preoperatively, the patient was an independent household ambulator, but used a wheelchair for longer distances. He was independent with transfers, toileting, and activities of daily living. The patient’s goal was to continue ambulation after the amputation. We recommended a knee disarticulation for the following reasons: a longer residual limb provides a better base of support for sitting, a longer lever arm is better for transfers, and less energy is expended during gait as compared with hip disarticulation or above-knee amputation. Regarding prosthetic fitting issues, the knee disarticulation would provide greater stability with the longer residual limb and partial distribution of weight bearing at the femoral condyles. Assessment/Results: The patient underwent a knee disarticulation without complication. The prosthesis included an ischial containment socket with a manual locking knee. Inpatient rehabilitation was planned for gait training. Discussion: This is the first reported case, to our knowledge, of a knee disarticulation with an ipsilateral Girdlestone hip. Conclusion: This exemplifies the importance of physiatric preoperative functional assessment, with attention to patient goals and consideration of prosthetic-fitting issues. Key Words: Amputee; Orthopedics; Rehabilitation. Poster 154 Quantitative Electromyographic Analysis of Disk Unloader Brace. Vijay Vad, MD; Michael S. Lee, MD (Hospital for Special Surgery, New York, NY), e-mail: [email protected]. Disclosure: None. Objective: To determine if the Disk Unloader brace is effective in reducing intradiskal pressure because there is a strong correlation between lumbar paraspinal activity and intradiskal pressure. Design: Descriptive crossover study. Setting: Academic-affiliated private physiatry practice. Participants: 10 healthy volunteers (7 women; 3 men; avg age, 39y; range, 26 – 46y). Interventions: We used 10 healthy volunteers to measure lumbar paraspinal activity at L5 using a Cadwell quantitative electromyography system. After completing reliability and reproducibility testing, which showed a margin of error of 7%, 10 volunteers were measure for quantitative electromyographic activity at the L5 paraspinal level in full lumbar flexion without the Disk Unloader brace 3 times and the results were averaged. The same quantitative electromyographic testing was done in full flexion with the Disk Unloader brace on at the L5 paraspinal level 3 times and the results were also averaged. For 5 of the 10 patients, we performed the test first with the Disk Unloader brace on whereas for the rest, the test was performed first without the brace. Main Outcome Measure: Quantitative electromyographic activity at the L5 paraspinal level in full lumbar flexion. Results: The average area under the curve (AUC) score was 173⫾27.1mV at the L5 paraspinal for the 10 healthy subjects without the Disk Unloader brace. The average AUC score was 102⫾19.6mV at the L5 paraspinal for 10 healthy subjects with the Disk Unloader brace. There was a statistically significant (P⬍.05) reduction in quantitative paraspinal activity of 41% with the Disk Unloader brace on. Conclusions: We conclude that the Disk Unloader brace is effective in reducing quantitative electromyographic lumbar paraspinal activity and therefore intradiskal pressures. Key Words: Brace; Electromyography; Rehabilitation.
Poster 155 Prosthetic Fitting for a Patient With a Traumatic Above-Knee Amputation Complicated by Sacroiliac Joint Dysfunction: A Case Report. Darren C. Rosenberg, DO (Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, MA); Dorothy D. Aiello, PT, MS, e-mail: [email protected]. Disclosure: None. Setting: Outpatient rehabilitation center. Patient: A 32-year-old woman after left traumatic above-knee amputation. This patient had been a pedestrian who was struck by a car and was thrown through a store window. Case Description: The patient presented 10 weeks after amputation with a complaint of inability to use her prosthesis because of severe groin pain. She reported that her prior therapist had the prosthetist adjust the prosthesis multiple times, but the groin pain did not abate. Her pain did not appear to relate to a prosthetic fitting issue. The patient’s pelvis was assessed and her left posterior superior iliac spine was 11/2in higher than the right side. Her left anterior superior iliac spine was lower and outflared excessively. She had a positive standing forward flexion test. Her left
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ACADEMY ANNUAL ASSEMBLY ABSTRACTS
quadratus lumborum had markedly increased tissue density and was shortened. Assessment/ Results: These findings were consistent with left anterior ilial rotation, out-flare, and up-slip. Intervention: To test the whether the pain was due to the pelvic dysfunction and not the prosthetic fitting, prosthetic modifications were held and the pelvis was treated with manual medicine techniques. Treatment included inferior mobilization with traction, muscle energy, strain and counterstrain, and posterior mobilization. Results: The patient’s anterior groin pain resolved after manual medicine treatment. No further prosthetic modifications were needed. Discussion: To our knowledge, this is the first published case of treatment of sacroiliac dysfunction after posttraumatic amputation. For this patient, proper prosthetic fitting was impaired because of pelvic dysfunction. We also noted some minor pelvic issues in other patients after traumatic amputations. Conclusion: A pelvic assessment should be done in all patients who have had traumatic amputations to optimize prosthetic fit and function. Key Words: Amputation; Pelvic pain; Rehabilitation. Poster 156 Ambulation After Bilateral Below-Knee Amputations Secondary to Necrotizing Fasciitis: A Case Report. Krishna P. Bhat, MD (Rush-Presbyterian-St. Luke’s Medical Center, Chicago, IL); Christopher Reger, MD; Henry R. Caoili, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care hospital. Patient: A 57-year-old woman with bilateral below-knee amputations secondary to necrotizing fasciitis. Case Description: This patient was initially admitted with respiratory distress, and she eventually developed bilateral lower-extremity open wounds caused by disseminated intravascular coagulation. Subsequently, she underwent bilateral belowknee amputations secondary to necrotizing fasciitis. Multiple skin grafts were done, with 100% grafting of both amputation stumps. She was informed that she would never be able to ambulate again. At a later date, she had right elbow capsular release surgery for flexion contracture. Her right index to ring proximal interphalangeal joints had a 30° to 40° contracture, however, she was able to make a partial fist. 10 months after her amputations, she commenced comprehensive inpatient prosthetic gait training and skin care education. A total-surface bearing hydrostatic socket prosthesis with extra-thick silicone gel liners was issued for optimal shear force reduction and suspension. A single-axis dynamic foot with soft heel describes the foot component. Assessment/Results: 3 weeks after admission, the patient was able to transfer and ambulate 50ft with supervision, and she required minimal to moderate assist for donning and doffing her prosthesis. Only 1 incident of skin breakdown occurred since surgery. The patient followed up regularly in clinic and she continued to improve. Currently, the patient is ambulating independently with a cane, and she manages her prosthesis with complete independence. Discussion: This is the first reported case, to our knowledge, of successful ambulation after bilateral below-knee amputations secondary to necrotizing fasciitis requiring complete skin grafting of residual limbs. Conclusions: This case illustrates that meticulous skin care in combination with an effective prosthetic device in skin grafted amputation stumps can lead to results that exceed expectation. Key Words: Fasciitis, necrotizing; Leg prosthesis; Rehabilitation. Poster 157 The Validity and Reliability of the SENSERite System: A Preliminary Evaluation. Joshua H. You, PT, PhD (University of Virginia, Hampton, VA), e-mail: [email protected]. Disclosure: None. Objectives: To establish the concurrent validity and reliability of the SENSERite computerized ankle proprioception analysis system and to determine and compare proprioceptive acuity (thresholds). Design: Within-groups, repeated-measures design with randomized sequence and control group. Setting: A university research laboratory. Participants: 10 healthy younger adults; 41 older adults (22 nonfallers, 14 fallers, 3 adults with stroke, 1 with peripheral neuropathy [PN], 1 with Parkinson’s disease [PD]). Interventions: Instrument validity was determined by comparing the system’s performance with a validated goniometer measure. Instrument reliability was determined by repeatedly measuring the established angles for the 5 different positions: neutral, inversion, eversion, plantarflexion, and dorsiflexion. In addition, proprioceptive acuities of the participants were measured by the SENSERite system. Data were analyzed using descriptive statistics, intraclass correlation coefficients (ICCs), and independent t tests. Main Outcome Measures: Composite proprioceptive acuity thresholds from the 5 position sense tests. Results: Excellent clinical goniometer and SENSERite correlation (ICC⫽.99, P⬍.0001) was found. The SENSERite system was reliable (ICC⫽1.0, P⬍.0001). A significant difference in proprioceptive acuity threshold was found between the younger adults and the older adults. No significant difference in proprioceptive acuity threshold was observed between nonfallers and fallers. The nonfallers’ proprioceptive acuity threshold was similar to that of stroke patients, whereas both the adult with PD and the adult with PN showed substantially increased thresholds. Conclusions: The SENSERite system is a valid and reliable instrument to measure ankle proprioception in the normal and pathologic populations. Persons with either a history of falls or neurologic impairments may or may not show diminished ankle proprioception. Key Words: Proprioception; Rehabilitation; Reproducibility of results.
Rehabilitation Topics Poster 158 Teaching Residents in Rehabilitation to Communicate Bad News to Their Patients. Thomas S. Kiser, MD, MPH (University of Arkansas for Medical Sciences, Little Rock, AR); Florian S. Keplinger, MD; Patricia O’Sullivan, PhD; Jeanne Heard, MD, e-mail: [email protected]. Disclosure: None. Objective: To determine if an educational program can improve a physical medicine and rehabilitation resident’s ability to deliver bad news to patients. Design: Preeducation and posteducation assessment of residents’ communication ability with a standardized patient. Setting: Clinical skills center. Participants: 10 rehabilitation residents (PGY-2 to PGY-4). Intervention: Preeducation experience with a standardized patient with a simulated C6 complete spinal cord injury
Arch Phys Med Rehabil Vol 84, September 2003
followed by a 1-hour educational lecture using the American Medical Association’s (AMA) Education for Physicians on End-of-Life Care (EPEC) program on communicating bad news to patients. This was followed by a posteducation experience with the original standardized patient. The person monitoring the session then provided feedback to the resident before a novel standardized patient, who simulated a mother of a patient who had been in a persistent vegetative state for over a year. The monitor and the standardized patient used a standardized checklist to assess the resident’s performance. Main Outcome Measures: Monitor checklist of 8 items: score 1 if done and 0 if not done (max⫽8, min⫽0). Standardized patient checklist of 7 items rated on a Likert scale: excellent, 5; very good, 4; good, 3; fair, 2; poor, 1 (max⫽35, min⫽7). Results: Monitor checklist: the preeducation mean was 2.9 (95% confidence interval [CI], 1.81–3.99); the posteducation mean was 5.4 (95% CI, 4.377– 6.423); and the novel case mean was 5.9 (95% CI, 5.044 – 6.756) (multivariate test [Hotelling trace], P⫽.002). Standardized patient checklist: the preeducation mean was 31.4 (95% CI, 29.609 –33.191); the posteducation mean was 34.2 (95% CI, 33.636 –34.764); and the novel case mean was 27.9 (95% CI, 25.577–30.223) (multivariate test [Hotelling trace], P⫽.001). Resident survey (5-point scale): worthwhile educational experience was 4.9; I will use what I learned in the future was 4.7; and I would participate again if not compensated was 4.4. Conclusions: A 1-hour lecture on delivering bad news to patients using the AMA’s EPEC program produced a significant change in resident behavior in interaction with a standardized patient. Residents felt that it was a worthwhile educational experience that would help them in their future practice. Key Words: Communication; Education; Rehabilitation.
Poster 159 Contact Precautions in a Rehabilitation Hospital. Steven Lewis, MD (Marianjoy Rehabilitation Hospital, Wheaton, IL); Barbara Lewis, MS; Estelle Zanotti, RN; Jan Jensen, RN; Cara Coomer, RN; Nelson Escobar, MD, e-mail: [email protected]. Disclosure: None. Objectives: To develop a modification of the US Centers for Disease Control and Prevention (CDC) contact precautions applicable to the rehabilitation environment and to determine its impact on implementation and nosocomial infection rates of specific pathogens. Design: Descriptive epidemiologic study. Setting: 110-bed free-standing comprehensive inpatient rehabilitation teaching hospital. Participants: All hospital staff and inpatients. Interventions: An infection prevention program, based on CDC contact precautions directed at Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE), was implemented. This program incorporated the following elements: new definitions for stop and start of precautions; establishment of criteria for private rooms and protective equipment utilization; institution of precautions within therapy departments; emphasis on housekeeping for prevention of environmental contamination; initiation of door-mounted isolation supplies; implementation of alcohol-based waterless hand hygiene; staff education; computer tracking of patients in isolation; surveillance of isolation implementation and compliance; and selective use of eradication therapy. Main Outcome Measures: The ability of staff to comprehend, implement, and adhere to the prevention program; efficiency in isolation resource utilization; and nosocomial rates for Clostridium difficile, MRSA, and VRE. Results: Staff demonstrated better understanding of precaution implementation and improved compliance with more reliable private room and protective equipment use. There was less disruption of the rehabilitation process. During the first year of program phase-in, the percentage of nosocomial infections decreased as follows: Clostridium difficile, 48.7%; MRSA, 69.5%; and VRE, 64.1%. Conclusion: We present a modification of the CDC contact precautions implementation specific for the rehabilitation environment that is more easily understood, more consistently and effectively implemented by staff, and that effectively prevents nosocomial transmission of epidemiologically important pathogens. Key Words: Epidemiology; Infection control; Nosocomial infections; Rehabilitation.
Poster 160 Dysphagia After West Nile Virus: A Report of 5 Cases. Nelson Escobar, MD (Marianjoy Rehabilitation Hospital, Wheaton, IL); Norman Aliga, MD; Richard Krieger, MD; Vasilios Stambolis, MD; Susan L. Brady, MS, e-mail: [email protected]. Disclosure: None. Setting: Free-standing rehabilitation hospital. Patients: 5 consecutive patients (3 men, 2 women; mean age, 57.20y; range, 34 –72y) who presented with dysphagia after West Nile virus (WNV) infection. Case Descriptions: All patients presented with their initial symptoms in August and September 2002. All diagnoses were confirmed by lumbar puncture. 3 patients were initially not eating by mouth and required nonoral nutritional support. 3 patients experienced pneumonia; 2 patients required mechanical ventilation; and 1 patient required a tracheotomy tube. Assessment/ Results: Swallowing therapy focused on compensatory swallowing safety strategies and swallowing rehabilitation and strengthening exercises. Videofluoroscopy was completed in 4 of the patients, with aspiration being present in 3 patients. Days from onset to discharge ranged from 24 to 183 (mean ⫾ SD, 85.8⫾69.1d). The patient who required mechanical ventilation, a tracheotomy tube, and a gastrostomy tube had the longest length of stay. All patients were eventually able to return to oral feedings after swallowing therapy during their inpatient rehabilitation stay without requiring any supplemental tube feedings. All patients were weaned from the ventilators and tracheotomy tube. 4 of the 5 patients were receiving a regular diet of thin liquids and bread at discharge. Discussion: Physicians should recognize that dysphagia is a potential complication after WNV infection and should provide appropriate direction for the team management of dysphagia with these patients. Conclusion: Functional gains can be made for dysphagia after WNV infection. Key Words: Dysphagia; Rehabilitation; West Nile virus.
Poster 161 Axonal Neuropathy of the Extremities After West Nile Virus: A Case Report. Vasilios Stambolis, MD (Marianjoy Rehabilitation Hospital, Wheaton, IL); Colleen Peterson, MPT; Deepthi Saxena, MD, e-mail: [email protected]. Disclosure: None.