- Email: [email protected]
Poster 250 Spontaneous potentials in animal models of spinal cord injury Anthony S. Burns MD (Thomas Jefferson Univ, Philadelphia, PA); Michel Lemay PhD; Alan Tessler MD, [email protected]
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using SSRs recordings. Conclusions: Our data suggest that destruction of spinal autonomic pathways could contribute to cardiovascular abnormalities after SCI. Presently, only assessments of motor and sensory spinal pathways are part of neurologic examination of people with SCI (ASIA grade). Developing clinical tools for the assessment of the severity of spinal autonomic pathway destruction may provide relevant insight in our understanding of the mechanisms of cardiovascular dysfunctions after SCI. Key Words: Autonomic dysreflexia; Rehabilitation; Spermatozoa; Spinal cord injuries; Stimulation. Poster 244: Refer to Abstract 26 in the Spinal Cord Injury Poster Grand Rounds for the full abstract. e-mail: [email protected]. Poster 245 Spirometric Tests in Paraplegic Athletes and Sedentary Paraplegics. Ahmet S. Goktepe, MD (Gulhane Mili Med Acad, Ankara, Turkey); Bilge Yilmaz; Ridvan Alaca; Sukru Gunduz, e-mail: [email protected]. Disclosure: A.S. Goktepe, None; B. Yilmaz, None; R. Alaca, None; S. Gunduz, None. Objective: To assess the effect of aerobic training on pulmonary functions of patients with spinal cord injury (SCI). Design: Controlled study comparing the pulmonary function tests of elite paraplegic basketball players with those of sedentary paraplegics. Setting: SCI unit of a rehabilitation center. Participants: 14 male paraplegic basketball players and 14 male paraplegic sedentary persons matched for the age and time since injury. Interventions: Not applicable. Main Outcome Measures: Forced vital capacity (FVC), slow vital capacity (VC), forced expired volume in 1s (FEV1), FEV1/FVC, and peak expiratory flow rate (PEFR) were measured. Demographic and clinical measures (age, time since injury, height, weight, level of injury, ASIA grade, smoking history) were also obtained. Results: FVC, FEV1, PEFR, and VC measurements were decreased in both groups (82%–92% of theoretical normative values for athletes, 81%– 88% for sedentary patients). Although all the parameters showed higher mean percentages of predicted values in the wheelchair athlete group than in the sedentary group, the difference between groups was not statistically significant. Conclusions: There was a tendency for the active group to have higher mean values of spirometric measurements. Further research is needed to clarify the effect of aerobic training on lung functions. Key Words: Athletics; Pulmonary function tests; Rehabilitation; Spinal cord injuries; Wheelchairs. Poster 246 Vascular Health in Arms and Legs of Paraplegic Patients: A Prospective Study. Danielle B. Groves, MD (Emory Univ Sch Med, Atlanta, GA); Lee Stoner; Leslie VanHiel; Manning Sabatier; David Ripley, MD; Kevin McCully, PhD, e-mail: [email protected]. Disclosure: D.B. Groves, None; L. Stoner, None; L. VanHiel, None; M. Sabatier, None; D. Ripley, None; K. McCully, None. Objective: To determine if vascular health, as measured by flow-mediate dilation, differs significantly between the arms and legs of paraplegic patients with spinal cord injury (SCI). Design: Prospective study. Setting: A rehabilitation hospital. Participants: 15 paraplegic men with SCI were tested. All subjects were ⬎1y postinjury and had ASIA grade A injuries between T2 and L2. Interventions: Not applicable. Main Outcome Measures: Radial artery and posterior tibial artery diameters were measured using B-mode duplex ultrasound. Images were measured before, during, and after 5 and 10min of proximal cuff occlusion. The minimum diameter during ischemia and the maximum diameter during reactive hyperemia were used to calculate the following measures of vascular health: minimum diameter, maximum diameter, vascular tone, vascular range, and flowmediate dilation after 5min of ischemia. Results: The radial and posterior tibial arteries showed similar baseline diameters (3.0mm, 3.0mm, P⫽.397). However, there was a significant difference in the flow-mediated dilation between the arms and legs of the paraplegic subjects (arms, 10.48%; legs, 6.17%; P⫽.006). Conclusions: Arteries in the upper extremities appear to be normal in chronic paraplegic patients. However, flow-mediated dilation was reduced by 41% in the posterior tibial artery of paraplegic subjects, suggesting impaired vascular health in the lower extremities. It is recommended that vascular screening studies be performed in the lower extremities as well as the upper extremities of paraplegic patients. Key Words: Rehabilitation; Spinal cord injuries; Vascular diseases. Poster 247 Neuralgic Amyotrophy in a Patient With T12 Paraplegia: A Case Report. Alison A. Stout, DO (Univ Washington, Seattle, WA); Stephen P. Burns, MD; Jennifer J. James, MD, e-mail: [email protected]. Disclosure: A.A. Stout, None; S.P. Burns, None; J.J. James, None. Setting: Regional care hospital. Patient: A 48-yo man with T12 paraplegia and new-onset upper- extremity pain and weakness. Case Description: 17y after sustaining complete T12 paraplegia, the patient had acute nontraumatic onset of right scapular pain, followed by progressive proximal upper-extremity weakness. There was a history of botulinum toxin type A injection for torticollis. Physical exam showed right greater than left proximal atrophy and weakness with new right scapular winging. Imaging studies ruled out shoulder pathology, syringomyelia, tumor, disk disease, and significant central or foraminal spinal stenosis. Electrodiagnostic findings were consistent with neuralgic amyotrophy. Multidisciplinary evaluations revealed significant functional decline. Assessment/Results: The patient required rehabilitation training for transfers and power wheelchair mobility. He received instruction in shoulder protection techniques and range of motion. Strength and function were noted to be improving 14mo later. Discussion: People with spinal cord injury (SCI) frequently develop pain and weakness of the shoulders and upper extremities, with a broad differential diagnosis. Acute nontraumatic onset of shoulder or scapular pain, followed by limb weakness, should lead to consideration of the diagnosis of neuralgic amyotrophy. Diagnosis is via clinical presentation and electromyography. Most cases show spontaneous resolution over 2 to 3y. However, its effect can be devastating, especially to persons with SCI. Increased upperextremity impairment can impact functional independence and predispose to musculoskeletal injury. Conclusions: This case illustrates the importance of a comprehensive evaluation of upper-extremity
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pathology in people with SCI. Treatment of neuralgic amyotrophy requires multidisciplinary intervention, including global assessment of functional skills with instruction in appropriate modifications and adaptations. Prompt recognition of this disorder accompanied by intervention could maximize function and prevent secondary injury during the recovery process. Key Words: Brachial plexus neuritis; Rehabilitation; Spinal cord injuries. Poster 248 Effects of Intrathecal Baclofen on Glycemic Management in a Diabetic Quadriplegic Patient: A Case Report. Michael Saulino, MD, PhD (Magee Rehabil Hosp, Philadelphia, PA); Vishal Kancherla, DO; Evelyn Phillip, MS, RD, LDN, e-mail: [email protected]. Disclosure: M. Saulino, None; V. Kancherla, None; E. Phillip, None. Setting: Inpatient rehabilitation hospital. Patient: Adult quadriplegic man with sensitive insulindependent diabetes mellitus (IDDM). Case Description: A man with spinal cord injury (SCI) and a medical history of IDDM presented with recalcitrant spasticity. His hypertonicity was resistant to conservative measures, including static stretching, positioning, and high doses of 2 oral medications (baclofen, tizanidine). After a successful test dose of intrathecal baclofen (ITB), he underwent pump implantation for continuous infusion. He was readmitted to an acute rehabilitation hospital after implantation for dose titration. Assessment/Results: The patient’s ITB dosing was adjusted 13 times over the first 30d postimplant. His initial dose was 50g/d and ultimately his dosage plateaued at 440g/d. Glycemic management was carefully monitored during this titration. His insulin needs were increased during these adjustments, at time requiring up to 150% of his baseline insulin needs. Discussion: The metabolic effects of spasticity reduction are poorly described. It is well recognized that exercising skeletal muscle will increase uptake of serum glucose. This observation is seen in both healthy and SCI patients. Because spasticity can be considered a form of muscle exercise, it is reasonable to postulate that spasticity reduction can result in decreased glucose utilization by peripheral muscle and subsequent increase in serum glucose. Conclusions: Spasticity may have an effect on glycemic control. Clinicians should consider careful monitoring of serum glucose and insulin needs when undertaking spasticity modulation. Further investigation into the interplay between spasticity and metabolism may be warranted. Key Words: Baclofen; Diabetes mellitus; Muscle spasticity; Rehabilitation. Poster 249 Long-Term Potentiation as a Possible Mechanism for Vibration-Induced Reflex Standing 8 Years After SCI. John G. Gianutsos, PhD (NYU Sch Med, New York, NY); Alan F. Vainrib, BA; Steven Weissbart, BA; Mark Ragucci, DO; Michael Hutchinson, MD, PhD; Jung H. Ahn, MD, e-mail: [email protected]. Disclosure: J.G. Gianutsos, None; A.F. Vainrib, None; S. Weissbart, None; M. Ragucci, None; M. Hutchinson, None; J.H. Ahn, None. Setting: Urban rehabilitation center. Patient: A 27-yo man without significant medical history sustained a C5-6 subluxation after a fall while involved in a fight. Noted to have tetraplegia, he underwent cervical stabilization and fusion. Case Description: After a 3-mo hospitalization, he was admitted to a rehabilitation facility with the following diagnoses: tetraplegia; left lower-extremity deep vein thrombosis; heterotopic ossification of the hips bilaterally; postrespiratory failure; post tracheostomy; history of ileus; chronic lower pneumonia; VY gluteus maximus myocutaneous flap surgery for sacral decubitus ulcer; partial sacral osteotomy; left heel ulcer excision with primary multiple closure; and osteoporosis. He entered our program 5y later having a status of ASIA grade A C5 tetraplegia. We employ whole body vibration (WBV) to determine the extent to which reflex standing could be induced in persons with spinal cord injury who are otherwise unable to stand without the use of exoskeletal devices. Segmental reflexes are activated through rapid mechanically delivered repetitive stretches to the lower extremities. The program consists of weekly 1-h sessions during which WBV is delivered for 20 to 30min with the person standing. We report on the evolution of changes in the vibratory-induced reflex standing of a person with tetraplegia at the C5 level. Assessment/Results: Duration of induced standing, sitting balance, trunk control, muscle tone, stamina, and dermal condition were assessed. All have improved. Standing continues for brief periods following cessation of WBV, which is suggestive of a mechanism of potentiation. Discussion: The continuation of standing after cessation of WBV suggests long-term potentiation—a form of plasticity that strengthens transmission at a synapse after high-frequency stimulation that lasts for more than a few minutes and may serve as the foundation for more permanent changes. Conclusions: WBV represents an alternative to fitness effects gained through other modalities. Key Words: Rehabilitation; Spinal cord injuries.
Poster 250 Spontaneous Potentials in Animal Models of Spinal Cord Injury. Anthony S. Burns, MD (Thomas Jefferson Univ, Philadelphia, PA); Michel Lemay, PhD; Alan Tessler, MD, e-mail: [email protected]. Disclosure: A.S. Burns, None; M. Lemay, None; A. Tessler, None. Objective: To confirm the existence of spontaneous potentials (fibrillations, positive sharp waves) in animal models of spinal cord injury (SCI). Design: Prospective cohort. Setting: Academic medical center and university. Animals: 9 Sprague-Dawley rats and 2 domestic short-haired cats. Interventions: Surgical transections of the thoracic spinal cord were performed on 6 rats and 2 cats. The cats were part of a separate investigational protocol and fibroblasts genetically modified to produce brain-derived neurotrophic factor (BDNF) and neurotrophin (NT3) were transplanted into the lesion at the time of transection. Main Outcome Measures: Hind limb muscles were studied for 4 to 6wk with serial electromyography. As a control for the effects of anesthesia and serial testing, 3 intact rats were anesthetized and tested weekly for 4wk. Results: In rats, denervation potentials emerged 4 to 7d after surgery. They increased in intensity and persisted through 28 to 32d, the longest time studied. In 1 animal, spontaneous potentials transiently emerged at day 7, then largely resolved by day 9. All animals underwent histologic examination to confirm that transections were complete. Spontaneous potentials were not present in any of the 3 control animals at any time point during the 4wk of serial testing. In unanesthetized cats, spontaneous potentials emerged by day 8 and were most prominent from day 8 to day 15. In both animals, the spontaneous potentials thereafter
2004 Academy Annual Assembly Abstracts diminished in intensity and were largely absent by day 43. It is unclear how the transplants of BDNF/NT3 expressing fibroblasts impacted the natural history, but 1 possibility is that grafts ameliorated postinjury physiologic conditions in motoneurons. Conclusions: Spontaneous potentials occur after SCI in animals as well as in humans and they appear to be conserved across mammalian species (rats, cats, humans). Key Words: Electromyography; Muscle denervation; Rehabilitation; Spinal cord injuries.
Poster 251: Refer to Abstract 23 in the Spinal Cord Injury Poster Grand Rounds for full abstract. e-mail: [email protected].
Poster 252: Refer to Abstract 24 in the Spinal Cord Injury Poster Grand Rounds for full abstract. e-mail: [email protected].
Poster 253 Is Monitoring Intragastric pH Necessary in Spinal Cord Injury Patients Receiving Famotidine Infusion? Chiwai E. Chan, DO (Stanford Univ Med Ctr/Santa Clara Valley Med Ctr, Palo Alto, CA); Agnes S. Wallbom, MD, e-mail: [email protected]. Disclosure: C.E. Chan, None; A.S. Wallbom, None. Objective: To determine whether monitoring intragastic pH has any effect on preventing stress ulcers in patients with acute spinal cord injury (SCI) who are receiving famotidine infusion. Design: A retrospective study from January to December 2003. Setting: Tertiary care, university-affiliated spinal cord trauma unit. Participants: 10 acute traumatic SCI patients admitted to a rehabilitation trauma center. Interventions: Not applicable. Main Outcome Measures: pH values and guaiac results. Results: There was no correlation between gastric pH and gastric Hemoccult occult blood test results. There was a predominance of positive guaiac in 75/87 (86%) tests performed. 84% of all guaiac tests were positive regardless of pH. Within the subgroup of pH ⬎7, 90% of guaiac tests were positive. The administration of aluminum-magnesium hydroxide suspension in an attempt to increase gastric pH failed to maintain negative Hemoccult test consistently. There were 4 (40%) patients who never had a negative guaiac result within the 48-h study period. The proportion of negative guaiac results did not differ significantly when compared by pH group (z ratio for proportions). All 10 subjects had no clinical symptoms of stress ulcers. Conclusions: It does not appear that gastric pH monitoring and administration of aluminum-magnesium hydroxide suspension are steps needed to prevent stress ulcers during famotidine infusion of acute SCI patients. Key Words: pH; Rehabilitation; Spinal cord injuries; Stress; Ulcers.
Poster 254 Assessing the Sensitivity of an Annual Abdominal Roentgenogram in Screening for Pathology in Chronic Spinal Cord Injury. Douglas B. Barber, MD (Univ Texas Health Sci Ctr, San Antonio, TX); Suzanne L. Woodbury, MD; Mark D. Fredrickson, MD; Gary L. Campbell, DO, e-mail: [email protected]. Disclosure: D.B. Barber, None; S.L. Woodbury, None; M.D. Fredrickson, None; G.L. Campbell, None. Objective: To assess the sensitivity of an annual abdominal roentgenogram (kidneys, ureters, bladder [KUB]). Design: Retrospective chart review. Setting: Department of Veterans Affairs Spinal Cord Injury Center. Participants: 318 patients who received an annual medical assessment including KUB in the 12mo before the study. Interventions: Not applicable. Main Outcome Measure: KUB read by board-certified radiologists. Results: 117 of 318 (37%) KUBs were read as “normal.” Pathology involving the skeleton (eg, previous fracture, heterotopic ossification, osteomyelitis) was described in 102 (32%). Gastrointestinal tract findings (eg, ileus, colonic distention, fecal impaction) were noted in 53 (17%). Probable phlebolith and vascular calcification were reported in 48 (15%). Possible calcification involving the renal system was noted in 42 (13%). Gallstones were noted in 5 (2%). No patients were reported to have received any negative sequelae from undergoing KUB. Conclusions: The prevalence of potential pathology involving the skeletal, gastrointestinal tract, and urinary tract systems suggests that there is value in performing surveillance KUBs annually in patients with SCI. Key Words: Rehabilitation; Spinal cord injuries.
Poster 255 Microarray Study of Gene Expression Profile After Acute Spinal Cord Injury. Leslie R. Morse, DO (Boston Med Ctr, Boston, MA); Ricardo A. Battaglino, PhD; Martha Joe; David Meguerdichian; Hajime Sasaki, DDS, PhD; Steve Williams, MD, e-mail: leslie.morse@ bmc.org. Disclosure: L.R. Morse, None; R.A. Battaglino, None; M. Joe, None; D. Meguerdichian, None; H. Sasaki, None; S. Williams, None. Objective: To perform a large-scale gene profiling of acute spinal cord injury (SCI) in humans. Design: Case-control study. Setting: Acute inpatient rehabilitation unit. Participants: 4 patients with acute, complete cervical SCI and 4 sex- and age-matched neurologically intact patients. Interventions: Not applicable. Main Outcome Measure: Differential gene expression in white blood cells as determined by the hybridization patterns of a microarray containing 12,000 human genes. Results: Preliminary data suggest that over 215 genes are differentially expressed in white blood cells derived from patients with acute SCI. Many genes are known immunoregulators, cell cycle regulators, and mediators of inflammation. Of these genes, approximately two thirds are suppressed and one third are overexpressed when compared with healthy controls. Of interest, several novel genes have been identified with differential expression patterns in this population. Conclusions: We have identified several genes whose expression appears to be altered in humans after acute SCI. We anticipate that this approach will help define the pathophysiology of this condition, and identify future areas of investigation and new treatment targets. Key Words: DNA microarray; Gene expression profiling; Rehabilitation; Spinal cord injuries
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Poster 256: Refer to Abstract 25 in the Spinal Cord Injury Poster Grand Rounds for full abstract. e-mail: [email protected]. Poster 257 Breathlessness During Daily Activities in Spinal Cord Injury. Noel F. Grandas, MD (VAMC Boston HealthCare Syst, West Roxbury, MA); Nitin Jain, MBBS, MSPH; Robert Brown, MD; Carlos G. Tun, MD; Eric Garshick, MD, MOH, e-mail: [email protected]. Disclosure: N.F. Grandas, None; N. Jain, None; R. Brown, None; C.G. Tun, None; E. Garshick, None. Objective: To assess factors associated with breathlessness during daily activities in chronic spinal cord injury (SCI). Design: Cross-sectional. Settings: Subjects recruited from Veterans Affairs SCI service and the community. Participants: Between 1994 and 2003, 441 subjects ⱖ1y after SCI and free from acute illness were recruited for assessment of respiratory health. Interventions: Respiratory questionnaire, spirometry, and neurologic exam. Data included injury date and extent, ability to get around (walk unassisted, walk with an aid, by hand-propelled wheelchair, by motorized wheelchair [MWC]), respiratory illnesses and symptoms, cigarette smoking, occupational exposures, and comorbid medical conditions. Main Outcome Measure: Breathlessness during eating, talking, and dressing. Results: Among 85 subjects who used MWC, the prevalence of breathlessness while eating, talking, or dressing was 24% versus 6% in 356 others (P⬍.0001). The main activity associated with breathlessness in MWC users was talking (18%). Among MWC users, the relative odds of current and former cigarette smokers reporting breathlessness while talking, eating, or dressing was 4.2 (95% CI, 0.9 – 41.0) as compared with never smokers. The relative odds increased by 1.02 (95% CI, 1.00 –1.03) per pack-year. Breathlessness was associated with chronic cough (OR⫽7.8; 95% CI, 2.0 –32.7) and wheeze (OR⫽3.5; 95% CI, 1.04 –13.6). In MWC users, heart disease, percentage of predicted forced vital capacity and forced expiratory volume in 1s, chest illness in the past year, SCI level, and maximal inspiratory pressures were not related to breathlessness. Conclusions: Breathlessness during selected daily activities (most commonly, talking) was greatest among SCI subjects who were most impaired with regard to mobility and was associated with cough, wheeze, and cigarette smoking. Therefore, therapy to relieve breathlessness may include smoking cessation, treatment of wheeze, and improvement of breathing patterns during speech. Key Words: Dyspnea; Activities of daily living; Rehabilitation; Spinal cord injuries
Stroke Poster 258 Crossed Cerebrocerebellar Diaschisis and Motor Weakness of Upper Extremity After Stroke. In Sung Choi (Chonnam National Univ Med Sch & Hosp, Gwangju, Republic of Korea); Sam Gyu Lee; So Young Lee; Jae Hyung Kim, e-mail: [email protected]. Disclosure: I. Choi, None; S. Lee, None; S. Lee, None; J. Kim, None. Objectives: To investigate the correlation between motor evoked potentials (MEPs) and crossed cerebrocerebellar diaschisis (CCD) and to study the relationship between CCD and the severity and prognosis of stroke. Design: Retrospective case series. Setting: Tertiary hospital-based, acute stroke rehabilitation center in Korea. Participants: 32 patients with first-ever stroke and 31 healthy control subjects. Interventions: MEPs were recorded from the abductor pollicis brevis and the abductor hallucis by stimulating the motor cortex relevant to the hand and foot. The localization and the volumetric analysis of brain lesion were performed by a radiologist. The existence of CCD was evaluated by single-photon emission computed tomography of brain. Main Outcome Measures: Central motor conduction times of upper and lower extremities, the existence of CCD, National Institutes of Health Stroke Scale score, FIM instrument score, and Motricity Index (MI). Results: The presence of CCD correlated significantly with “not evoked” MEPs in the upper extremity (22⫽10.667, P⫽.005), but not in the lower extremity (22⫽2.143, P⫽.343). There was no significant correlation between lesion locations and the existence of CCD (P⫽.563). There was a significant correlation between the absence of CCD and higher MI score of the upper extremity (P⫽.048). There were significant correlations between MI score and MEP findings of upper and lower extremities at 1 mo after onset (P⫽.033, P⫽.012). Conclusions: The existence of CCD would reflect the severe insult on descending motor pathways and the severity of paralysis of upper extremity. Key Words: Evoked potentials, motor; Rehabilitation; Stroke. Poster 259: Refer to Abstract 35 in the Stroke Poster Grand Rounds for the full abstract. e-mail: [email protected]. Poster 260: Refer to Abstract 33 in the Stroke Poster Grand Rounds for the full abstract. e-mail: [email protected]. Poster 261 Recovery of Hemiplegic Upper-Limb Functions After the Amputation of Unaffected Upper Limb: A Case Report. Divakara Kedlaya, MD (Corona Regional Med Ctr, Corona, CA); Murray Brandstater, MD, PhD, e-mail: [email protected]. Disclosure: D. Kedlaya, None; M. Brandstater, None. Setting: Community acute rehabilitation unit. Patient: A 50-yo woman with a history of protein C deficiency and stroke. Case Description: The patient suffered a stroke 8y ago, with left hemiplegia. Magnetic resonance imaging at that time showed right posterior parietal lobe infarction. She was also found to have protein C deficiency and was treated with long-term anticoagulation. Although she had some neurologic recovery of left upper limb, it was nonfunctional. She suffered an acute arterial thrombotic event in her right upper limb, which resulted in right below elbow amputation. She had 2wk of acute rehabilitation, focusing on functional use of the left upper limb, and was discharged home at a stand-by assistance level in all aspect of self-care when using the left upper limb. Assessment/Results: The Modified Wolf Motor Test was performed at admission and at discharge. Discussion: Amputation of the unaffected upper limb in our stroke patient forced her
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2004 Academy Annual Assembly Abstracts
using SSRs recordings. Conclusions: Our data suggest that destruction of spinal autonomic pathways could contribute to cardiovascular abnormalities after SCI. Presently, only assessments of motor and sensory spinal pathways are part of neurologic examination of people with SCI (ASIA grade). Developing clinical tools for the assessment of the severity of spinal autonomic pathway destruction may provide relevant insight in our understanding of the mechanisms of cardiovascular dysfunctions after SCI. Key Words: Autonomic dysreflexia; Rehabilitation; Spermatozoa; Spinal cord injuries; Stimulation. Poster 244: Refer to Abstract 26 in the Spinal Cord Injury Poster Grand Rounds for the full abstract. e-mail: [email protected]. Poster 245 Spirometric Tests in Paraplegic Athletes and Sedentary Paraplegics. Ahmet S. Goktepe, MD (Gulhane Mili Med Acad, Ankara, Turkey); Bilge Yilmaz; Ridvan Alaca; Sukru Gunduz, e-mail: [email protected]. Disclosure: A.S. Goktepe, None; B. Yilmaz, None; R. Alaca, None; S. Gunduz, None. Objective: To assess the effect of aerobic training on pulmonary functions of patients with spinal cord injury (SCI). Design: Controlled study comparing the pulmonary function tests of elite paraplegic basketball players with those of sedentary paraplegics. Setting: SCI unit of a rehabilitation center. Participants: 14 male paraplegic basketball players and 14 male paraplegic sedentary persons matched for the age and time since injury. Interventions: Not applicable. Main Outcome Measures: Forced vital capacity (FVC), slow vital capacity (VC), forced expired volume in 1s (FEV1), FEV1/FVC, and peak expiratory flow rate (PEFR) were measured. Demographic and clinical measures (age, time since injury, height, weight, level of injury, ASIA grade, smoking history) were also obtained. Results: FVC, FEV1, PEFR, and VC measurements were decreased in both groups (82%–92% of theoretical normative values for athletes, 81%– 88% for sedentary patients). Although all the parameters showed higher mean percentages of predicted values in the wheelchair athlete group than in the sedentary group, the difference between groups was not statistically significant. Conclusions: There was a tendency for the active group to have higher mean values of spirometric measurements. Further research is needed to clarify the effect of aerobic training on lung functions. Key Words: Athletics; Pulmonary function tests; Rehabilitation; Spinal cord injuries; Wheelchairs. Poster 246 Vascular Health in Arms and Legs of Paraplegic Patients: A Prospective Study. Danielle B. Groves, MD (Emory Univ Sch Med, Atlanta, GA); Lee Stoner; Leslie VanHiel; Manning Sabatier; David Ripley, MD; Kevin McCully, PhD, e-mail: [email protected]. Disclosure: D.B. Groves, None; L. Stoner, None; L. VanHiel, None; M. Sabatier, None; D. Ripley, None; K. McCully, None. Objective: To determine if vascular health, as measured by flow-mediate dilation, differs significantly between the arms and legs of paraplegic patients with spinal cord injury (SCI). Design: Prospective study. Setting: A rehabilitation hospital. Participants: 15 paraplegic men with SCI were tested. All subjects were ⬎1y postinjury and had ASIA grade A injuries between T2 and L2. Interventions: Not applicable. Main Outcome Measures: Radial artery and posterior tibial artery diameters were measured using B-mode duplex ultrasound. Images were measured before, during, and after 5 and 10min of proximal cuff occlusion. The minimum diameter during ischemia and the maximum diameter during reactive hyperemia were used to calculate the following measures of vascular health: minimum diameter, maximum diameter, vascular tone, vascular range, and flowmediate dilation after 5min of ischemia. Results: The radial and posterior tibial arteries showed similar baseline diameters (3.0mm, 3.0mm, P⫽.397). However, there was a significant difference in the flow-mediated dilation between the arms and legs of the paraplegic subjects (arms, 10.48%; legs, 6.17%; P⫽.006). Conclusions: Arteries in the upper extremities appear to be normal in chronic paraplegic patients. However, flow-mediated dilation was reduced by 41% in the posterior tibial artery of paraplegic subjects, suggesting impaired vascular health in the lower extremities. It is recommended that vascular screening studies be performed in the lower extremities as well as the upper extremities of paraplegic patients. Key Words: Rehabilitation; Spinal cord injuries; Vascular diseases. Poster 247 Neuralgic Amyotrophy in a Patient With T12 Paraplegia: A Case Report. Alison A. Stout, DO (Univ Washington, Seattle, WA); Stephen P. Burns, MD; Jennifer J. James, MD, e-mail: [email protected]. Disclosure: A.A. Stout, None; S.P. Burns, None; J.J. James, None. Setting: Regional care hospital. Patient: A 48-yo man with T12 paraplegia and new-onset upper- extremity pain and weakness. Case Description: 17y after sustaining complete T12 paraplegia, the patient had acute nontraumatic onset of right scapular pain, followed by progressive proximal upper-extremity weakness. There was a history of botulinum toxin type A injection for torticollis. Physical exam showed right greater than left proximal atrophy and weakness with new right scapular winging. Imaging studies ruled out shoulder pathology, syringomyelia, tumor, disk disease, and significant central or foraminal spinal stenosis. Electrodiagnostic findings were consistent with neuralgic amyotrophy. Multidisciplinary evaluations revealed significant functional decline. Assessment/Results: The patient required rehabilitation training for transfers and power wheelchair mobility. He received instruction in shoulder protection techniques and range of motion. Strength and function were noted to be improving 14mo later. Discussion: People with spinal cord injury (SCI) frequently develop pain and weakness of the shoulders and upper extremities, with a broad differential diagnosis. Acute nontraumatic onset of shoulder or scapular pain, followed by limb weakness, should lead to consideration of the diagnosis of neuralgic amyotrophy. Diagnosis is via clinical presentation and electromyography. Most cases show spontaneous resolution over 2 to 3y. However, its effect can be devastating, especially to persons with SCI. Increased upperextremity impairment can impact functional independence and predispose to musculoskeletal injury. Conclusions: This case illustrates the importance of a comprehensive evaluation of upper-extremity
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pathology in people with SCI. Treatment of neuralgic amyotrophy requires multidisciplinary intervention, including global assessment of functional skills with instruction in appropriate modifications and adaptations. Prompt recognition of this disorder accompanied by intervention could maximize function and prevent secondary injury during the recovery process. Key Words: Brachial plexus neuritis; Rehabilitation; Spinal cord injuries. Poster 248 Effects of Intrathecal Baclofen on Glycemic Management in a Diabetic Quadriplegic Patient: A Case Report. Michael Saulino, MD, PhD (Magee Rehabil Hosp, Philadelphia, PA); Vishal Kancherla, DO; Evelyn Phillip, MS, RD, LDN, e-mail: [email protected]. Disclosure: M. Saulino, None; V. Kancherla, None; E. Phillip, None. Setting: Inpatient rehabilitation hospital. Patient: Adult quadriplegic man with sensitive insulindependent diabetes mellitus (IDDM). Case Description: A man with spinal cord injury (SCI) and a medical history of IDDM presented with recalcitrant spasticity. His hypertonicity was resistant to conservative measures, including static stretching, positioning, and high doses of 2 oral medications (baclofen, tizanidine). After a successful test dose of intrathecal baclofen (ITB), he underwent pump implantation for continuous infusion. He was readmitted to an acute rehabilitation hospital after implantation for dose titration. Assessment/Results: The patient’s ITB dosing was adjusted 13 times over the first 30d postimplant. His initial dose was 50g/d and ultimately his dosage plateaued at 440g/d. Glycemic management was carefully monitored during this titration. His insulin needs were increased during these adjustments, at time requiring up to 150% of his baseline insulin needs. Discussion: The metabolic effects of spasticity reduction are poorly described. It is well recognized that exercising skeletal muscle will increase uptake of serum glucose. This observation is seen in both healthy and SCI patients. Because spasticity can be considered a form of muscle exercise, it is reasonable to postulate that spasticity reduction can result in decreased glucose utilization by peripheral muscle and subsequent increase in serum glucose. Conclusions: Spasticity may have an effect on glycemic control. Clinicians should consider careful monitoring of serum glucose and insulin needs when undertaking spasticity modulation. Further investigation into the interplay between spasticity and metabolism may be warranted. Key Words: Baclofen; Diabetes mellitus; Muscle spasticity; Rehabilitation. Poster 249 Long-Term Potentiation as a Possible Mechanism for Vibration-Induced Reflex Standing 8 Years After SCI. John G. Gianutsos, PhD (NYU Sch Med, New York, NY); Alan F. Vainrib, BA; Steven Weissbart, BA; Mark Ragucci, DO; Michael Hutchinson, MD, PhD; Jung H. Ahn, MD, e-mail: [email protected]. Disclosure: J.G. Gianutsos, None; A.F. Vainrib, None; S. Weissbart, None; M. Ragucci, None; M. Hutchinson, None; J.H. Ahn, None. Setting: Urban rehabilitation center. Patient: A 27-yo man without significant medical history sustained a C5-6 subluxation after a fall while involved in a fight. Noted to have tetraplegia, he underwent cervical stabilization and fusion. Case Description: After a 3-mo hospitalization, he was admitted to a rehabilitation facility with the following diagnoses: tetraplegia; left lower-extremity deep vein thrombosis; heterotopic ossification of the hips bilaterally; postrespiratory failure; post tracheostomy; history of ileus; chronic lower pneumonia; VY gluteus maximus myocutaneous flap surgery for sacral decubitus ulcer; partial sacral osteotomy; left heel ulcer excision with primary multiple closure; and osteoporosis. He entered our program 5y later having a status of ASIA grade A C5 tetraplegia. We employ whole body vibration (WBV) to determine the extent to which reflex standing could be induced in persons with spinal cord injury who are otherwise unable to stand without the use of exoskeletal devices. Segmental reflexes are activated through rapid mechanically delivered repetitive stretches to the lower extremities. The program consists of weekly 1-h sessions during which WBV is delivered for 20 to 30min with the person standing. We report on the evolution of changes in the vibratory-induced reflex standing of a person with tetraplegia at the C5 level. Assessment/Results: Duration of induced standing, sitting balance, trunk control, muscle tone, stamina, and dermal condition were assessed. All have improved. Standing continues for brief periods following cessation of WBV, which is suggestive of a mechanism of potentiation. Discussion: The continuation of standing after cessation of WBV suggests long-term potentiation—a form of plasticity that strengthens transmission at a synapse after high-frequency stimulation that lasts for more than a few minutes and may serve as the foundation for more permanent changes. Conclusions: WBV represents an alternative to fitness effects gained through other modalities. Key Words: Rehabilitation; Spinal cord injuries.
Poster 250 Spontaneous Potentials in Animal Models of Spinal Cord Injury. Anthony S. Burns, MD (Thomas Jefferson Univ, Philadelphia, PA); Michel Lemay, PhD; Alan Tessler, MD, e-mail: [email protected]. Disclosure: A.S. Burns, None; M. Lemay, None; A. Tessler, None. Objective: To confirm the existence of spontaneous potentials (fibrillations, positive sharp waves) in animal models of spinal cord injury (SCI). Design: Prospective cohort. Setting: Academic medical center and university. Animals: 9 Sprague-Dawley rats and 2 domestic short-haired cats. Interventions: Surgical transections of the thoracic spinal cord were performed on 6 rats and 2 cats. The cats were part of a separate investigational protocol and fibroblasts genetically modified to produce brain-derived neurotrophic factor (BDNF) and neurotrophin (NT3) were transplanted into the lesion at the time of transection. Main Outcome Measures: Hind limb muscles were studied for 4 to 6wk with serial electromyography. As a control for the effects of anesthesia and serial testing, 3 intact rats were anesthetized and tested weekly for 4wk. Results: In rats, denervation potentials emerged 4 to 7d after surgery. They increased in intensity and persisted through 28 to 32d, the longest time studied. In 1 animal, spontaneous potentials transiently emerged at day 7, then largely resolved by day 9. All animals underwent histologic examination to confirm that transections were complete. Spontaneous potentials were not present in any of the 3 control animals at any time point during the 4wk of serial testing. In unanesthetized cats, spontaneous potentials emerged by day 8 and were most prominent from day 8 to day 15. In both animals, the spontaneous potentials thereafter
2004 Academy Annual Assembly Abstracts diminished in intensity and were largely absent by day 43. It is unclear how the transplants of BDNF/NT3 expressing fibroblasts impacted the natural history, but 1 possibility is that grafts ameliorated postinjury physiologic conditions in motoneurons. Conclusions: Spontaneous potentials occur after SCI in animals as well as in humans and they appear to be conserved across mammalian species (rats, cats, humans). Key Words: Electromyography; Muscle denervation; Rehabilitation; Spinal cord injuries.
Poster 251: Refer to Abstract 23 in the Spinal Cord Injury Poster Grand Rounds for full abstract. e-mail: [email protected].
Poster 252: Refer to Abstract 24 in the Spinal Cord Injury Poster Grand Rounds for full abstract. e-mail: [email protected].
Poster 253 Is Monitoring Intragastric pH Necessary in Spinal Cord Injury Patients Receiving Famotidine Infusion? Chiwai E. Chan, DO (Stanford Univ Med Ctr/Santa Clara Valley Med Ctr, Palo Alto, CA); Agnes S. Wallbom, MD, e-mail: [email protected]. Disclosure: C.E. Chan, None; A.S. Wallbom, None. Objective: To determine whether monitoring intragastic pH has any effect on preventing stress ulcers in patients with acute spinal cord injury (SCI) who are receiving famotidine infusion. Design: A retrospective study from January to December 2003. Setting: Tertiary care, university-affiliated spinal cord trauma unit. Participants: 10 acute traumatic SCI patients admitted to a rehabilitation trauma center. Interventions: Not applicable. Main Outcome Measures: pH values and guaiac results. Results: There was no correlation between gastric pH and gastric Hemoccult occult blood test results. There was a predominance of positive guaiac in 75/87 (86%) tests performed. 84% of all guaiac tests were positive regardless of pH. Within the subgroup of pH ⬎7, 90% of guaiac tests were positive. The administration of aluminum-magnesium hydroxide suspension in an attempt to increase gastric pH failed to maintain negative Hemoccult test consistently. There were 4 (40%) patients who never had a negative guaiac result within the 48-h study period. The proportion of negative guaiac results did not differ significantly when compared by pH group (z ratio for proportions). All 10 subjects had no clinical symptoms of stress ulcers. Conclusions: It does not appear that gastric pH monitoring and administration of aluminum-magnesium hydroxide suspension are steps needed to prevent stress ulcers during famotidine infusion of acute SCI patients. Key Words: pH; Rehabilitation; Spinal cord injuries; Stress; Ulcers.
Poster 254 Assessing the Sensitivity of an Annual Abdominal Roentgenogram in Screening for Pathology in Chronic Spinal Cord Injury. Douglas B. Barber, MD (Univ Texas Health Sci Ctr, San Antonio, TX); Suzanne L. Woodbury, MD; Mark D. Fredrickson, MD; Gary L. Campbell, DO, e-mail: [email protected]. Disclosure: D.B. Barber, None; S.L. Woodbury, None; M.D. Fredrickson, None; G.L. Campbell, None. Objective: To assess the sensitivity of an annual abdominal roentgenogram (kidneys, ureters, bladder [KUB]). Design: Retrospective chart review. Setting: Department of Veterans Affairs Spinal Cord Injury Center. Participants: 318 patients who received an annual medical assessment including KUB in the 12mo before the study. Interventions: Not applicable. Main Outcome Measure: KUB read by board-certified radiologists. Results: 117 of 318 (37%) KUBs were read as “normal.” Pathology involving the skeleton (eg, previous fracture, heterotopic ossification, osteomyelitis) was described in 102 (32%). Gastrointestinal tract findings (eg, ileus, colonic distention, fecal impaction) were noted in 53 (17%). Probable phlebolith and vascular calcification were reported in 48 (15%). Possible calcification involving the renal system was noted in 42 (13%). Gallstones were noted in 5 (2%). No patients were reported to have received any negative sequelae from undergoing KUB. Conclusions: The prevalence of potential pathology involving the skeletal, gastrointestinal tract, and urinary tract systems suggests that there is value in performing surveillance KUBs annually in patients with SCI. Key Words: Rehabilitation; Spinal cord injuries.
Poster 255 Microarray Study of Gene Expression Profile After Acute Spinal Cord Injury. Leslie R. Morse, DO (Boston Med Ctr, Boston, MA); Ricardo A. Battaglino, PhD; Martha Joe; David Meguerdichian; Hajime Sasaki, DDS, PhD; Steve Williams, MD, e-mail: leslie.morse@ bmc.org. Disclosure: L.R. Morse, None; R.A. Battaglino, None; M. Joe, None; D. Meguerdichian, None; H. Sasaki, None; S. Williams, None. Objective: To perform a large-scale gene profiling of acute spinal cord injury (SCI) in humans. Design: Case-control study. Setting: Acute inpatient rehabilitation unit. Participants: 4 patients with acute, complete cervical SCI and 4 sex- and age-matched neurologically intact patients. Interventions: Not applicable. Main Outcome Measure: Differential gene expression in white blood cells as determined by the hybridization patterns of a microarray containing 12,000 human genes. Results: Preliminary data suggest that over 215 genes are differentially expressed in white blood cells derived from patients with acute SCI. Many genes are known immunoregulators, cell cycle regulators, and mediators of inflammation. Of these genes, approximately two thirds are suppressed and one third are overexpressed when compared with healthy controls. Of interest, several novel genes have been identified with differential expression patterns in this population. Conclusions: We have identified several genes whose expression appears to be altered in humans after acute SCI. We anticipate that this approach will help define the pathophysiology of this condition, and identify future areas of investigation and new treatment targets. Key Words: DNA microarray; Gene expression profiling; Rehabilitation; Spinal cord injuries
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Poster 256: Refer to Abstract 25 in the Spinal Cord Injury Poster Grand Rounds for full abstract. e-mail: [email protected]. Poster 257 Breathlessness During Daily Activities in Spinal Cord Injury. Noel F. Grandas, MD (VAMC Boston HealthCare Syst, West Roxbury, MA); Nitin Jain, MBBS, MSPH; Robert Brown, MD; Carlos G. Tun, MD; Eric Garshick, MD, MOH, e-mail: [email protected]. Disclosure: N.F. Grandas, None; N. Jain, None; R. Brown, None; C.G. Tun, None; E. Garshick, None. Objective: To assess factors associated with breathlessness during daily activities in chronic spinal cord injury (SCI). Design: Cross-sectional. Settings: Subjects recruited from Veterans Affairs SCI service and the community. Participants: Between 1994 and 2003, 441 subjects ⱖ1y after SCI and free from acute illness were recruited for assessment of respiratory health. Interventions: Respiratory questionnaire, spirometry, and neurologic exam. Data included injury date and extent, ability to get around (walk unassisted, walk with an aid, by hand-propelled wheelchair, by motorized wheelchair [MWC]), respiratory illnesses and symptoms, cigarette smoking, occupational exposures, and comorbid medical conditions. Main Outcome Measure: Breathlessness during eating, talking, and dressing. Results: Among 85 subjects who used MWC, the prevalence of breathlessness while eating, talking, or dressing was 24% versus 6% in 356 others (P⬍.0001). The main activity associated with breathlessness in MWC users was talking (18%). Among MWC users, the relative odds of current and former cigarette smokers reporting breathlessness while talking, eating, or dressing was 4.2 (95% CI, 0.9 – 41.0) as compared with never smokers. The relative odds increased by 1.02 (95% CI, 1.00 –1.03) per pack-year. Breathlessness was associated with chronic cough (OR⫽7.8; 95% CI, 2.0 –32.7) and wheeze (OR⫽3.5; 95% CI, 1.04 –13.6). In MWC users, heart disease, percentage of predicted forced vital capacity and forced expiratory volume in 1s, chest illness in the past year, SCI level, and maximal inspiratory pressures were not related to breathlessness. Conclusions: Breathlessness during selected daily activities (most commonly, talking) was greatest among SCI subjects who were most impaired with regard to mobility and was associated with cough, wheeze, and cigarette smoking. Therefore, therapy to relieve breathlessness may include smoking cessation, treatment of wheeze, and improvement of breathing patterns during speech. Key Words: Dyspnea; Activities of daily living; Rehabilitation; Spinal cord injuries
Stroke Poster 258 Crossed Cerebrocerebellar Diaschisis and Motor Weakness of Upper Extremity After Stroke. In Sung Choi (Chonnam National Univ Med Sch & Hosp, Gwangju, Republic of Korea); Sam Gyu Lee; So Young Lee; Jae Hyung Kim, e-mail: [email protected]. Disclosure: I. Choi, None; S. Lee, None; S. Lee, None; J. Kim, None. Objectives: To investigate the correlation between motor evoked potentials (MEPs) and crossed cerebrocerebellar diaschisis (CCD) and to study the relationship between CCD and the severity and prognosis of stroke. Design: Retrospective case series. Setting: Tertiary hospital-based, acute stroke rehabilitation center in Korea. Participants: 32 patients with first-ever stroke and 31 healthy control subjects. Interventions: MEPs were recorded from the abductor pollicis brevis and the abductor hallucis by stimulating the motor cortex relevant to the hand and foot. The localization and the volumetric analysis of brain lesion were performed by a radiologist. The existence of CCD was evaluated by single-photon emission computed tomography of brain. Main Outcome Measures: Central motor conduction times of upper and lower extremities, the existence of CCD, National Institutes of Health Stroke Scale score, FIM instrument score, and Motricity Index (MI). Results: The presence of CCD correlated significantly with “not evoked” MEPs in the upper extremity (22⫽10.667, P⫽.005), but not in the lower extremity (22⫽2.143, P⫽.343). There was no significant correlation between lesion locations and the existence of CCD (P⫽.563). There was a significant correlation between the absence of CCD and higher MI score of the upper extremity (P⫽.048). There were significant correlations between MI score and MEP findings of upper and lower extremities at 1 mo after onset (P⫽.033, P⫽.012). Conclusions: The existence of CCD would reflect the severe insult on descending motor pathways and the severity of paralysis of upper extremity. Key Words: Evoked potentials, motor; Rehabilitation; Stroke. Poster 259: Refer to Abstract 35 in the Stroke Poster Grand Rounds for the full abstract. e-mail: [email protected]. Poster 260: Refer to Abstract 33 in the Stroke Poster Grand Rounds for the full abstract. e-mail: [email protected]. Poster 261 Recovery of Hemiplegic Upper-Limb Functions After the Amputation of Unaffected Upper Limb: A Case Report. Divakara Kedlaya, MD (Corona Regional Med Ctr, Corona, CA); Murray Brandstater, MD, PhD, e-mail: [email protected]. Disclosure: D. Kedlaya, None; M. Brandstater, None. Setting: Community acute rehabilitation unit. Patient: A 50-yo woman with a history of protein C deficiency and stroke. Case Description: The patient suffered a stroke 8y ago, with left hemiplegia. Magnetic resonance imaging at that time showed right posterior parietal lobe infarction. She was also found to have protein C deficiency and was treated with long-term anticoagulation. Although she had some neurologic recovery of left upper limb, it was nonfunctional. She suffered an acute arterial thrombotic event in her right upper limb, which resulted in right below elbow amputation. She had 2wk of acute rehabilitation, focusing on functional use of the left upper limb, and was discharged home at a stand-by assistance level in all aspect of self-care when using the left upper limb. Assessment/Results: The Modified Wolf Motor Test was performed at admission and at discharge. Discussion: Amputation of the unaffected upper limb in our stroke patient forced her
Arch Phys Med Rehabil Vol 85, September 2004