- Email: [email protected]
Poster 159
A32
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.
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.