- Email: [email protected]
Poster 161
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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.
ACADEMY ANNUAL ASSEMBLY ABSTRACTS Setting: Free-standing rehabilitation hospital. Patient: A 69-year-old white man. Case Description: The patient was admitted to inpatient rehabilitation after being diagnosed with West Nile virus (WNV) infection. He initially presented to acute care with weakness, fatigue, elevated body temperature. His cerebrospinal fluid was positive for WNV. On initial examination, he had less than antigravity strength in both lower extremities and proximally in the upper extremities. Distal upper-extremity strength was 3/5. He was hyporeflexic and had normal sensation to light touch and proprioception. The patient’s higher-level cognitive and communication skills were within full limits and he was continent to bowel and bladder. He required total assistance for all transfers and toileting. Results: Nerve conduction and electromyography studies were done for the right median, ulnar, deep peroneal, tibial, and sural nerves. The electrodiagnostic findings were consistent with significant axonal neuropathy involving the upper and lower extremities. The patient was discharged after 21/2 months of inpatient rehabilitation. At this time, his strength had improved by 1 grade to 3/5 in the lower and proximal upper-extremities. Distal upper-extremity strength was 4/5. The patient needed maximal assistance with transfers and standing in parallel bars, moderate assistance with lower-body bathing, and minimal assistance with upper-body dressing. He was independent with grooming. Discussion: This is a rare case of WNV infection with axonal neuropathy and no cognitive deficits. Conclusion: Functional recovery of patients with WNV presenting with axonal neuropathy is slower compared with those presenting with encephalitis. Key Words: Neuropathy; Rehabilitation; West Nile virus. Poster 162 Depression Assessment in Rehabilitation Patients With Communication Difficulties: The Cornell Depression Scale. Peter A. Lim, MD (Singapore General Hospital and Baylor College of Medicine, Singapore, Singapore); Deidre A. De Silva, MD; Yee Sien Ng, MD, e-mail: [email protected]. Disclosure: None. Objective: To use the Cornell Depression Scale (CDS) to diagnose major depression in rehabilitation inpatients with communication difficulties, using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), as standard assessment tool. Design: Prospective clinical trial. Setting: Rehabilitation medicine unit in a tertiary teaching hospital. Participants: Consecutive general rehabilitation patients (61.8% strokes, others being head injuries, spinal cord injuries, deconditioning) admitted between May and August 2002. Patients who did not complete their rehabilitation program for various reasons (including medical instability) were excluded from analysis. Interventions: All 78 patients admitted were screened by the same investigator for depressive signs and symptoms using DSM-IV criteria on admission, and then on a weekly basis until discharge. Of the 68 patients who completed rehabilitation, 14 (20.6%) had communication difficulties (defined as a score of ⬍5 for comprehension and/or expression on the initial FIM™ instrument score) and were also assessed using the CDS. Main Outcome Measure: Presence or absence of major depression, as determined by the CDS and/or DSM-IV criteria. Results: 13 (19.1%) of the 68 patients were diagnosed with major depression using the DSM IV. Of these, 4 patients had communication difficulty; they also fulfilled the criteria for major depression on the CDS. Importantly, the remaining 10 patients with communication difficulty did not have depression as assessed by the DSM-IV and the CDS. There was hence a 100% correlation between the 2 tools. Conclusions: Diagnosis of major depression in the presence of communication difficulties can be challenging. The CDS, a nonverbal assessment tool focusing on observers’ ratings and originally constructed for patients with dementia, showed accurate correlation with the well-established DSM-IV and may hence be useful in rehabilitation patients with communication difficulties. A larger study, to ensure accuracy and statistical significance of this correlation, is necessary. Key Words: Cerebrovascular accident; Communication; Depression; Rehabilitation. Poster 163 Rehabilitation Outcomes of Patients After West Nile Virus Infection: A Report of 5 Cases. David Char, MD (Marianjoy Rehabilitation Hospital, Wheaton, IL); Noel Rao, MD; Steve Gnatz, MD, e-mail: [email protected]. Disclosure: None. Setting: Free-standing rehabilitation hospital. Patients: 5 consecutive patients (3 men, 2 women; age range 34 –72y) who presented with West Nile virus (WNV). Case Descriptions: The patients were admitted to an inpatient rehabilitation hospital over 5 months with severe functional deficits. 3 patients presented with quadriparesis and 2 with generalized muscle weakness. All patients presented with cognitive deficits and dysphagia. Comorbidities included diabetes, constrictive obstructive pulmonary disease, coronary artery disease, chronic hepatitis B, and end-stage renal disease. Results: On admission, overall FIM™ instrument scores ranged from 32 to 68 (mean, 44). At discharge, overall FIM scores ranged from 52 to 90 (mean, 76). Progress made during their inpatient rehabilitation as documented by the admission and discharge FIM scores was considered significant (P⬍.0001). Length of stay (LOS) was from 10 to 71 days (mean, 32d). An electromyography study revealed axonal neuropathy and diffuse denervation in 2 patients. Discussion: All 5 patients were discharged to home with oral feedings and at modified independent level. Conclusion: All patients demonstrated significant functional improvement. None had complete recovery to their premorbid status. At discharge, all participated in comprehensive outpatient rehabilitation. The youngest patient presented with the least comorbidity, demonstrated the best FIM score gain, and had the shortest LOS for inpatient rehabilitation. This suggests that the patient’s immunocompetence and biologic reserve played an important part in not only WNV susceptibility but also recovery of function. The results also suggest that those patients with multiple premorbid conditions are more vulnerable to WNV and have severe complications with slow recovery, which leads to longer rehabilitation stays and higher rehabilitation costs. Key Words: Rehabilitation; Treatment outcomes; West Nile virus.
Poster 164 Bilateral Achilles’ Tendon Partial Rupture Due to Ciprofloxacin: A Case Report. Sylvia T. John, MD (Long Island Jewish Medical Center, New Hyde Park, NY); Barry Root, MD. Disclosure: None.
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Setting: Physiatry outpatient office. Patient: A 35-year-old woman with bilateral ankle pain. Case Description: The patient, with no significant medical history, presented to the office with a complaint of acute bilateral posterior ankle pain and swelling, 1 week after a 10-day course of ciprofloxacin for a urinary tract infection. Magnetic resonance imaging (MRI) of both ankles showed bilateral partial achilles’ tendon rupture. Assessment/Results: Absent trauma and any significant medical history, the tendon rupture was attributed to the use of ciprofloxacin. Discussion: Fluoroquinolones are extensively used in physiatry practice, especially in an inpatient setting. A few cases have been reported of Achilles’ and other tendon inflammation or ruptures that required surgical repair or resulted in prolonged disability with use of fluoroquinolones. None were noted in the rehabilitation literature. Pathologic mechanism for tendon rupture is poorly understood and may be due to alteration in tendon fibroblast metabolism. Treatment with fluoroquinolones should be stopped at the first sign of pain or inflammation so to reduce the risk of subsequent rupture. This effect is not dose dependent. There is a variable period (3–5d) between introduction of an antimicrobial agent and onset of pain. Pain is the most frequently reported symptom. MRI helps to differentiate between tendinitis and rupture. Conclusion: Fluoroquinolones are widely used in medicine. This case report should make rehabilitation pracititioners aware of this uncommon complication with use of fluoroquinolones. Key Words: Fluoroquinolones; Rehabilitation; Tendinitis.
Poster 165 Control of Oral Secretions in Bulbar Amyotrophoic Lateral Sclerosis Using Botulinum Toxin Type A: A Pilot Study and Safety Trial. Albert S. Cheng, MD (University of Toronto, Toronto, ON, Canada); Anthony Newall, MD, FRCPC, e-mail: [email protected]. Disclosure: None. Objectives: To determine the effectiveness of botulinum toxin type A (BTX) in reducing sialorrhea for patients with bulbar amyotrophoic lateral sclerosis (ALS), through ultrasound-guided, intrasalivary gland injections, and to titrate to the minimum dosage of BTX required to significantly reduce salivary flow clinically, while minimizing adverse effects. Design: Open-label, nonblinded safety trial. Setting: Outpatient neuromuscular clinic in a large tertiary care center in Ontario, Canada. Participants: Referred sample of 3 patients with advanced bulbar ALS, presenting with disabling sialorrhea unresponsive to previous conventional treatments. Intervention: BTX was injected directly into bilateral parotid and submandibular glands after gland visualization was made using ultrasound. 10, 20 and 30U were injected at baseline, 1 and 2 months postbaseline, respectively. Main Outcome Measures: Subjective evaluation was made using a questionnaire comprised of rating scales for items including severity and frequency of salivation, improvement from baseline, and overall effectiveness of treatment. Objective measurements of salivation was performed by calculating saliva output per minute using the weight of intraoral dental gauze retained in the mouth. Results: All 3 subjects reported moderate to marked improvement in the severity and frequency of their sialorrhea after the 10- and 20-U dose injections, with a reported 37.5% to 75% reduction in salivation from baseline. An apparent supratherapeutic effect was seen after the 30-U injection in 2 subjects. Objective reductions in saliva secretion of 23.9%, 34.0%, and 36.6% were seen after the 10-, 20-, and 30-U injections, respectively. No side effects (eg, worsening of dysarthria, dysphagia, facial nerve paralysis) were reported. Conclusions: Ultrasound-guided injections of BTX into the salivary glands is a minimally invasive, safe, and efficacious treatment alternative for patients with sialorrhea secondary to bulbar ALS. An upper-dose tolerance of 25U was found in our safety trial. Key Words: Amyotrophoic lateral sclerosis; Botulinum toxin type A; Drooling; Rehabilitation; Sialorrhea.
Poster 166 Bilateral Thigh Pain After Unilateral Deep Brain Stimulator Placement: A Case Report. Stacy Suskauer, MD (Cincinnati Children’s Hospital Medical Center/University of Cincinnati College of Medicine, Cincinnati, OH); Susan Pierson, MD; Mark Goddard, MD; Benjamin Nguyen, MD, e-mail: [email protected]. Disclosure: None. Setting: Rehabilitation hospital. Patient: An 81-year-old right-handed woman with bilateral essential tremor. Case Description: The patient underwent deep brain stimulator placement in the ventral intermediate nucleus of the left thalamus at another institution to treat right-sided tremor. The procedure was complicated by injury to the anomalous left subclavian artery. Left upperextremity arterial emboli resulted and required open thrombectomies. The postoperative course was notable for confusion attributed to anesthesia and urinary tract infection. Because of ongoing functional deficits (patient required moderate assistance with dressing and bathing and minimum assistance to ambulate 75ft with an assistive device), the patient was admitted to inpatient rehabilitation on postoperative day 10 from stimulator placement. On admission to rehabilitation, she complained of bilateral thigh pain, which had developed during hospitalization. The aching thigh pain disrupted sleep and therapies and did not respond to anti-inflammatory, narcotic, or neuropathic pain medications. Lumbar spine imaging revealed degenerative disease without foraminal stenosis. Electromyography of the lower extremities was normal. Head computed tomography confirmed stimulator placement in the left thalamus. Assessment/Results: Bilateral thigh pain resolved after the deep brain stimulator frequency was increased to control upper-extremity tremor. Pain medications were subsequently discontinued successfully. The patient was discharged to home at a modified independence level and could ambulate ⬎1000ft after 22 days of inpatient rehabilitation. Discussion: Complications associated with deep brain stimulator placement can cause functional impairments requiring rehabilitation, and physiatrists should be familiar with side effects associated with deep brain stimulation (DBS). Although parasthesias are a known side effect of deep brain stimulator placement, discomfort is typically treated by decreasing stimulation. This is the first reported case, to our knowledge, of bilateral pain from unilateral DBS that responded to increased frequency of stimulation. Conclusions: Unilateral DBS can cause bilateral pain; increasing DBS frequency can relieve pain. Key Words: Electric stimulation; Essential tremor; Pain; Rehabilitation.
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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
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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.
ACADEMY ANNUAL ASSEMBLY ABSTRACTS Setting: Free-standing rehabilitation hospital. Patient: A 69-year-old white man. Case Description: The patient was admitted to inpatient rehabilitation after being diagnosed with West Nile virus (WNV) infection. He initially presented to acute care with weakness, fatigue, elevated body temperature. His cerebrospinal fluid was positive for WNV. On initial examination, he had less than antigravity strength in both lower extremities and proximally in the upper extremities. Distal upper-extremity strength was 3/5. He was hyporeflexic and had normal sensation to light touch and proprioception. The patient’s higher-level cognitive and communication skills were within full limits and he was continent to bowel and bladder. He required total assistance for all transfers and toileting. Results: Nerve conduction and electromyography studies were done for the right median, ulnar, deep peroneal, tibial, and sural nerves. The electrodiagnostic findings were consistent with significant axonal neuropathy involving the upper and lower extremities. The patient was discharged after 21/2 months of inpatient rehabilitation. At this time, his strength had improved by 1 grade to 3/5 in the lower and proximal upper-extremities. Distal upper-extremity strength was 4/5. The patient needed maximal assistance with transfers and standing in parallel bars, moderate assistance with lower-body bathing, and minimal assistance with upper-body dressing. He was independent with grooming. Discussion: This is a rare case of WNV infection with axonal neuropathy and no cognitive deficits. Conclusion: Functional recovery of patients with WNV presenting with axonal neuropathy is slower compared with those presenting with encephalitis. Key Words: Neuropathy; Rehabilitation; West Nile virus. Poster 162 Depression Assessment in Rehabilitation Patients With Communication Difficulties: The Cornell Depression Scale. Peter A. Lim, MD (Singapore General Hospital and Baylor College of Medicine, Singapore, Singapore); Deidre A. De Silva, MD; Yee Sien Ng, MD, e-mail: [email protected]. Disclosure: None. Objective: To use the Cornell Depression Scale (CDS) to diagnose major depression in rehabilitation inpatients with communication difficulties, using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), as standard assessment tool. Design: Prospective clinical trial. Setting: Rehabilitation medicine unit in a tertiary teaching hospital. Participants: Consecutive general rehabilitation patients (61.8% strokes, others being head injuries, spinal cord injuries, deconditioning) admitted between May and August 2002. Patients who did not complete their rehabilitation program for various reasons (including medical instability) were excluded from analysis. Interventions: All 78 patients admitted were screened by the same investigator for depressive signs and symptoms using DSM-IV criteria on admission, and then on a weekly basis until discharge. Of the 68 patients who completed rehabilitation, 14 (20.6%) had communication difficulties (defined as a score of ⬍5 for comprehension and/or expression on the initial FIM™ instrument score) and were also assessed using the CDS. Main Outcome Measure: Presence or absence of major depression, as determined by the CDS and/or DSM-IV criteria. Results: 13 (19.1%) of the 68 patients were diagnosed with major depression using the DSM IV. Of these, 4 patients had communication difficulty; they also fulfilled the criteria for major depression on the CDS. Importantly, the remaining 10 patients with communication difficulty did not have depression as assessed by the DSM-IV and the CDS. There was hence a 100% correlation between the 2 tools. Conclusions: Diagnosis of major depression in the presence of communication difficulties can be challenging. The CDS, a nonverbal assessment tool focusing on observers’ ratings and originally constructed for patients with dementia, showed accurate correlation with the well-established DSM-IV and may hence be useful in rehabilitation patients with communication difficulties. A larger study, to ensure accuracy and statistical significance of this correlation, is necessary. Key Words: Cerebrovascular accident; Communication; Depression; Rehabilitation. Poster 163 Rehabilitation Outcomes of Patients After West Nile Virus Infection: A Report of 5 Cases. David Char, MD (Marianjoy Rehabilitation Hospital, Wheaton, IL); Noel Rao, MD; Steve Gnatz, MD, e-mail: [email protected]. Disclosure: None. Setting: Free-standing rehabilitation hospital. Patients: 5 consecutive patients (3 men, 2 women; age range 34 –72y) who presented with West Nile virus (WNV). Case Descriptions: The patients were admitted to an inpatient rehabilitation hospital over 5 months with severe functional deficits. 3 patients presented with quadriparesis and 2 with generalized muscle weakness. All patients presented with cognitive deficits and dysphagia. Comorbidities included diabetes, constrictive obstructive pulmonary disease, coronary artery disease, chronic hepatitis B, and end-stage renal disease. Results: On admission, overall FIM™ instrument scores ranged from 32 to 68 (mean, 44). At discharge, overall FIM scores ranged from 52 to 90 (mean, 76). Progress made during their inpatient rehabilitation as documented by the admission and discharge FIM scores was considered significant (P⬍.0001). Length of stay (LOS) was from 10 to 71 days (mean, 32d). An electromyography study revealed axonal neuropathy and diffuse denervation in 2 patients. Discussion: All 5 patients were discharged to home with oral feedings and at modified independent level. Conclusion: All patients demonstrated significant functional improvement. None had complete recovery to their premorbid status. At discharge, all participated in comprehensive outpatient rehabilitation. The youngest patient presented with the least comorbidity, demonstrated the best FIM score gain, and had the shortest LOS for inpatient rehabilitation. This suggests that the patient’s immunocompetence and biologic reserve played an important part in not only WNV susceptibility but also recovery of function. The results also suggest that those patients with multiple premorbid conditions are more vulnerable to WNV and have severe complications with slow recovery, which leads to longer rehabilitation stays and higher rehabilitation costs. Key Words: Rehabilitation; Treatment outcomes; West Nile virus.
Poster 164 Bilateral Achilles’ Tendon Partial Rupture Due to Ciprofloxacin: A Case Report. Sylvia T. John, MD (Long Island Jewish Medical Center, New Hyde Park, NY); Barry Root, MD. Disclosure: None.
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Setting: Physiatry outpatient office. Patient: A 35-year-old woman with bilateral ankle pain. Case Description: The patient, with no significant medical history, presented to the office with a complaint of acute bilateral posterior ankle pain and swelling, 1 week after a 10-day course of ciprofloxacin for a urinary tract infection. Magnetic resonance imaging (MRI) of both ankles showed bilateral partial achilles’ tendon rupture. Assessment/Results: Absent trauma and any significant medical history, the tendon rupture was attributed to the use of ciprofloxacin. Discussion: Fluoroquinolones are extensively used in physiatry practice, especially in an inpatient setting. A few cases have been reported of Achilles’ and other tendon inflammation or ruptures that required surgical repair or resulted in prolonged disability with use of fluoroquinolones. None were noted in the rehabilitation literature. Pathologic mechanism for tendon rupture is poorly understood and may be due to alteration in tendon fibroblast metabolism. Treatment with fluoroquinolones should be stopped at the first sign of pain or inflammation so to reduce the risk of subsequent rupture. This effect is not dose dependent. There is a variable period (3–5d) between introduction of an antimicrobial agent and onset of pain. Pain is the most frequently reported symptom. MRI helps to differentiate between tendinitis and rupture. Conclusion: Fluoroquinolones are widely used in medicine. This case report should make rehabilitation pracititioners aware of this uncommon complication with use of fluoroquinolones. Key Words: Fluoroquinolones; Rehabilitation; Tendinitis.
Poster 165 Control of Oral Secretions in Bulbar Amyotrophoic Lateral Sclerosis Using Botulinum Toxin Type A: A Pilot Study and Safety Trial. Albert S. Cheng, MD (University of Toronto, Toronto, ON, Canada); Anthony Newall, MD, FRCPC, e-mail: [email protected]. Disclosure: None. Objectives: To determine the effectiveness of botulinum toxin type A (BTX) in reducing sialorrhea for patients with bulbar amyotrophoic lateral sclerosis (ALS), through ultrasound-guided, intrasalivary gland injections, and to titrate to the minimum dosage of BTX required to significantly reduce salivary flow clinically, while minimizing adverse effects. Design: Open-label, nonblinded safety trial. Setting: Outpatient neuromuscular clinic in a large tertiary care center in Ontario, Canada. Participants: Referred sample of 3 patients with advanced bulbar ALS, presenting with disabling sialorrhea unresponsive to previous conventional treatments. Intervention: BTX was injected directly into bilateral parotid and submandibular glands after gland visualization was made using ultrasound. 10, 20 and 30U were injected at baseline, 1 and 2 months postbaseline, respectively. Main Outcome Measures: Subjective evaluation was made using a questionnaire comprised of rating scales for items including severity and frequency of salivation, improvement from baseline, and overall effectiveness of treatment. Objective measurements of salivation was performed by calculating saliva output per minute using the weight of intraoral dental gauze retained in the mouth. Results: All 3 subjects reported moderate to marked improvement in the severity and frequency of their sialorrhea after the 10- and 20-U dose injections, with a reported 37.5% to 75% reduction in salivation from baseline. An apparent supratherapeutic effect was seen after the 30-U injection in 2 subjects. Objective reductions in saliva secretion of 23.9%, 34.0%, and 36.6% were seen after the 10-, 20-, and 30-U injections, respectively. No side effects (eg, worsening of dysarthria, dysphagia, facial nerve paralysis) were reported. Conclusions: Ultrasound-guided injections of BTX into the salivary glands is a minimally invasive, safe, and efficacious treatment alternative for patients with sialorrhea secondary to bulbar ALS. An upper-dose tolerance of 25U was found in our safety trial. Key Words: Amyotrophoic lateral sclerosis; Botulinum toxin type A; Drooling; Rehabilitation; Sialorrhea.
Poster 166 Bilateral Thigh Pain After Unilateral Deep Brain Stimulator Placement: A Case Report. Stacy Suskauer, MD (Cincinnati Children’s Hospital Medical Center/University of Cincinnati College of Medicine, Cincinnati, OH); Susan Pierson, MD; Mark Goddard, MD; Benjamin Nguyen, MD, e-mail: [email protected]. Disclosure: None. Setting: Rehabilitation hospital. Patient: An 81-year-old right-handed woman with bilateral essential tremor. Case Description: The patient underwent deep brain stimulator placement in the ventral intermediate nucleus of the left thalamus at another institution to treat right-sided tremor. The procedure was complicated by injury to the anomalous left subclavian artery. Left upperextremity arterial emboli resulted and required open thrombectomies. The postoperative course was notable for confusion attributed to anesthesia and urinary tract infection. Because of ongoing functional deficits (patient required moderate assistance with dressing and bathing and minimum assistance to ambulate 75ft with an assistive device), the patient was admitted to inpatient rehabilitation on postoperative day 10 from stimulator placement. On admission to rehabilitation, she complained of bilateral thigh pain, which had developed during hospitalization. The aching thigh pain disrupted sleep and therapies and did not respond to anti-inflammatory, narcotic, or neuropathic pain medications. Lumbar spine imaging revealed degenerative disease without foraminal stenosis. Electromyography of the lower extremities was normal. Head computed tomography confirmed stimulator placement in the left thalamus. Assessment/Results: Bilateral thigh pain resolved after the deep brain stimulator frequency was increased to control upper-extremity tremor. Pain medications were subsequently discontinued successfully. The patient was discharged to home at a modified independence level and could ambulate ⬎1000ft after 22 days of inpatient rehabilitation. Discussion: Complications associated with deep brain stimulator placement can cause functional impairments requiring rehabilitation, and physiatrists should be familiar with side effects associated with deep brain stimulation (DBS). Although parasthesias are a known side effect of deep brain stimulator placement, discomfort is typically treated by decreasing stimulation. This is the first reported case, to our knowledge, of bilateral pain from unilateral DBS that responded to increased frequency of stimulation. Conclusions: Unilateral DBS can cause bilateral pain; increasing DBS frequency can relieve pain. Key Words: Electric stimulation; Essential tremor; Pain; Rehabilitation.
Arch Phys Med Rehabil Vol 84, September 2003