- Email: [email protected]
Poster 168
A34
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Poster 167 Initial and Follow-Up Motor Scores and Functional Status in Patients With West Nile Virus Infection: A Report of 4 Cases. Christina K. Hynes, MD (Rehabilitation Institute of Chicago, Chicago, IL); Susan C. Sorosky, MD; Christina M. Marciniak, MD, e-mail: [email protected]. Disclosure: None. Setting: Acute inpatient rehabilitation hospital. Patients: 4 patients (age range, 29 –72y) with West Nile virus (WNV) infection and weakness. Case Description: The patients presented to community hospitals with myalgia, headache, neck pain, weakness, areflexia, and normal sensation. All patients had positive titers for WNV in cerebrospinal fluid or serum. 2 patients had acute flaccid paraplegia; one received intravenous (IV) steroids without improvement. 2 patients presented with diffuse weakness and meningoencephalitis and required prolonged ventilatory support; 1 received IV gamma globulin without improvement. All patients were then transferred to an acute inpatient rehabilitation hospital. Assessment/Results: On admission, 2 patients had electrodiagnostic studies that revealed motor axonal loss without sensory abnormalities consistent with anterior horn cell involvement. Initial motor scores ranged from 30 to 66 with a mean of 43.5 (normal, 100). Initial score ranges on the FIM™ instrument ranged from 6 to 22 for self-care, 2 to 6 for sphincter control, 1 to 5 for mobility, 1 to 5 for wheelchair locomotion, 13 to 14 for communication, and 15 to 20 for cognition. All patients participated in comprehensive in- and outpatient rehabilitation programs. At 6-month follow-up, electrodiagnostic studies showed evidence of reinnervation in all 4 patients. Motor scores ranged from 32 to 70 (mean, 48.5). Follow-up FIM scores also showed modest improvements. In self-care, scores ranged from 10 to 37, with all patients showing increased independence. 2 patients were continent of bowel and bladder, and 2 patients were transferring independently. In locomotion, scores improved to a range of 6 to 8, however, no patients was ambulating independently. Communication and cognition were within normal limits. Discussion: WNV can cause severe neurologic disease, including acute flaccid paralysis and meningoencephalitis. There are limited data regarding functional recovery in such patients. Conclusions: Patients with WNV-associated weakness appear to make modest improvements in strength and function over time. Persistent weakness in the lower extremities limits ambulation skills at 6 months. Key Words: Rehabilitation; West Nile virus.
Poster 168 Ludwig’s Angina Complicated by Nerve Injury: A Case Report. Sanjeev Agarwal, MD, MS, MCH (Nassau University Medical Center, East Meadow, NY); Lynn Weiss, MD; Alberto Rivera, MD, e-mail: [email protected]. Disclosure: None. Setting: Inpatient rehabilitation unit of a tertiary care hospital. Patient: A 21-year-old white man. Case Description: The patient developed Ludwig’s angina after a tooth extraction for an abscess, which was complicated by mediastinitis, pericarditis, pericardial effusion, empyema, multiple pneumonias, respiratory failure leading to tracheostomy and mechanical ventilation, profound weight loss, bilateral hypoglossal nerve injury, and left brachial plexus involvement resulting in upper-extremity weakness. Assessment/Results: The patient had multiple admissions to the department of medicine, medical intensive care, and rehabilitation unit. The medical course was complicated by mediastinitis and pericardial effusion requiring pericardial window, empyema leading to thoracostomy, respiratory failure requiring emergency tracheostomy and ventilatory support, and malnutrition requiring percutaneous endoscopic gastrostomy placement. During his hospital stay, tongue and left upper-extremity weakness was noticed. Electrodiagnostic studies revealed extensive spontaneous potentials and no active motor units in the tongue, the left biceps, deltoid, supraspinatus, and brachioradialis muscles. Discussion: The patient was an active young man with no comorbid conditions. The sublingual and submandibular spaces were infected by direct extension, causing the Ludwig’s angina. In adults, 52% of cases of Ludwig’s angina are caused by dental caries and have a mortality rate of 5% to 10%. Submandibular and sublingual spaces freely communicate and, with involvement of deep cervical fascia, infection may spread rapidly with grave consequences. Extension along the carotid sheath or the retropharyngeal space can cause the mediastinitis. In this patient, nerve injury to both the hypoglossal nerve and the brachial plexus complicated his physical condition and rehabilitation. Conclusions: This case demonstrates the potentially catastrophic complications of odontogenic infections. Prompt diagnosis and early definitive care can minimize the morbidity and mortality of these serious infections.The rehabilitation can be prolonged and requires thorough attention to complications. Key Words: Brachial plexus; Hypoglossal nerve; Ludwig’s angina; Rehabilitation.
Poster 169 The Effect of Comorbidities on Rehabilitation Outcomes in Orthopedic Patients. Xin Wang, MD (Baylor College of Medicine/University of Texas, Houston, TX); Diana H. Rintala, PhD; Helene K. Henson, MD; Susan L. Garber, MA, OTR, e-mail: [email protected]. Disclosure: None. Objective: To investigate the effects of comorbidities (heart disease, diabetes, anemia, hypertension) on functional outcomes and rehabilitation length of stay after total knee or hip replacement or lower-extremity amputation. Design: Retrospective chart review study. Setting: A Veterans Affairs medical center in Texas. Participants: The medical records of 90 patients admitted to inpatient rehabilitation from the orthopedic ward between 1999 and 2002 were reviewed: 50 knee arthroplasty patients (age range, 47– 85y; mean, 64.38y), 18 hip arthroplasty patients (age range, 46 – 85y; mean, 63.3y), and 22 amputees (age, 44 –79y; mean, 64.82y). Interventions: Not applicable. Main Outcome Measures: Comorbidity data (heart disease, diabetes, anemia, hypertension) were obtained from the medical history taken prior to surgery. Hemoglobin was measured presurgery and at admission to rehabilitation. The motor subscale of the FIM™ instrument was administered at admission to and discharge from rehabilitation. Length of stay (LOS) in rehabilitation also was recorded. Results: Heart disease, diabetes, and anemia were more common among patients who had amputations than those who had knee and hip arthroplasty. Amputation patients tended to have lower discharge motor FIM scores and longer LOS than knee arthroplasty patients. However, all 3 groups made substantial motor FIM gains (amputation, 19; knee, 23; hip, 20). Patients with chronic
Arch Phys Med Rehabil Vol 84, September 2003
anemia had longer rehabilitation LOS and lower discharge motor FIM scores. There were no differences between discharge motor FIM scores and motor FIM gains based on whether a person had heart disease, diabetes, or hypertension. Conclusions: The results indicate that patients admitted to rehabilitation for amputation or hip and knee arthroplasty have the potential to improve motor function regardless of comorbidities. However, the surgery itself and some comorbidities may affect functional recovery and LOS after surgery. Key Words: Amputation; Anemia; Arthroplasty; Comorbidity; Rehabilitation. Poster 170 A Study on the Correlation Between Peripheral Dual-Energy X-Ray Absorptiometry and Thoracolumbar X-Ray in the Diagnosis of Compression Deformity Among Patients With Low Bone Mineral Density. Nathaniel Francis G. Precilla, MD (University of Santo Tomas, Quezon City, Philippines), e-mail: n_precilla@ hotmail.com. Disclosure: None. Objectives: To determine the correlation between calcaneal bone mineral density (BMD) and thoracolumbar compression deformities in patients with low BMD. Design: Cross-sectional correlation study. Setting: A veterans medical center in the Philippines. Participants: 147 subjects with a calcaneal BMD fulfilling the World Health Organization’s criteria for osteopenia and osteoporosis. Interventions: Not applicable. Main Outcome Measures: Calcaneal t score using Lunar PIXI dual-energy x-ray absorptiometry; and vertebral compression deformity on thoracolumbar radiography. Results: The bivariate correlation coefficient (r) was equal to –.748 using the Pearson test (P⫽.000). The mean calcaneal t score of subjects with vertebral compression deformity was –3.0649⫾0.6468. A high prevalence of compression deformity was noted in the t score range of –2.4426 to –3.7162. The number of compression deformities increased as the calcaneal t score decreased. Conclusions: There is a significant correlation between the peripheral calcaneal t score and the presence of vertebral compression deformities among patients with low BMD. Key Words: Bone mineral density; Rehabilitation. Poster 171 Treatment of Postanoxic Myoclonus (Lance-Adams Syndrome): A Case Report. Alena Polesin, MD (Columbia University-College of Physician and Surgeons and New York Presbyterian Hospital, New York, NY); Michelle Stern, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care center. Patient: A 62-year-old woman with postanoxic myoclonus. Case Description: The patient presented after cardiopulmonary arrest as a result of aspiration. She developed status epilepticus and was comatose for 3 days. After regaining consciousness, she developed constant jerking movements in all extremities. She was placed on levetriacetam, phenobarbital, and diazepam, but continued to be symptomatic. She was admitted to our facility for treatment of this severely incapacitating movement disorder. After a work-up that included magnetic resonance imaging of the brain and an electroencephalogram, she was diagnosed with Lance-Adams syndrome. She was started on 250mg of divalproex sodium twice daily and 200mg of zonisamide every day, along with lowering her diazepam and phenobarbital dosages and discontinuation of levetriacetam. Over the next 3 days, the patient demonstrated marked functional improvement. The dose of zonisamide was further increased to twice daily and the patient was discharged to home after completing her acute rehabilitation stay. However, 2 weeks later she was readmitted for an exacerbation of myoclonus. Further medication adjustments included discontinuing phenobarbital, divalproex sodium, and diazepam; starting clonazepam at 0.5mg 3 times daily; restarting levetriacetam at 500mg twice daily; and adjusting zonisamide to 100mg 4 times daily. This regimen greatly improved her symptoms. Assessment/Results: At a 2-month follow-up, the patient continued to improve with an increase in clonazepam to 0.5mg 5 times a day and the rest of the regimen unchanged. Discussion: Treatment of postanoxic myoclonus can be difficult and frequently requires medication adjustments to best control the symptoms. It appears that the “second-generation” antiseizure medications can play an important role in ameliorating this disabling condition. Conclusion: Myoclonus can be a disabling complication of an anoxic event. Improvement can occur with use of clonazepam as well as levetriacetam and zonisamide, which deserve further investigation of their antimyoclonic properties. Key Words: Lance-Adams syndrome; Myoclonus; Rehabilitation.
Poster 172 Return of Muscle Strength and Function After Use of Intravenous Immunoglobulin for Lyme Disease–Associated Acute Demyelinating Polyneuropathy. Cynthia Majerske, MD (University of Pittsburgh, Pittsburgh, PA); Brad Dicianno, MD; Gargi Raval, MD; Ross D. Zafonte, DO; Sasa Zivkovic, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care hospital acute rehabilitation unit. Patient: A 58-year-old man with babesiosis and Lyme disease. Case Description: The patient, who had a history of splenectomy, was admitted with diffuse myalgias, fevers, and chills. He had a history of foreign and domestic travel 6 weeks prior. He was diagnosed with babesiosis. The patient’s muscle strength on admission was 5/5 throughout, but declined during his acute care stay. The patient was transferred to the acute rehabilitation floor, where he demonstrated noted weakness primarily in the lower extremities. Through his first week of rehabilitation, he became significantly weaker in hip flexors and knee extensors (to 2⫹/5) as well as developed proximal upper-extremity weakness (to 3⫹/5) for shoulder flexion. An electromyogram (EMG) on day 14 showed primary demyelinating sensorimotor polyneuropathy. Sural nerve biopsy was unremarkable. Western blot for Lyme disease returned positive. He was started on intravenous ceftriaxone, yet deterioration of muscle strength and function was noted. An EMG on day 30 showed continued evidence of demyelinating polyneuropathy with significantly prolonged F-wave latencies in the upper extremities and moderate worsening in conduction velocities in 3 of 4 nerves. He was started on intravenous immunoglobulin (IVIG) on day 33 and received a total of 5 doses over 5 days. Assessment/Results: Patient was discharged on day 38 with improving muscle strength and he was able to ambulate 150ft using a wheeled walker with supervision. At follow-up 8 weeks later, muscle strength had fully returned. Discussion: This case
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Poster 167 Initial and Follow-Up Motor Scores and Functional Status in Patients With West Nile Virus Infection: A Report of 4 Cases. Christina K. Hynes, MD (Rehabilitation Institute of Chicago, Chicago, IL); Susan C. Sorosky, MD; Christina M. Marciniak, MD, e-mail: [email protected]. Disclosure: None. Setting: Acute inpatient rehabilitation hospital. Patients: 4 patients (age range, 29 –72y) with West Nile virus (WNV) infection and weakness. Case Description: The patients presented to community hospitals with myalgia, headache, neck pain, weakness, areflexia, and normal sensation. All patients had positive titers for WNV in cerebrospinal fluid or serum. 2 patients had acute flaccid paraplegia; one received intravenous (IV) steroids without improvement. 2 patients presented with diffuse weakness and meningoencephalitis and required prolonged ventilatory support; 1 received IV gamma globulin without improvement. All patients were then transferred to an acute inpatient rehabilitation hospital. Assessment/Results: On admission, 2 patients had electrodiagnostic studies that revealed motor axonal loss without sensory abnormalities consistent with anterior horn cell involvement. Initial motor scores ranged from 30 to 66 with a mean of 43.5 (normal, 100). Initial score ranges on the FIM™ instrument ranged from 6 to 22 for self-care, 2 to 6 for sphincter control, 1 to 5 for mobility, 1 to 5 for wheelchair locomotion, 13 to 14 for communication, and 15 to 20 for cognition. All patients participated in comprehensive in- and outpatient rehabilitation programs. At 6-month follow-up, electrodiagnostic studies showed evidence of reinnervation in all 4 patients. Motor scores ranged from 32 to 70 (mean, 48.5). Follow-up FIM scores also showed modest improvements. In self-care, scores ranged from 10 to 37, with all patients showing increased independence. 2 patients were continent of bowel and bladder, and 2 patients were transferring independently. In locomotion, scores improved to a range of 6 to 8, however, no patients was ambulating independently. Communication and cognition were within normal limits. Discussion: WNV can cause severe neurologic disease, including acute flaccid paralysis and meningoencephalitis. There are limited data regarding functional recovery in such patients. Conclusions: Patients with WNV-associated weakness appear to make modest improvements in strength and function over time. Persistent weakness in the lower extremities limits ambulation skills at 6 months. Key Words: Rehabilitation; West Nile virus.
Poster 168 Ludwig’s Angina Complicated by Nerve Injury: A Case Report. Sanjeev Agarwal, MD, MS, MCH (Nassau University Medical Center, East Meadow, NY); Lynn Weiss, MD; Alberto Rivera, MD, e-mail: [email protected]. Disclosure: None. Setting: Inpatient rehabilitation unit of a tertiary care hospital. Patient: A 21-year-old white man. Case Description: The patient developed Ludwig’s angina after a tooth extraction for an abscess, which was complicated by mediastinitis, pericarditis, pericardial effusion, empyema, multiple pneumonias, respiratory failure leading to tracheostomy and mechanical ventilation, profound weight loss, bilateral hypoglossal nerve injury, and left brachial plexus involvement resulting in upper-extremity weakness. Assessment/Results: The patient had multiple admissions to the department of medicine, medical intensive care, and rehabilitation unit. The medical course was complicated by mediastinitis and pericardial effusion requiring pericardial window, empyema leading to thoracostomy, respiratory failure requiring emergency tracheostomy and ventilatory support, and malnutrition requiring percutaneous endoscopic gastrostomy placement. During his hospital stay, tongue and left upper-extremity weakness was noticed. Electrodiagnostic studies revealed extensive spontaneous potentials and no active motor units in the tongue, the left biceps, deltoid, supraspinatus, and brachioradialis muscles. Discussion: The patient was an active young man with no comorbid conditions. The sublingual and submandibular spaces were infected by direct extension, causing the Ludwig’s angina. In adults, 52% of cases of Ludwig’s angina are caused by dental caries and have a mortality rate of 5% to 10%. Submandibular and sublingual spaces freely communicate and, with involvement of deep cervical fascia, infection may spread rapidly with grave consequences. Extension along the carotid sheath or the retropharyngeal space can cause the mediastinitis. In this patient, nerve injury to both the hypoglossal nerve and the brachial plexus complicated his physical condition and rehabilitation. Conclusions: This case demonstrates the potentially catastrophic complications of odontogenic infections. Prompt diagnosis and early definitive care can minimize the morbidity and mortality of these serious infections.The rehabilitation can be prolonged and requires thorough attention to complications. Key Words: Brachial plexus; Hypoglossal nerve; Ludwig’s angina; Rehabilitation.
Poster 169 The Effect of Comorbidities on Rehabilitation Outcomes in Orthopedic Patients. Xin Wang, MD (Baylor College of Medicine/University of Texas, Houston, TX); Diana H. Rintala, PhD; Helene K. Henson, MD; Susan L. Garber, MA, OTR, e-mail: [email protected]. Disclosure: None. Objective: To investigate the effects of comorbidities (heart disease, diabetes, anemia, hypertension) on functional outcomes and rehabilitation length of stay after total knee or hip replacement or lower-extremity amputation. Design: Retrospective chart review study. Setting: A Veterans Affairs medical center in Texas. Participants: The medical records of 90 patients admitted to inpatient rehabilitation from the orthopedic ward between 1999 and 2002 were reviewed: 50 knee arthroplasty patients (age range, 47– 85y; mean, 64.38y), 18 hip arthroplasty patients (age range, 46 – 85y; mean, 63.3y), and 22 amputees (age, 44 –79y; mean, 64.82y). Interventions: Not applicable. Main Outcome Measures: Comorbidity data (heart disease, diabetes, anemia, hypertension) were obtained from the medical history taken prior to surgery. Hemoglobin was measured presurgery and at admission to rehabilitation. The motor subscale of the FIM™ instrument was administered at admission to and discharge from rehabilitation. Length of stay (LOS) in rehabilitation also was recorded. Results: Heart disease, diabetes, and anemia were more common among patients who had amputations than those who had knee and hip arthroplasty. Amputation patients tended to have lower discharge motor FIM scores and longer LOS than knee arthroplasty patients. However, all 3 groups made substantial motor FIM gains (amputation, 19; knee, 23; hip, 20). Patients with chronic
Arch Phys Med Rehabil Vol 84, September 2003
anemia had longer rehabilitation LOS and lower discharge motor FIM scores. There were no differences between discharge motor FIM scores and motor FIM gains based on whether a person had heart disease, diabetes, or hypertension. Conclusions: The results indicate that patients admitted to rehabilitation for amputation or hip and knee arthroplasty have the potential to improve motor function regardless of comorbidities. However, the surgery itself and some comorbidities may affect functional recovery and LOS after surgery. Key Words: Amputation; Anemia; Arthroplasty; Comorbidity; Rehabilitation. Poster 170 A Study on the Correlation Between Peripheral Dual-Energy X-Ray Absorptiometry and Thoracolumbar X-Ray in the Diagnosis of Compression Deformity Among Patients With Low Bone Mineral Density. Nathaniel Francis G. Precilla, MD (University of Santo Tomas, Quezon City, Philippines), e-mail: n_precilla@ hotmail.com. Disclosure: None. Objectives: To determine the correlation between calcaneal bone mineral density (BMD) and thoracolumbar compression deformities in patients with low BMD. Design: Cross-sectional correlation study. Setting: A veterans medical center in the Philippines. Participants: 147 subjects with a calcaneal BMD fulfilling the World Health Organization’s criteria for osteopenia and osteoporosis. Interventions: Not applicable. Main Outcome Measures: Calcaneal t score using Lunar PIXI dual-energy x-ray absorptiometry; and vertebral compression deformity on thoracolumbar radiography. Results: The bivariate correlation coefficient (r) was equal to –.748 using the Pearson test (P⫽.000). The mean calcaneal t score of subjects with vertebral compression deformity was –3.0649⫾0.6468. A high prevalence of compression deformity was noted in the t score range of –2.4426 to –3.7162. The number of compression deformities increased as the calcaneal t score decreased. Conclusions: There is a significant correlation between the peripheral calcaneal t score and the presence of vertebral compression deformities among patients with low BMD. Key Words: Bone mineral density; Rehabilitation. Poster 171 Treatment of Postanoxic Myoclonus (Lance-Adams Syndrome): A Case Report. Alena Polesin, MD (Columbia University-College of Physician and Surgeons and New York Presbyterian Hospital, New York, NY); Michelle Stern, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care center. Patient: A 62-year-old woman with postanoxic myoclonus. Case Description: The patient presented after cardiopulmonary arrest as a result of aspiration. She developed status epilepticus and was comatose for 3 days. After regaining consciousness, she developed constant jerking movements in all extremities. She was placed on levetriacetam, phenobarbital, and diazepam, but continued to be symptomatic. She was admitted to our facility for treatment of this severely incapacitating movement disorder. After a work-up that included magnetic resonance imaging of the brain and an electroencephalogram, she was diagnosed with Lance-Adams syndrome. She was started on 250mg of divalproex sodium twice daily and 200mg of zonisamide every day, along with lowering her diazepam and phenobarbital dosages and discontinuation of levetriacetam. Over the next 3 days, the patient demonstrated marked functional improvement. The dose of zonisamide was further increased to twice daily and the patient was discharged to home after completing her acute rehabilitation stay. However, 2 weeks later she was readmitted for an exacerbation of myoclonus. Further medication adjustments included discontinuing phenobarbital, divalproex sodium, and diazepam; starting clonazepam at 0.5mg 3 times daily; restarting levetriacetam at 500mg twice daily; and adjusting zonisamide to 100mg 4 times daily. This regimen greatly improved her symptoms. Assessment/Results: At a 2-month follow-up, the patient continued to improve with an increase in clonazepam to 0.5mg 5 times a day and the rest of the regimen unchanged. Discussion: Treatment of postanoxic myoclonus can be difficult and frequently requires medication adjustments to best control the symptoms. It appears that the “second-generation” antiseizure medications can play an important role in ameliorating this disabling condition. Conclusion: Myoclonus can be a disabling complication of an anoxic event. Improvement can occur with use of clonazepam as well as levetriacetam and zonisamide, which deserve further investigation of their antimyoclonic properties. Key Words: Lance-Adams syndrome; Myoclonus; Rehabilitation.
Poster 172 Return of Muscle Strength and Function After Use of Intravenous Immunoglobulin for Lyme Disease–Associated Acute Demyelinating Polyneuropathy. Cynthia Majerske, MD (University of Pittsburgh, Pittsburgh, PA); Brad Dicianno, MD; Gargi Raval, MD; Ross D. Zafonte, DO; Sasa Zivkovic, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care hospital acute rehabilitation unit. Patient: A 58-year-old man with babesiosis and Lyme disease. Case Description: The patient, who had a history of splenectomy, was admitted with diffuse myalgias, fevers, and chills. He had a history of foreign and domestic travel 6 weeks prior. He was diagnosed with babesiosis. The patient’s muscle strength on admission was 5/5 throughout, but declined during his acute care stay. The patient was transferred to the acute rehabilitation floor, where he demonstrated noted weakness primarily in the lower extremities. Through his first week of rehabilitation, he became significantly weaker in hip flexors and knee extensors (to 2⫹/5) as well as developed proximal upper-extremity weakness (to 3⫹/5) for shoulder flexion. An electromyogram (EMG) on day 14 showed primary demyelinating sensorimotor polyneuropathy. Sural nerve biopsy was unremarkable. Western blot for Lyme disease returned positive. He was started on intravenous ceftriaxone, yet deterioration of muscle strength and function was noted. An EMG on day 30 showed continued evidence of demyelinating polyneuropathy with significantly prolonged F-wave latencies in the upper extremities and moderate worsening in conduction velocities in 3 of 4 nerves. He was started on intravenous immunoglobulin (IVIG) on day 33 and received a total of 5 doses over 5 days. Assessment/Results: Patient was discharged on day 38 with improving muscle strength and he was able to ambulate 150ft using a wheeled walker with supervision. At follow-up 8 weeks later, muscle strength had fully returned. Discussion: This case