- Email: [email protected]
Poster 17 Anton Syndrome After Gun Shot Wound to Head: A Case Report
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in pain when including all 18 patients. The patients had an average follow up of 55 days, with follow pain score of 0 in most of the cases. Adverse events included one patient who had transient numbness of the face in superior orbital distribution and one subject who felt light-headed for 10 minutes after the procedure. Conclusions: Trigeminal and occipital nerve blocks in patients with post traumatic headaches who meet criteria for trigeminal and/or occipital neuralgia appear safe and effective. Further prospective randomized controlled trials are needed to corroborate the efficacy and safety of these procedures in post concussive headaches. Poster 15 Cause of Tears in a Patient with Tolosa-Hunt and Locked-In Syndromes. Yan Gu, MD, PhD (Temple University Hospital, Philadelphia, PA, United States); Alyson F. Axelrod, DO; Sooja Cho, MD. Disclosures: Y. Gu, No Disclosures. Case Description: A patient with Tolosa-Hunt syndrome and left eye blindness presented with generalized weakness to acute care and was diagnosed with a basilar infarct affecting the bilateral pontine, left cerebellar, and occipital and right thalamic regions of the brain. She developed locked-in-syndrome requiring a tracheostomy and jejunostomy. Over 2 months in a longterm care facility, she was weaned off the ventilator. She then presented to acute rehabilitation, and on examination had poor oral and head control, was tetraparetic, and was unable to communicate her basic needs. She was taught to look upward for yes and downward for no with her right eye. However, she was often tearful, making this communication technique ineffective. The patient’s tearfulness had a differential diagnosis of pain, pseudobulbar affect, or depression. With trials using a cylindrical device around her head with an attached laser pointer, she pointed to pictures or words on a sheet of paper in front of her to communicate. She spelled “pain” to explain her tearfulness. Her pain medication was titrated to minimize discomfort. With improving head control at around 3 weeks, she was able to use a computer communication device with eye gaze. Program Description: A 39-year-old woman. Setting: Tertiary care rehabilitation center. Results or Clinical Course: Within 1 month, the patient achieved up to a 90% accuracy rate for yes/no and object identification questions with mild to moderate delay when targeting words or pictures. Discussion: Tolosa-Hunt syndrome is a rare disorder characterized by severe and unilateral headaches with extraocular palsies. This is the first reported case, to our knowledge, complicated with locked-in syndrome, which is a great challenge for basic communication. We do not know the internal relationship of these two individual diseases, and there is no available literature to explain the possible pathophysiology. Keen observation and a comprehensive approach for effective communication is vital in the rehabilitation setting to treat patients effectively and to improve quality of life. Conclusions: Effective communication can be achieved in a patient with Tolosa-Hunt and locked-in syndromes.
PRESENTATIONS
Poster 16 Can Virtual Reality Inform Our Understanding of the Cognitive Demands of Driving? Anna C. Graefe, BA (Drexel University, Philadelphia, PA, United States); Linda N. Boyle, PhD; Nicole Graff, n/a; Kevin J. Manning, MA; Roman Mitura, B.S.; David M. Neyens, PhD; Maria T. Schultheis, PhD. Disclosures: A. C. Graefe, No Disclosures. Objective: Virtual reality driving simulation (VRDS) offers the ability to examine driving performance in challenging conditions that can enhance our knowledge of the cognitive demands of driving. The current study examined differences among drivers with a brain injury with no cognitive impairment (NP-) and those with cognitive impairment (NP⫹) and healthy controls (HC) drivers in a VRDS driving task requiring participants to stop unexpectedly when a boy follows a ball into the road. Design: Between group comparisons. Setting: Laboratory-based VRDS. Participants: 10 NP⫺, 13 NP⫹ and 26 HC participants were matched on age, gender, and driving experience. The current study was part of a larger study involving on-road performance and required participants to be licensed, community dwelling individuals. Interventions: Not Applicable. Main Outcome Measures: Speed during approach to the boy and ball task, time to stop, distance stopped from the boy, and time paused before beginning to drive again; neuropsychological tests measuring verbal and visual memory, attention, inhibition, and visual-spatial skills. Results: Results of a group X driving outcome one-way ANOVA conducted for each of the driving outcome measures showed no significant differences among the three groups. Correlations between neuropsychological performance measures and driving outcome measures for those with brain injury (both NP⫹ and NPgroups) showed that poorer verbal memory was related to slower speed when approaching the boy, but that slower processing speed was associated with greater speed when approaching the boy. In addition, slower processing speed was related to stopping a farther distance from the boy. Conclusions: These findings suggest that drivers with BI demonstrate similar driving behaviors to matched HC drivers. Importantly, VRDS is related to specific cognitive domains relevant to driving and may help define skills needed to respond to changing driving conditions. Poster 17 Anton Syndrome After Gun Shot Wound to Head: A Case Report. Anuradha Mutyala, MD (Nassau University Medical Center, New york, NY, United States); Ricardo Cruz, MD; Sasha Iversen; Farah Siddiqui, MD; Lyn Weiss, MD. Disclosures: A. Mutyala, No Disclosures. Setting: Inpatient acute rehab (hospital). Results or Clinical Course: 23-year-old man sustained a gun shot wound to the left occipital lobe. His initial GCS was 7T, and was found to have a left occipital entry point with ricochet off left temporal inner table, with fragments projecting into the right anterior cranial fossa. He sustained hemorrhages to the right occipital and temporal regions, right subdural hematoma, bilateral subarachnoid hemorrhages, midline shift with subfalcine herniation, and
PM&R
cerebellar tonsillar herniation. He underwent emergent craniectomy and right anterior temporoparietal lobectomy. On POD 5, he was found to have intact EOMs and pupillary reflex, intact light perception, but he was unable to visually track or identify objects. At this time he denied vision loss, and was found to be confabulating parts of the visual examination, and was diagnosed with Anton Syndrome. The remainder of his examination was intact for strength, sensation, and cranial nerves, and he was classified as a Ranchos los Amigos level IV. He was transferred to an acute inpatient rehabilitation setting with Ranchos level VI on POD 17. At this time he was only able to identify shadows. On POD 18 he was able to distinguish outline of shapes; by POD 21 he was able to identify colors and track objects. At this time it was apparent that the patient was recovering some vision but was demonstrating visual object agnosia and prosopagnosia in that he was unable to recognize details of objects or his own face. He also demonstrated alexia without agraphia. Therapies focused on tactile kinesthetic input to facilitate object recognition and initiation of eye movements. By discharge on POD 31 he was able to identify objects and characteristics of faces, read large letters and numbers, with MME of 28/30 on discharge. Conclusions: Cortical blindness (Anton Syndrome) is a rare symptom of brain damage occurring in the bilateral occipital lobes, with preservation of pupillary reaction, optic nerve function, with denial of visual loss and confabulation. This patient had Anton syndrome secondary to TBI resulting from GSW. Resolving cortical edema resolved the Anton Sydrome, but revealed agnosia, prosopagnosia, and alexia without agraphia. Patient participated in Speech therapy, PT, and OT with improvement in ambulation, cognition and ADLs. Poster 18 A Correlative Study of the Self-Reported Pain Disability Questionnaire, from the AMA Guides 6th Edition, and the Clinician-Derived Physical Performance Tests on Subjects with Traumatic Brain Injury > 2 Years and with Chronic Pain: Case Series. Armando S. Miciano, MD (Nevada Rehabilitation Institute, Las Vegas, NV, United States); Chad Cross, PhD, PStat(R); Monique David, RN. Disclosures: A. S. Miciano, No Disclosures. Objective: The objectives were to quantify the pain-related impairments (PRI) of individuals with traumatic brain injury (TBI) ⬎2 years and chronic non-malignant pain (CNP) using the self-reported Pain Disability Questionnaire (PDQ), from the AMA Guides to Evaluation of Permanent Impairment 6th Edition, and to investigate the correlation between PRI and scores from clinician-derived Physical Performance Test (PPT) scores. Design: Retrospective cross-sectional study. Setting: Outpatient physical medicine and rehabilitation clinic. Participants: 70 participants reporting poly-trauma (ages 22-78 years). Interventions: None. Main Outcome Measures: The Self-Administered Co-Morbidity Questionnaire identified 21 individuals with TBI afflicted with CNP. The PDQ quantified PRI via two sub-scales: Functional Status (FS) and Psychosocial Status (PS). The PPT was: 6-Minute Walk (6MWT), Berg Balance Scale (BBS), and Dynamic Gait Index
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(DGI). Owing to small sample size, all statistical tests used nonparametric procedures. Results: Median differences among all variables were found to be similar for males and females (all P⬎.05). Pain severity, as measured by total PDQ score, was also the same among participants (all P⬎.05). Hence, all data were pooled prior to calculating Spearman’s rank correlations. The PDQ Functional Status score was significantly correlated with DGI (rs ⫽ ⫺.565, P⫽.008), BBS (rs ⫽ ⫺.451, P⫽.040), and all three 6MWT metrics (Distance: rs ⫽ ⫺.590, P⫽.005; METS: rs ⫽ ⫺.565, P⫽.008; and Speed: rs ⫽ ⫺.579, P⫽.006). PDQ psychosocial scores were not correlated with the PPT measures. Conclusions: Individuals with TBI ⬎ 2 years and CNP on average had moderate pain-related impairments. These findings suggest that the self-reported PDQ is a reliable indicator of physical performance and a valuable alternative to PPT for clinicians assessing individuals with TBI and chronic pain. The PDQ and its FS subscale show promise as a clinical tool that is relatively easy and quick to administer in a busy practice. Further research into the application of the PDQ and the PPT amongst other patient populations with nervous system disorders would be beneficial. Poster 19 The Health-Related Quality of Life, Global Physical Health, and the Work Performance of Individuals with Traumatic Brain Injury and Chronic Musculoskeletal Disorder. Armando S. Miciano, MD (Nevada Rehabilitation Institute, Las Vegas, NV, United States); Chad Cross, PhD, PStat(R); Monique David, RN. Disclosures: A. S. Miciano, No Disclosures. Objective: The objective is to examine the impact of physical musculoskeletal complaints (MSC) in a traumatic brain injury (TBI) survivor population ⬎ 2 years post-injury. Design: Retrospective cohort design. Setting: Outpatient rehabilitation clinic. Participants: 100 Individuals with history of poly-trauma (PTM) ⬎2 years. Interventions: None. Main Outcome Measures: The Self-Administered Co-Morbidity Questionnaire (SCQ) screened individuals with history of PTM and separate the individuals with TBI and MSC (n⫽11) and those without TBI but with a MSC (n⫽25) owing to a spine impairment (WSI). Outcome measures used were: SCQ for determining multi-morbidity burden, SF-36 Physical Component (PC) for health-related quality of life, and PROMIS-57 Physical Function (PF) sub-scale for global physical health. The 6-Minute Walk Test (6MWT) measured the work performance (WP) using a prediction equation. Results: PTM subjects demonstrated (mean TBI/WSI; SD; range): SCQ (6.8/7.4; 2.79/3.64; 2-9/0-15), PC (32.0/31.4; 9.63/6.63; 1851/22-48), PF (19.6/20; 9.71/6.84; 9-35/8-32), and 6MWT-WP (54.1/57.9; 10.03/7.81; 38-67/43-73). No statistical differences were found between those with TBI & MSC and those with WSI (Mann-Whitney U, all P⬎.05). Observations of the means and standard deviations indicate that there was very little difference in any variable that was measured, despite subjects having co-morbid musculoskeletal impairments, making it unlikely that increasing sample sizes, even dramatically, would lead to a significant difference in the outcome measures.
in pain when including all 18 patients. The patients had an average follow up of 55 days, with follow pain score of 0 in most of the cases. Adverse events included one patient who had transient numbness of the face in superior orbital distribution and one subject who felt light-headed for 10 minutes after the procedure. Conclusions: Trigeminal and occipital nerve blocks in patients with post traumatic headaches who meet criteria for trigeminal and/or occipital neuralgia appear safe and effective. Further prospective randomized controlled trials are needed to corroborate the efficacy and safety of these procedures in post concussive headaches. Poster 15 Cause of Tears in a Patient with Tolosa-Hunt and Locked-In Syndromes. Yan Gu, MD, PhD (Temple University Hospital, Philadelphia, PA, United States); Alyson F. Axelrod, DO; Sooja Cho, MD. Disclosures: Y. Gu, No Disclosures. Case Description: A patient with Tolosa-Hunt syndrome and left eye blindness presented with generalized weakness to acute care and was diagnosed with a basilar infarct affecting the bilateral pontine, left cerebellar, and occipital and right thalamic regions of the brain. She developed locked-in-syndrome requiring a tracheostomy and jejunostomy. Over 2 months in a longterm care facility, she was weaned off the ventilator. She then presented to acute rehabilitation, and on examination had poor oral and head control, was tetraparetic, and was unable to communicate her basic needs. She was taught to look upward for yes and downward for no with her right eye. However, she was often tearful, making this communication technique ineffective. The patient’s tearfulness had a differential diagnosis of pain, pseudobulbar affect, or depression. With trials using a cylindrical device around her head with an attached laser pointer, she pointed to pictures or words on a sheet of paper in front of her to communicate. She spelled “pain” to explain her tearfulness. Her pain medication was titrated to minimize discomfort. With improving head control at around 3 weeks, she was able to use a computer communication device with eye gaze. Program Description: A 39-year-old woman. Setting: Tertiary care rehabilitation center. Results or Clinical Course: Within 1 month, the patient achieved up to a 90% accuracy rate for yes/no and object identification questions with mild to moderate delay when targeting words or pictures. Discussion: Tolosa-Hunt syndrome is a rare disorder characterized by severe and unilateral headaches with extraocular palsies. This is the first reported case, to our knowledge, complicated with locked-in syndrome, which is a great challenge for basic communication. We do not know the internal relationship of these two individual diseases, and there is no available literature to explain the possible pathophysiology. Keen observation and a comprehensive approach for effective communication is vital in the rehabilitation setting to treat patients effectively and to improve quality of life. Conclusions: Effective communication can be achieved in a patient with Tolosa-Hunt and locked-in syndromes.
PRESENTATIONS
Poster 16 Can Virtual Reality Inform Our Understanding of the Cognitive Demands of Driving? Anna C. Graefe, BA (Drexel University, Philadelphia, PA, United States); Linda N. Boyle, PhD; Nicole Graff, n/a; Kevin J. Manning, MA; Roman Mitura, B.S.; David M. Neyens, PhD; Maria T. Schultheis, PhD. Disclosures: A. C. Graefe, No Disclosures. Objective: Virtual reality driving simulation (VRDS) offers the ability to examine driving performance in challenging conditions that can enhance our knowledge of the cognitive demands of driving. The current study examined differences among drivers with a brain injury with no cognitive impairment (NP-) and those with cognitive impairment (NP⫹) and healthy controls (HC) drivers in a VRDS driving task requiring participants to stop unexpectedly when a boy follows a ball into the road. Design: Between group comparisons. Setting: Laboratory-based VRDS. Participants: 10 NP⫺, 13 NP⫹ and 26 HC participants were matched on age, gender, and driving experience. The current study was part of a larger study involving on-road performance and required participants to be licensed, community dwelling individuals. Interventions: Not Applicable. Main Outcome Measures: Speed during approach to the boy and ball task, time to stop, distance stopped from the boy, and time paused before beginning to drive again; neuropsychological tests measuring verbal and visual memory, attention, inhibition, and visual-spatial skills. Results: Results of a group X driving outcome one-way ANOVA conducted for each of the driving outcome measures showed no significant differences among the three groups. Correlations between neuropsychological performance measures and driving outcome measures for those with brain injury (both NP⫹ and NPgroups) showed that poorer verbal memory was related to slower speed when approaching the boy, but that slower processing speed was associated with greater speed when approaching the boy. In addition, slower processing speed was related to stopping a farther distance from the boy. Conclusions: These findings suggest that drivers with BI demonstrate similar driving behaviors to matched HC drivers. Importantly, VRDS is related to specific cognitive domains relevant to driving and may help define skills needed to respond to changing driving conditions. Poster 17 Anton Syndrome After Gun Shot Wound to Head: A Case Report. Anuradha Mutyala, MD (Nassau University Medical Center, New york, NY, United States); Ricardo Cruz, MD; Sasha Iversen; Farah Siddiqui, MD; Lyn Weiss, MD. Disclosures: A. Mutyala, No Disclosures. Setting: Inpatient acute rehab (hospital). Results or Clinical Course: 23-year-old man sustained a gun shot wound to the left occipital lobe. His initial GCS was 7T, and was found to have a left occipital entry point with ricochet off left temporal inner table, with fragments projecting into the right anterior cranial fossa. He sustained hemorrhages to the right occipital and temporal regions, right subdural hematoma, bilateral subarachnoid hemorrhages, midline shift with subfalcine herniation, and
PM&R
cerebellar tonsillar herniation. He underwent emergent craniectomy and right anterior temporoparietal lobectomy. On POD 5, he was found to have intact EOMs and pupillary reflex, intact light perception, but he was unable to visually track or identify objects. At this time he denied vision loss, and was found to be confabulating parts of the visual examination, and was diagnosed with Anton Syndrome. The remainder of his examination was intact for strength, sensation, and cranial nerves, and he was classified as a Ranchos los Amigos level IV. He was transferred to an acute inpatient rehabilitation setting with Ranchos level VI on POD 17. At this time he was only able to identify shadows. On POD 18 he was able to distinguish outline of shapes; by POD 21 he was able to identify colors and track objects. At this time it was apparent that the patient was recovering some vision but was demonstrating visual object agnosia and prosopagnosia in that he was unable to recognize details of objects or his own face. He also demonstrated alexia without agraphia. Therapies focused on tactile kinesthetic input to facilitate object recognition and initiation of eye movements. By discharge on POD 31 he was able to identify objects and characteristics of faces, read large letters and numbers, with MME of 28/30 on discharge. Conclusions: Cortical blindness (Anton Syndrome) is a rare symptom of brain damage occurring in the bilateral occipital lobes, with preservation of pupillary reaction, optic nerve function, with denial of visual loss and confabulation. This patient had Anton syndrome secondary to TBI resulting from GSW. Resolving cortical edema resolved the Anton Sydrome, but revealed agnosia, prosopagnosia, and alexia without agraphia. Patient participated in Speech therapy, PT, and OT with improvement in ambulation, cognition and ADLs. Poster 18 A Correlative Study of the Self-Reported Pain Disability Questionnaire, from the AMA Guides 6th Edition, and the Clinician-Derived Physical Performance Tests on Subjects with Traumatic Brain Injury > 2 Years and with Chronic Pain: Case Series. Armando S. Miciano, MD (Nevada Rehabilitation Institute, Las Vegas, NV, United States); Chad Cross, PhD, PStat(R); Monique David, RN. Disclosures: A. S. Miciano, No Disclosures. Objective: The objectives were to quantify the pain-related impairments (PRI) of individuals with traumatic brain injury (TBI) ⬎2 years and chronic non-malignant pain (CNP) using the self-reported Pain Disability Questionnaire (PDQ), from the AMA Guides to Evaluation of Permanent Impairment 6th Edition, and to investigate the correlation between PRI and scores from clinician-derived Physical Performance Test (PPT) scores. Design: Retrospective cross-sectional study. Setting: Outpatient physical medicine and rehabilitation clinic. Participants: 70 participants reporting poly-trauma (ages 22-78 years). Interventions: None. Main Outcome Measures: The Self-Administered Co-Morbidity Questionnaire identified 21 individuals with TBI afflicted with CNP. The PDQ quantified PRI via two sub-scales: Functional Status (FS) and Psychosocial Status (PS). The PPT was: 6-Minute Walk (6MWT), Berg Balance Scale (BBS), and Dynamic Gait Index
Vol. 4, Iss. 10S, 2012
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(DGI). Owing to small sample size, all statistical tests used nonparametric procedures. Results: Median differences among all variables were found to be similar for males and females (all P⬎.05). Pain severity, as measured by total PDQ score, was also the same among participants (all P⬎.05). Hence, all data were pooled prior to calculating Spearman’s rank correlations. The PDQ Functional Status score was significantly correlated with DGI (rs ⫽ ⫺.565, P⫽.008), BBS (rs ⫽ ⫺.451, P⫽.040), and all three 6MWT metrics (Distance: rs ⫽ ⫺.590, P⫽.005; METS: rs ⫽ ⫺.565, P⫽.008; and Speed: rs ⫽ ⫺.579, P⫽.006). PDQ psychosocial scores were not correlated with the PPT measures. Conclusions: Individuals with TBI ⬎ 2 years and CNP on average had moderate pain-related impairments. These findings suggest that the self-reported PDQ is a reliable indicator of physical performance and a valuable alternative to PPT for clinicians assessing individuals with TBI and chronic pain. The PDQ and its FS subscale show promise as a clinical tool that is relatively easy and quick to administer in a busy practice. Further research into the application of the PDQ and the PPT amongst other patient populations with nervous system disorders would be beneficial. Poster 19 The Health-Related Quality of Life, Global Physical Health, and the Work Performance of Individuals with Traumatic Brain Injury and Chronic Musculoskeletal Disorder. Armando S. Miciano, MD (Nevada Rehabilitation Institute, Las Vegas, NV, United States); Chad Cross, PhD, PStat(R); Monique David, RN. Disclosures: A. S. Miciano, No Disclosures. Objective: The objective is to examine the impact of physical musculoskeletal complaints (MSC) in a traumatic brain injury (TBI) survivor population ⬎ 2 years post-injury. Design: Retrospective cohort design. Setting: Outpatient rehabilitation clinic. Participants: 100 Individuals with history of poly-trauma (PTM) ⬎2 years. Interventions: None. Main Outcome Measures: The Self-Administered Co-Morbidity Questionnaire (SCQ) screened individuals with history of PTM and separate the individuals with TBI and MSC (n⫽11) and those without TBI but with a MSC (n⫽25) owing to a spine impairment (WSI). Outcome measures used were: SCQ for determining multi-morbidity burden, SF-36 Physical Component (PC) for health-related quality of life, and PROMIS-57 Physical Function (PF) sub-scale for global physical health. The 6-Minute Walk Test (6MWT) measured the work performance (WP) using a prediction equation. Results: PTM subjects demonstrated (mean TBI/WSI; SD; range): SCQ (6.8/7.4; 2.79/3.64; 2-9/0-15), PC (32.0/31.4; 9.63/6.63; 1851/22-48), PF (19.6/20; 9.71/6.84; 9-35/8-32), and 6MWT-WP (54.1/57.9; 10.03/7.81; 38-67/43-73). No statistical differences were found between those with TBI & MSC and those with WSI (Mann-Whitney U, all P⬎.05). Observations of the means and standard deviations indicate that there was very little difference in any variable that was measured, despite subjects having co-morbid musculoskeletal impairments, making it unlikely that increasing sample sizes, even dramatically, would lead to a significant difference in the outcome measures.