- Email: [email protected]
Poster 194
A38
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
change was 11.91⫾12.02 and 19.55⫾15.90, respectively; and FIM efficiency score was .2867⫾.4265 and 1.4276⫾1.5205, respectively. ISO patients, compared with non-ISO, had a statistically significant increased LOS, increased charges, and lower FIM efficiency scores. No statistical significance was seen in FIM change between the 2 groups. Conclusions: We found that persons with SCI in isolation had a significantly longer LOS and increased medical charges resulting in lower FIM efficiency score. Ultimately, FIM changes did not differ significantly between groups. Thus, both groups eventually reached similar functional gains, but the nonisolation group reached them with a lower LOS, less cost, and greater efficiency. Key Words: Drug resistance; Rehabilitation; Spinal cord injuries. Poster 192 A CD-ROM–Based Virtual Patient Teaching Resource on Spinal Cord Injury. Sunil Sabharwal, MD (Medical College of Wisconsin, Milwaukee, WI); Deborah Simpson, PhD; Thomasine Dankert, e-mail: [email protected]. Disclosure: None. Setting: A US medical school. Program: In consultation with basic scientists and clinicians, a real-life case of a patient with SCI was adapted to ensure that critical basic science and clinical issues emerged. Program Description: The patient ages over time, providing a longitudinal perspective on changes over a 30-year period after injury. Case details were transcribed into a video script, with each scene under 2 minutes in length to allow for ease of insertion into existing curriculum. The video was digitized for ease of access on a CD-ROM that also includes images, radiograms, lab results, and other files that highlight specific aspects of the case. To facilitate access, the CD is indexed by specific topics (eg, sensory nerves) or by course (eg, physiology). For example, a patient’s neurologic findings are used in an anatomy lecture on spinal dermatomes, and used later in clinical clerkships to teach neurologic examination. A scene with the patient refusing to be turned in bed is used to discuss decision-making capacity in a medical ethics course. The same scene is used in clinical rotations to stress positioning after paralysis or to discuss patient compliance. Assessment/Results: Response by faculty to this initiative has been very positive. The virtual patient with SCI has been incorporated into multiple clinical and basic science courses at our institution. Discussion: Based on positive feedback, the CD-ROM is being distributed nationally. Conclusion: This initiative incorporates SCI and disability education in an overflowing medical curriculum by supporting concepts that are already being taught. Key Words: Medical students; Problem-based learning; Rehabilitation; Spinal cord injuries. Poster 193 The Effect of Hand Dominance on Motor Recovery in Incomplete Cervical Spinal Cord Injury. Jason H. Lee, MD (Thomas Jefferson University, Philadelphia, PA); Anthony Burns, MD; William Staas, MD, e-mail: [email protected]. Disclosure: None. Objective: To determine the relationship between hand dominance and motor recovery in incomplete cervical spinal cord injury (SCI). Design: Retrospective analysis using neurologic assessment at admission and 1 year or later postinjury. Hand dominance prior to injury was obtained via telephone. Setting: Regional SCI center affiliated with a university hospital. Participants: 58 subjects (51 right handed, 7 left handed) with incomplete cervical SCI. Interventions: Traditional medical and rehabilitation care. Main Outcome Measures: Motor point recovery per extremity and percentage recovery per extremity. Percentage recovery was defined as actual motor point recovery per extremity divided by maximum possible motor point recovery per extremity. Outcome measures were analyzed for statistical significance using Wilcoxon test for P values, the Hodges-Lehmann estimates for median differences, and 95% confidence intervals (CIs). Results: The average motor point recovery for upper extremities was 7.84 for the dominant side and 8.97 for the nondominant side. Corresponding values for the lower extremities were 7.19 for the dominant side and 7.66 for the nondominant side. The percentage recovery for the upper extremities was 50% for the dominant side and 51% for the nondominant side; for the lower extremities, 38% for the dominant side and 36% for the nondominant side. The median difference between dominant and nondominant motor point recovery for the upper extremities was –1.0 point (95% CI, –3.0 to 0.5) and – 0.5 points (95% CI, –3.5 to 2.5) in the lower extremities. The median difference between dominant and nondominant percentage of motor recovery was – 4% (95% CI, –13% to 5%) in the upper extremities and –2% (95% CI, –12% to 12%) in the lower extremities. P values failed to reach statistical significance (P⬍.05). Conclusions: Hand dominance does not influence motor recovery in incomplete cervical SCI. Key Words: Dominance, cerebral; Rehabilitation; Spinal cord injuries.
Stroke Poster 194 Association Between Community Independence Level and the Ability to Perform Everyday Tasks in Community-Dwelling Stroke Survivors. Elliot J. Roth, MD (Rehabilitation Institute of Chicago, Chicago, IL); Linda L. Lovell, BS; Rita K. Bode, PhD; Richard L. Harvey, MD, e-mail: [email protected]. Disclosure: None. Objective: To describe the relationship between functional independence in basic activities of daily living and instrumental activities of daily living (IADLs) of stroke survivors living in the community. Design: Prospective, cohort, observational study. Setting: Community. Participants: Stroke survivors living in the community 1 year postdischarge from an acute inpatient rehabilitation program. Interventions: Not applicable. Main Outcome Measures: A structured survey was administered by telephone. Outcome measures were the Frenchay Activities Index (FAI), a measure of IADLs (scores can range from 15 to 52), and the FIM™ instrument, a measure of disability (scores can range from 18 to 126). Results: 57% of the stroke survivors were white, with a mean age ⫾ SD of 63.8⫾14.4 years. The sample was evenly split between men and women. The majority of stroke patients (92%) were living in a private residence. The mean FIM score was 95.9⫾26.8 and mean total FAI score was 26.8⫾9.7. There was a significant and positive correlation between FAI
Arch Phys Med Rehabil Vol 84, September 2003
scores and FIM scores (r⫽.73, P⬍.001). Visual inspection of the relationship between FAI scores and FIM scores revealed that the data largely followed a curvilinear pattern. Curve estimation regression models were used to determine the line of best fit. A cubic function was found to give a good fit with an R2 of .679. A score of approximately ⱖ80 on the FIM was associated with a substantially increased level of participation in home and community activities. Conclusion: There was a strong relationship between the level of participation in IADLs and level of functional independence. Key Words: Activities of daily living; Cerebrovascular accident; Disability evaluation; Rehabilitation. Poster 195 Focal Dystonia After Stroke Leading to Trismus: A Case Report. Michael T. Engle, MD (Ohio State University, Columbus, OH); Vivek Kadyan, MD; Albert Clairmont, MD, e-mail: [email protected]. Disclosure: None. Setting: Midwest acute inpatient rehabilitation hospital. Patient: A 58-year-old woman. Case Description: The patient was diagnosed with a middle cerebral artery and lacunar stroke on January 9, 2002. She was admitted to acute inpatient rehabilitation on February 14, 2002, and was found to have trismus on the second day of admission. Differential diagnoses included: tetanus, abscess, dislocation, slipped disk, fracture, volitional noncooperation, and dystonia. Plain films followed by facial computed tomography with thin cuts did not reveal pathologic findings. Manipulation at bedside with sedation and bilateral masseter muscle block did not result in resolution of trismus. Treatment for tetanus was initiated while titer results were pending. The patient subsequently underwent exam under anesthesia, where her jaw was opened fully and no evidence of fractures, abscess, or dislocation was noted. Facial electromyography revealed increased activity in the left temporalis muscle, consistent with spastic dystonia. The tetanus titers were negative and the most likely diagnosis was focal spastic dystonia. Aggressive treatment was pursued because the patient was unable to accept oral intake and had been at severe nutrition risk since the onset of trismus. Tizanidine was started, and she received adjunctive treatment with 10U of botulinum toxin type A (BTX) by electromyographic guidance to the left temporalis muscle. 6 days later, she had partial resolution of her trismus and was able to tolerate oral intake. Assessment/Results: Focal dystonia of the left temporalis muscle. Discussion: Alterations in muscle tone are a common finding after acute stroke. However, this case demonstrates an unreported complication of stroke, and the importance of dystonia in the differential diagnosis of trismus. We demonstrate the use of BTX for focal spastic dystonia in the acute rehabilitation setting. Conclusions: Focal dystonia of the temporalis muscle is a rare complication of stroke, and must be considered in the differential diagnosis of trismus. Key Words: Cerebrovascular accident; Rehabilitation; Trismus. Poster 196 Fatigue in Stroke Patients During Acute Inpatient Rehabilitation. Christina Kwasnica, MD (Barrow Neurological Institute, Phoenix, AZ); Susan Borgaro, PhD; Heather Caples, PhD, e-mail: [email protected]. Disclosure: None. Objective: To compare patients’ reports of fatigue between inpatient rehabilitation participants and healthy controls. Design: Cohort study. Setting: Inpatient neurorehabilitation unit. Participants: Inpatient rehabilitation participants and neurologically normal controls. Interventions: Not applicable. Main Outcome Measure: Barrow Neurological Institute (BNI) Fatigue Scale. Results: Participants responses on the 11-item BNI Fatigue Scale were recorded for 3 groups: those admitted for cerebrovascular accident (CVA) (n⫽21), those admitted for other neurologic diagnoses (n⫽26), and normal controls (n⫽20). The BNI Fatigue Scale asks patients to describe their level of difficulty on 10 fatigue-related items, such as staying awake during the day or participating in activities throughout the day. A final item (item 11) asks patients to provide an overall rating of their fatigue in the early stages after brain injury. The CVA group reported significantly more fatigue on the total items combined than the non-CVA group, and the non-CVA group reported significantly more fatigue than the normal controls (F2,112⫽8.51, P⬍.001). Individual items were examined to determine group differences. Alpha was set at .005 to control for multiple comparisons. The CVA group reported significantly more fatigue than the control group on items 3, 4, 7, 10, and 11, with the CVA group reporting significantly more fatigue than the non-CVA group on items 3 and 10 (all P⬍.005). Conclusions: For inpatient rehabilitation participants, fatigue is a common influencing factor. Stroke patients reported higher fatigue levels even as early as acute rehabilitation, which can influence participation in therapies. This difference can be see in comparison to other non-CVA diagnoses, as well as to normal controls. Interventions can be aimed at relieving fatigue, both behaviorally and pharmacologically. Future studies must also assess the degree of fatigue in individual patients and how it impacts level of function during inpatient rehabilitation. Key Words: Cerebrovascular accident; Fatigue; Rehabilitation.
Poster 197 Hypotension in Poststroke Patients: Effects on Outcome. Amir M. Qureshi, MD (University of Arkansas for Medical Sciences, Little Rock, AR); Richard P. Gray, MD; Danell Mauldin, OTR; Alice V. Fann, MD, e-mail: [email protected]. Disclosure: None. Objectives: To evaluate (1) the incidence of orthostatic hypotension and hypotension without documented orthostatic blood pressures in poststroke patients who participate in inpatient rehabilitation, and (2) whether hypotension increases length of stay (LOS) or FIM™ instrument changes compare with stroke patients who do not have hypotension. Design: Retrospective study. Setting: Veterans Affairs inpatient rehabilitation ward. Participants: 75 subjects (74 men, 1 women) with first-time acute cerebrovascular accident admitted to rehabilitation floor. Interventions: Not applicable. Main Outcome Measures: Acute and rehabilitation LOS, admission and discharge FIM scores, FIM change, and FIM efficiency (FIM change/rehabilitation LOS). Results: 25 subjects had hypotension, 7 of 25 subjects had orthostatic hypotension, and 18 of 25 had hypotension (at least ⬎20mmHg decrease in blood pressure from the baseline with or without dizziness) without documented orthostatic blood pressures. 50 subjects had no hypotension. Hypotension subjects had
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
change was 11.91⫾12.02 and 19.55⫾15.90, respectively; and FIM efficiency score was .2867⫾.4265 and 1.4276⫾1.5205, respectively. ISO patients, compared with non-ISO, had a statistically significant increased LOS, increased charges, and lower FIM efficiency scores. No statistical significance was seen in FIM change between the 2 groups. Conclusions: We found that persons with SCI in isolation had a significantly longer LOS and increased medical charges resulting in lower FIM efficiency score. Ultimately, FIM changes did not differ significantly between groups. Thus, both groups eventually reached similar functional gains, but the nonisolation group reached them with a lower LOS, less cost, and greater efficiency. Key Words: Drug resistance; Rehabilitation; Spinal cord injuries. Poster 192 A CD-ROM–Based Virtual Patient Teaching Resource on Spinal Cord Injury. Sunil Sabharwal, MD (Medical College of Wisconsin, Milwaukee, WI); Deborah Simpson, PhD; Thomasine Dankert, e-mail: [email protected]. Disclosure: None. Setting: A US medical school. Program: In consultation with basic scientists and clinicians, a real-life case of a patient with SCI was adapted to ensure that critical basic science and clinical issues emerged. Program Description: The patient ages over time, providing a longitudinal perspective on changes over a 30-year period after injury. Case details were transcribed into a video script, with each scene under 2 minutes in length to allow for ease of insertion into existing curriculum. The video was digitized for ease of access on a CD-ROM that also includes images, radiograms, lab results, and other files that highlight specific aspects of the case. To facilitate access, the CD is indexed by specific topics (eg, sensory nerves) or by course (eg, physiology). For example, a patient’s neurologic findings are used in an anatomy lecture on spinal dermatomes, and used later in clinical clerkships to teach neurologic examination. A scene with the patient refusing to be turned in bed is used to discuss decision-making capacity in a medical ethics course. The same scene is used in clinical rotations to stress positioning after paralysis or to discuss patient compliance. Assessment/Results: Response by faculty to this initiative has been very positive. The virtual patient with SCI has been incorporated into multiple clinical and basic science courses at our institution. Discussion: Based on positive feedback, the CD-ROM is being distributed nationally. Conclusion: This initiative incorporates SCI and disability education in an overflowing medical curriculum by supporting concepts that are already being taught. Key Words: Medical students; Problem-based learning; Rehabilitation; Spinal cord injuries. Poster 193 The Effect of Hand Dominance on Motor Recovery in Incomplete Cervical Spinal Cord Injury. Jason H. Lee, MD (Thomas Jefferson University, Philadelphia, PA); Anthony Burns, MD; William Staas, MD, e-mail: [email protected]. Disclosure: None. Objective: To determine the relationship between hand dominance and motor recovery in incomplete cervical spinal cord injury (SCI). Design: Retrospective analysis using neurologic assessment at admission and 1 year or later postinjury. Hand dominance prior to injury was obtained via telephone. Setting: Regional SCI center affiliated with a university hospital. Participants: 58 subjects (51 right handed, 7 left handed) with incomplete cervical SCI. Interventions: Traditional medical and rehabilitation care. Main Outcome Measures: Motor point recovery per extremity and percentage recovery per extremity. Percentage recovery was defined as actual motor point recovery per extremity divided by maximum possible motor point recovery per extremity. Outcome measures were analyzed for statistical significance using Wilcoxon test for P values, the Hodges-Lehmann estimates for median differences, and 95% confidence intervals (CIs). Results: The average motor point recovery for upper extremities was 7.84 for the dominant side and 8.97 for the nondominant side. Corresponding values for the lower extremities were 7.19 for the dominant side and 7.66 for the nondominant side. The percentage recovery for the upper extremities was 50% for the dominant side and 51% for the nondominant side; for the lower extremities, 38% for the dominant side and 36% for the nondominant side. The median difference between dominant and nondominant motor point recovery for the upper extremities was –1.0 point (95% CI, –3.0 to 0.5) and – 0.5 points (95% CI, –3.5 to 2.5) in the lower extremities. The median difference between dominant and nondominant percentage of motor recovery was – 4% (95% CI, –13% to 5%) in the upper extremities and –2% (95% CI, –12% to 12%) in the lower extremities. P values failed to reach statistical significance (P⬍.05). Conclusions: Hand dominance does not influence motor recovery in incomplete cervical SCI. Key Words: Dominance, cerebral; Rehabilitation; Spinal cord injuries.
Stroke Poster 194 Association Between Community Independence Level and the Ability to Perform Everyday Tasks in Community-Dwelling Stroke Survivors. Elliot J. Roth, MD (Rehabilitation Institute of Chicago, Chicago, IL); Linda L. Lovell, BS; Rita K. Bode, PhD; Richard L. Harvey, MD, e-mail: [email protected]. Disclosure: None. Objective: To describe the relationship between functional independence in basic activities of daily living and instrumental activities of daily living (IADLs) of stroke survivors living in the community. Design: Prospective, cohort, observational study. Setting: Community. Participants: Stroke survivors living in the community 1 year postdischarge from an acute inpatient rehabilitation program. Interventions: Not applicable. Main Outcome Measures: A structured survey was administered by telephone. Outcome measures were the Frenchay Activities Index (FAI), a measure of IADLs (scores can range from 15 to 52), and the FIM™ instrument, a measure of disability (scores can range from 18 to 126). Results: 57% of the stroke survivors were white, with a mean age ⫾ SD of 63.8⫾14.4 years. The sample was evenly split between men and women. The majority of stroke patients (92%) were living in a private residence. The mean FIM score was 95.9⫾26.8 and mean total FAI score was 26.8⫾9.7. There was a significant and positive correlation between FAI
Arch Phys Med Rehabil Vol 84, September 2003
scores and FIM scores (r⫽.73, P⬍.001). Visual inspection of the relationship between FAI scores and FIM scores revealed that the data largely followed a curvilinear pattern. Curve estimation regression models were used to determine the line of best fit. A cubic function was found to give a good fit with an R2 of .679. A score of approximately ⱖ80 on the FIM was associated with a substantially increased level of participation in home and community activities. Conclusion: There was a strong relationship between the level of participation in IADLs and level of functional independence. Key Words: Activities of daily living; Cerebrovascular accident; Disability evaluation; Rehabilitation. Poster 195 Focal Dystonia After Stroke Leading to Trismus: A Case Report. Michael T. Engle, MD (Ohio State University, Columbus, OH); Vivek Kadyan, MD; Albert Clairmont, MD, e-mail: [email protected]. Disclosure: None. Setting: Midwest acute inpatient rehabilitation hospital. Patient: A 58-year-old woman. Case Description: The patient was diagnosed with a middle cerebral artery and lacunar stroke on January 9, 2002. She was admitted to acute inpatient rehabilitation on February 14, 2002, and was found to have trismus on the second day of admission. Differential diagnoses included: tetanus, abscess, dislocation, slipped disk, fracture, volitional noncooperation, and dystonia. Plain films followed by facial computed tomography with thin cuts did not reveal pathologic findings. Manipulation at bedside with sedation and bilateral masseter muscle block did not result in resolution of trismus. Treatment for tetanus was initiated while titer results were pending. The patient subsequently underwent exam under anesthesia, where her jaw was opened fully and no evidence of fractures, abscess, or dislocation was noted. Facial electromyography revealed increased activity in the left temporalis muscle, consistent with spastic dystonia. The tetanus titers were negative and the most likely diagnosis was focal spastic dystonia. Aggressive treatment was pursued because the patient was unable to accept oral intake and had been at severe nutrition risk since the onset of trismus. Tizanidine was started, and she received adjunctive treatment with 10U of botulinum toxin type A (BTX) by electromyographic guidance to the left temporalis muscle. 6 days later, she had partial resolution of her trismus and was able to tolerate oral intake. Assessment/Results: Focal dystonia of the left temporalis muscle. Discussion: Alterations in muscle tone are a common finding after acute stroke. However, this case demonstrates an unreported complication of stroke, and the importance of dystonia in the differential diagnosis of trismus. We demonstrate the use of BTX for focal spastic dystonia in the acute rehabilitation setting. Conclusions: Focal dystonia of the temporalis muscle is a rare complication of stroke, and must be considered in the differential diagnosis of trismus. Key Words: Cerebrovascular accident; Rehabilitation; Trismus. Poster 196 Fatigue in Stroke Patients During Acute Inpatient Rehabilitation. Christina Kwasnica, MD (Barrow Neurological Institute, Phoenix, AZ); Susan Borgaro, PhD; Heather Caples, PhD, e-mail: [email protected]. Disclosure: None. Objective: To compare patients’ reports of fatigue between inpatient rehabilitation participants and healthy controls. Design: Cohort study. Setting: Inpatient neurorehabilitation unit. Participants: Inpatient rehabilitation participants and neurologically normal controls. Interventions: Not applicable. Main Outcome Measure: Barrow Neurological Institute (BNI) Fatigue Scale. Results: Participants responses on the 11-item BNI Fatigue Scale were recorded for 3 groups: those admitted for cerebrovascular accident (CVA) (n⫽21), those admitted for other neurologic diagnoses (n⫽26), and normal controls (n⫽20). The BNI Fatigue Scale asks patients to describe their level of difficulty on 10 fatigue-related items, such as staying awake during the day or participating in activities throughout the day. A final item (item 11) asks patients to provide an overall rating of their fatigue in the early stages after brain injury. The CVA group reported significantly more fatigue on the total items combined than the non-CVA group, and the non-CVA group reported significantly more fatigue than the normal controls (F2,112⫽8.51, P⬍.001). Individual items were examined to determine group differences. Alpha was set at .005 to control for multiple comparisons. The CVA group reported significantly more fatigue than the control group on items 3, 4, 7, 10, and 11, with the CVA group reporting significantly more fatigue than the non-CVA group on items 3 and 10 (all P⬍.005). Conclusions: For inpatient rehabilitation participants, fatigue is a common influencing factor. Stroke patients reported higher fatigue levels even as early as acute rehabilitation, which can influence participation in therapies. This difference can be see in comparison to other non-CVA diagnoses, as well as to normal controls. Interventions can be aimed at relieving fatigue, both behaviorally and pharmacologically. Future studies must also assess the degree of fatigue in individual patients and how it impacts level of function during inpatient rehabilitation. Key Words: Cerebrovascular accident; Fatigue; Rehabilitation.
Poster 197 Hypotension in Poststroke Patients: Effects on Outcome. Amir M. Qureshi, MD (University of Arkansas for Medical Sciences, Little Rock, AR); Richard P. Gray, MD; Danell Mauldin, OTR; Alice V. Fann, MD, e-mail: [email protected]. Disclosure: None. Objectives: To evaluate (1) the incidence of orthostatic hypotension and hypotension without documented orthostatic blood pressures in poststroke patients who participate in inpatient rehabilitation, and (2) whether hypotension increases length of stay (LOS) or FIM™ instrument changes compare with stroke patients who do not have hypotension. Design: Retrospective study. Setting: Veterans Affairs inpatient rehabilitation ward. Participants: 75 subjects (74 men, 1 women) with first-time acute cerebrovascular accident admitted to rehabilitation floor. Interventions: Not applicable. Main Outcome Measures: Acute and rehabilitation LOS, admission and discharge FIM scores, FIM change, and FIM efficiency (FIM change/rehabilitation LOS). Results: 25 subjects had hypotension, 7 of 25 subjects had orthostatic hypotension, and 18 of 25 had hypotension (at least ⬎20mmHg decrease in blood pressure from the baseline with or without dizziness) without documented orthostatic blood pressures. 50 subjects had no hypotension. Hypotension subjects had