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Poster 247 Treatment of hip flexor spasticity post traumatic brain injury with botulinum toxin: A case report
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
periods were scored, averaged, and compared using standard statistical tests. For the subject in the caffeine study definite trends were noted in crossover from caffeinated to placebo treatment periods and overall mean performance scores were significantly lower during caffeine administration (p < .01). In the amantidine study no observable trends or significant differences were noted. Study design, methods, test results and their possible implication and use in this population are discussed.
Poster 246 "Akathisia Resulting from Traumatic Brain Injury." Bernard V. Silver, PhD (Bayior College of Medicine/The Institute for Rehabilitation and Research, Houston, TX); Stuart A. Yablon, MD. Agitation and restlessness are commonly reported sequelae of traumatic brain injury (TBI). A recent case study reported severe restlessness (akathisia) in a patient with bilateral orbitofrontal lesions after TBI. Administration of bromocriptine coincided with rapid resolution of the akathisia leading to speculation that such behavior is related to decreased dopaminergic activity resulting from prefrontal lesions. We report an unusual case of marked restlessness following TBI in a 17-year-old woman. When admitted for rehabilitation 6 weeks after injury, she was alert but agitated and severely restless. She constantly paced her room and the unit repeatedly retracing the same route. While generally mute, she would provide terse written responses to questions. Due to these behavioral sequelae, a trial of bromocriptine was considered. The Agitated Behavior Scale and Galveston Orientation and Amnesia Test were used to monitor restlessness and agitation. Unexpectedly, during baseline evaluation, her restlessness began to resolve rapidly with simultaneous improvement in orientation. While remaining appreciably restless, she became verbal and oriented within expected limits. MRI showed large, well-delineated bifrontal contusions. This case lends support to the hypothesis that agitation and restlessness are related to lesions of prefrontal cortex.
Poster 247 "Treatment of Hip Flexor Spasticity Post Traumatic Brain Injury with Botulinum Toxin: A Case Report." Elie P. Elovic, MD (JFK Hospital, Johnson Rehabilitation Institute); Todd J. Cooperman, MD; Cindy A. Fong, PT; Thomas Strax, MD. Treatment of spasticity is one of the most challenging aspects of the physical rehabilitation of the individual who has sustained a Traumatic brain injury (TBI). Sitting, positioning, transfers, and ambulation are all affected by spasticity and treatment of a hip flexor with abnormal tone can be extremely difficult. The administration of anti-spasticity medications are of very limited efficacy for the patient with TBI, while many of the therapeutic modalities are of limited benefit for the hip flexors. Percutaneous nerve blocks for the lliopsoas are demanding procedures and require either ultrasound guidance or a lumbar L2-L3 block with resultant increase in discomfort and risk of complications. In our case a 17-year-old boy had extensive tone in his left hip flexors 3 months after injury. Attempts at stretching by therapy were of limited value and as a result he had decreased range of motion, short step length, and a slow pace. A Botulinum toxin injection to the lliopsoas with EMG guidance was performed with excellent results. ROM increased by 25 °, step length increased from 8 to 12 inches~ and step pace increased from 76 to 116 per minute. As a result of this simple short procedure the patient had significant improvement in ambulation. The authors will review the relevant literature and advocate the consideration of using Botulinum toxin to treat hip flexor spasticity.
1087
Because of the patient's high fevers she also developed rhabdomyolysis and subsequent myoglobinuria with acute renal failure and hepatic injury. This case report emphasizes the rare but significant occurrence of central fever causing renal failure in a pediatric patient with a remote traumatic brain injury.
Poster 249 "Brain Injury Rehabilitation: Meeting the Needs of the Family." J. Preston Harley, PhD (Marianjoy Rehabilitation Hospital & Clinics, Wheaton, IL); Nelson G. Escobar, MD. Family well-being and adjustment following brain injury is significantly disturbed. The family usually reports high levels of distress with the changes in family roles, demands placed on financial resources and the related cognitive, physical, and behavioral changes produced by the patient's brain injury. Optimal rehabilitation requires the close involvement and participation of family members. Therefore, it is important that clinical programs meet the needs of families during the rehabilitation process. An analysis of the importance and extent of meeting the family's perceived needs was conducted for 20 families in a community reentry brain injury program to elucidate and develop relevant support/ information for families. Needs were rated using the Family Needs Questionnaire (FNQ) at time of admission and discharge. Response patterns were analyzed for importance of needs and change in ratings from the beginning to the completion of the brain injury program. Findings support the requirement for strong family education, support and ongoing communication. The ratings of importance of various needs change during the course of treatment. Utilization of systematic assessment procedures can be critical to identify family members who are in greatest need of professional intervention, and to develop relevant educational support for the family during the rehabilitation process.
Poster 250 "Utilization of Subacute Rehabilitation in the Treatment of a Closed Head Injury Patient." Jeffrey E. Oken, MD (Marianjoy Rehabilitation Hospital and Clinics, Wheaton, IL); Lise P. Miller, BFA. The subacute care field is growing rapidly, but little scientific data are available about who is appropriate for subacute care. This case study uses an example of a closed head injury patient to demonstrate a cost effective approach to her rehabilitation. The patient is a 44-year-old woman involved in a motor vehicle accident who sustained multiple fractures and suffered a closed head injury. Her initial glascow coma score was 8. The patient was stabilized at an acute care hospital. Tracheostomy and PEG were placed. She was transferred to a subacute setting 16 days after her accident at a Rancho I/II level. During her stay in subacute rehabilitation, she progressed to minimal assistance level for wheelchair mobility and upper extremity dressing. In addition, she was weaned from the tracheostomy and swallowed well enough to take therapeutic feedings. She was transferred to the acute inpatient rehabilitation setting where her functional status improved to standby assistance for wheelchair mobility, limited independence for upper extremity dressing, and she was able to stand unassisted for 5 minutes to perform dynamic activities. She returned home and continued therapy in a community reentry program. With utilization of subacute care as opposed to traditional inpatient rehabilitation, a 21% cost savings was achieved. We will discuss the parameters for progression to the acute level and the appropriate program design for a traumatic brain injury subacute rehabilitation program. For patients who are appropriate, subacute placement, when used initially in a continuum of care, is functionally beneficial and can be a cost effective alternative.
Poster 248 "Central Fever in a Pediatric Patient with a Remote Brain Injury." Jude T. Cook, MD (Loyola University Medical Center, Maywood, IL); Amy Ao, MD; Mary Elizabeth Keen, MD; Nelson G. Escobar, MD.
Poster 251 "Incidence of Symptomatic Thromboembolism in Traumatic Brain Injury." Jenny M. Lai, MD (Baylor College of Medicine, Houston, TX); Stuart A. Yablon, MD; Cindy H. Ivanhoe, MD.
Central fevers occur in patients with traumatic brain injury during the acute and rehabilitative periods, but rarely in the chronic phase. Central fever is a diagnosis of exclusion and usually presents with extremely high fevers, tachycardia, tachypnea, and diaphoresis without associated infection. We present a pediatric patient who developed characteristics of central fever approximately 2 years after her initial brain injury. She developed fevers up to 108F with associated decorticate posturing, tachypnea, and tachycardia. Central fever was considered after an extensive workup failed to find an infectious, mechanical, or toxic etiology.
Venous thromboembolism (VTE) can be a life-threatening complication for patients with traumatic brain injury (TBI). However, few reports exist describing the incidence of this important illness. We reviewed the incidence of symptomatic VTE among 124 consecutive admissions with TBI to a free-standing rehabilitation hospital over an 18-month period. Four patients (3%) manifested evidence of VTE within two months of injury: 2 with leg swelling, 1 with an edematous arm, and 1 with respiratory distress. None of the patients with suspected VTE were treated with prophylactic anticoagulant therapy. VTE was confirmed
Arch Phys Med Rehabil Vol 76, November 1995
periods were scored, averaged, and compared using standard statistical tests. For the subject in the caffeine study definite trends were noted in crossover from caffeinated to placebo treatment periods and overall mean performance scores were significantly lower during caffeine administration (p < .01). In the amantidine study no observable trends or significant differences were noted. Study design, methods, test results and their possible implication and use in this population are discussed.
Poster 246 "Akathisia Resulting from Traumatic Brain Injury." Bernard V. Silver, PhD (Bayior College of Medicine/The Institute for Rehabilitation and Research, Houston, TX); Stuart A. Yablon, MD. Agitation and restlessness are commonly reported sequelae of traumatic brain injury (TBI). A recent case study reported severe restlessness (akathisia) in a patient with bilateral orbitofrontal lesions after TBI. Administration of bromocriptine coincided with rapid resolution of the akathisia leading to speculation that such behavior is related to decreased dopaminergic activity resulting from prefrontal lesions. We report an unusual case of marked restlessness following TBI in a 17-year-old woman. When admitted for rehabilitation 6 weeks after injury, she was alert but agitated and severely restless. She constantly paced her room and the unit repeatedly retracing the same route. While generally mute, she would provide terse written responses to questions. Due to these behavioral sequelae, a trial of bromocriptine was considered. The Agitated Behavior Scale and Galveston Orientation and Amnesia Test were used to monitor restlessness and agitation. Unexpectedly, during baseline evaluation, her restlessness began to resolve rapidly with simultaneous improvement in orientation. While remaining appreciably restless, she became verbal and oriented within expected limits. MRI showed large, well-delineated bifrontal contusions. This case lends support to the hypothesis that agitation and restlessness are related to lesions of prefrontal cortex.
Poster 247 "Treatment of Hip Flexor Spasticity Post Traumatic Brain Injury with Botulinum Toxin: A Case Report." Elie P. Elovic, MD (JFK Hospital, Johnson Rehabilitation Institute); Todd J. Cooperman, MD; Cindy A. Fong, PT; Thomas Strax, MD. Treatment of spasticity is one of the most challenging aspects of the physical rehabilitation of the individual who has sustained a Traumatic brain injury (TBI). Sitting, positioning, transfers, and ambulation are all affected by spasticity and treatment of a hip flexor with abnormal tone can be extremely difficult. The administration of anti-spasticity medications are of very limited efficacy for the patient with TBI, while many of the therapeutic modalities are of limited benefit for the hip flexors. Percutaneous nerve blocks for the lliopsoas are demanding procedures and require either ultrasound guidance or a lumbar L2-L3 block with resultant increase in discomfort and risk of complications. In our case a 17-year-old boy had extensive tone in his left hip flexors 3 months after injury. Attempts at stretching by therapy were of limited value and as a result he had decreased range of motion, short step length, and a slow pace. A Botulinum toxin injection to the lliopsoas with EMG guidance was performed with excellent results. ROM increased by 25 °, step length increased from 8 to 12 inches~ and step pace increased from 76 to 116 per minute. As a result of this simple short procedure the patient had significant improvement in ambulation. The authors will review the relevant literature and advocate the consideration of using Botulinum toxin to treat hip flexor spasticity.
1087
Because of the patient's high fevers she also developed rhabdomyolysis and subsequent myoglobinuria with acute renal failure and hepatic injury. This case report emphasizes the rare but significant occurrence of central fever causing renal failure in a pediatric patient with a remote traumatic brain injury.
Poster 249 "Brain Injury Rehabilitation: Meeting the Needs of the Family." J. Preston Harley, PhD (Marianjoy Rehabilitation Hospital & Clinics, Wheaton, IL); Nelson G. Escobar, MD. Family well-being and adjustment following brain injury is significantly disturbed. The family usually reports high levels of distress with the changes in family roles, demands placed on financial resources and the related cognitive, physical, and behavioral changes produced by the patient's brain injury. Optimal rehabilitation requires the close involvement and participation of family members. Therefore, it is important that clinical programs meet the needs of families during the rehabilitation process. An analysis of the importance and extent of meeting the family's perceived needs was conducted for 20 families in a community reentry brain injury program to elucidate and develop relevant support/ information for families. Needs were rated using the Family Needs Questionnaire (FNQ) at time of admission and discharge. Response patterns were analyzed for importance of needs and change in ratings from the beginning to the completion of the brain injury program. Findings support the requirement for strong family education, support and ongoing communication. The ratings of importance of various needs change during the course of treatment. Utilization of systematic assessment procedures can be critical to identify family members who are in greatest need of professional intervention, and to develop relevant educational support for the family during the rehabilitation process.
Poster 250 "Utilization of Subacute Rehabilitation in the Treatment of a Closed Head Injury Patient." Jeffrey E. Oken, MD (Marianjoy Rehabilitation Hospital and Clinics, Wheaton, IL); Lise P. Miller, BFA. The subacute care field is growing rapidly, but little scientific data are available about who is appropriate for subacute care. This case study uses an example of a closed head injury patient to demonstrate a cost effective approach to her rehabilitation. The patient is a 44-year-old woman involved in a motor vehicle accident who sustained multiple fractures and suffered a closed head injury. Her initial glascow coma score was 8. The patient was stabilized at an acute care hospital. Tracheostomy and PEG were placed. She was transferred to a subacute setting 16 days after her accident at a Rancho I/II level. During her stay in subacute rehabilitation, she progressed to minimal assistance level for wheelchair mobility and upper extremity dressing. In addition, she was weaned from the tracheostomy and swallowed well enough to take therapeutic feedings. She was transferred to the acute inpatient rehabilitation setting where her functional status improved to standby assistance for wheelchair mobility, limited independence for upper extremity dressing, and she was able to stand unassisted for 5 minutes to perform dynamic activities. She returned home and continued therapy in a community reentry program. With utilization of subacute care as opposed to traditional inpatient rehabilitation, a 21% cost savings was achieved. We will discuss the parameters for progression to the acute level and the appropriate program design for a traumatic brain injury subacute rehabilitation program. For patients who are appropriate, subacute placement, when used initially in a continuum of care, is functionally beneficial and can be a cost effective alternative.
Poster 248 "Central Fever in a Pediatric Patient with a Remote Brain Injury." Jude T. Cook, MD (Loyola University Medical Center, Maywood, IL); Amy Ao, MD; Mary Elizabeth Keen, MD; Nelson G. Escobar, MD.
Poster 251 "Incidence of Symptomatic Thromboembolism in Traumatic Brain Injury." Jenny M. Lai, MD (Baylor College of Medicine, Houston, TX); Stuart A. Yablon, MD; Cindy H. Ivanhoe, MD.
Central fevers occur in patients with traumatic brain injury during the acute and rehabilitative periods, but rarely in the chronic phase. Central fever is a diagnosis of exclusion and usually presents with extremely high fevers, tachycardia, tachypnea, and diaphoresis without associated infection. We present a pediatric patient who developed characteristics of central fever approximately 2 years after her initial brain injury. She developed fevers up to 108F with associated decorticate posturing, tachypnea, and tachycardia. Central fever was considered after an extensive workup failed to find an infectious, mechanical, or toxic etiology.
Venous thromboembolism (VTE) can be a life-threatening complication for patients with traumatic brain injury (TBI). However, few reports exist describing the incidence of this important illness. We reviewed the incidence of symptomatic VTE among 124 consecutive admissions with TBI to a free-standing rehabilitation hospital over an 18-month period. Four patients (3%) manifested evidence of VTE within two months of injury: 2 with leg swelling, 1 with an edematous arm, and 1 with respiratory distress. None of the patients with suspected VTE were treated with prophylactic anticoagulant therapy. VTE was confirmed
Arch Phys Med Rehabil Vol 76, November 1995