- Email: [email protected]
Poster 29
ACADEMY ANNUAL ASSEMBLY ABSTRACTS effect. There were no trends for changes in peak torque or WOMAC measures. Rate of drop out prior to completion of all study requirements was high (42%) and all patients admitted using other pain medications during the trial. The desire for more pain control was implicated in dropping out. Conclusion: The efficacy of glucosamine for treating Canadians who have OA of the knee remains unclear despite positive industry-linked trials. Key Words: Glucosamine; Osteoarthritis; Pain; Rehabilitation. Poster 29 Functional Outcomes of Liver Transplant Patients Treated in an Acute Rehabilitation Setting. Frederick S. Frost, MD (Cleveland Clinic Foundation, Cleveland, OH); Josef Endredi, MD; Vinod Sahgal, MD, e-mail: [email protected]. Disclosure: None. Objective: To determine associations between categorical and continuous variables that characterize liver transplant patients and outcome variables measuring resource utilization and functional gains during inpatient rehabilitation. Design: Retrospective review. Setting: Inpatient acute rehabilitation unit and community follow-up. Participants: 13 liver transplant patients undergoing initial acute rehabilitation. Interventions: ⱖ3h/d of acute multidisciplinary rehabilitation treatment. Main Outcome Measures: Rasch-converted FIM™ instrument scores, and categorical and continuous clinical variables. Results: Patients of a mean age of 52⫾12.35 years were admitted at a mean of 34.77⫾18.27 days after transplant. 9 of 13 patients were discharged to a residential setting, with mean rehabilitation length of stay (LOS) of 15.9⫾13.1 days. The median hospital charge was $21,500 (range, $7137–$107,568). These patients had a mean Model for End-Stage Liver Disease (MELD) score of 24.17⫾11.26 and serum ammonia averaged 104.46⫾73.08mol/L. The Wilcoxon signed-rank assessment of paired t tests for differences between time points (admission, discharge, follow-up) showed that motor scores (P⬍.001) improved for all timed comparisons, but cognitive scores did not improve (P⬍.99). Motor function at admission correlated with hypoalbuminemia (Spearman P⫽.01), while cognitive function correlated with low levels of total protein (Spearman P⫽.014) and low globulin (Spearman P⫽.059). Despite this, these patients did not differ in the degree of cognitive or motor gains across their stay. Subgroups characterized by other clinical characteristics (eg, alcoholism, gender, cigarette use, diabetes) did not differ in rehabilitation outcomes, although LOS varied by group. Conclusion: Patients with end-stage liver disease are among the most medically complex and debilitated in the hospital. Despite this, we found that liver transplantation patients demonstrated significant reduction in motor disabilities when rehabilitation was provided in an inpatient rehabilitation unit setting. Cognition did not improve during the study period. Key Words: Liver transplantation; Outcomes research; Rehabilitation. Poster 30 Receipt of Depression Diagnoses in the Veteran Spinal Cord Injuries and Disorders Population. Bridget Smith, MPA (Department of Veterans Affairs, Hines, IL); Frances M. Weaver, PhD, e-mail: [email protected]. Disclosure: None. Objectives: To examine (1) the frequency of hospitalizations and outpatient visits for depression in spinal cord injury (SCI) and disorders (SCD) and (2) the association between patient characteristics and the receipt of a depression diagnosis. Design: Retrospective study of administrative data. Setting: Department of Veterans Affairs (VA) facilities, October 1, 1998 to September 30, 2001 (fiscal year 1999 –2001). Participants: Subjects were selected from a cumulative VA registry based on International Classification of Diseases, 9th Edition codes for SCI and SCD. All subjects in the registry with any VA utilization during the study time period were included. Interventions: Not applicable. Main Outcome Measures: Frequency of hospitalizations and visits with a depression diagnosis; and frequency of other diagnoses with depression. Results: Approximately 20% (n⫽4177) of the veterans with SCI and SCD had at least 1 encounter with a depression diagnosis; 8% (n⫽1727) had at least 1 hospitalization; and 16% (n⫽3299) had at least 1 outpatient encounter. In the regression analysis, being younger (OR⫽1.98), female (OR⫽0.49), white (OR⫽1.36), having chronic renal disease (OR⫽1.00), chronic pulmonary disease (OR⫽1.60), coronary artery disease (OR⫽1.57), diabetes (OR⫽1.40), or a hospitalization for a skin (OR⫽1.10) or kidney problem (OR⫽1.24), or drug use (OR⫽7.18) significantly increased the odds of having a depression diagnosis. Conclusions: Demographic characteristics, including age, gender, and race, and health status characteristics such as the presence of chronic diseases, were associated with the likelihood of receipt of a depression diagnosis. These findings could result from differences in depression prevalence between groups and/or could occur because some groups are more likely to be screened. This study is the basis for additional work to examine outcomes of antidepressant use in the VA population with SCI and SCD. Key Words: Depression; Rehabilitation; Spinal cord injuries.
Poster 31 Community-Acquired Pneumonia in Veterans With Spinal Cord Injury. Charlesnika T. Evans, MPH (Department of Veterans Affairs, Hines, IL); Frances M. Weaver, PhD; Heidi T. Chang, MPH; Raquel Hampton, MS; Stephen Burns, MD, e-mail: [email protected]. Disclosure: None. Objective: To describe the characteristics of community-acquired pneumonia (CAP) in persons with spinal cord injury (SCI) and how management is related to outcomes. Design: Cross-sectional retrospective review of administrative and clinical data. Setting: Department of Veterans Affairs (VA) facilities, and for substudy, 3 VA SCI centers (October 1998 –September 2000). Participants: Veterans with SCI: 260 inpatients with CAP; in the substudy, 41 inpatients and outpatients with CAP from 3 sites. Interventions: Not applicable. Main Outcome Measures: Percentage of patients with an etiologic diagnosis, mortality rate, mean length of stay (LOS), and number and types of procedures and treatments. Results: Of the 260 inpatients with SCI identified from administrative data with CAP, only 24% had an etiologic diagnosis. Etiologic diagnosis was not associated with mortality after adjusting for several factors (OR⫽1.38; CI, 0.45– 4.20), however, it was associated with an increase in LOS (P⫽.024). For the substudy, almost 75% of the 41 patients were hospitalized (mean LOS⫽16.3d) and 3 patients died. Most received chest radiographs (85%), but up
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to 54% did not receive other tests standard for management of CAP during the first day of care (eg, blood cultures, CHEM 7). Of the 16 patients with sputum cultures, an organism was identified in 44% through microbiology testing. Over 90% received antibiotics within 24 hours of admission. Conclusions: Many patients do not receive the minimum recommended testing. Empiric treatment appears to have been the predominant type of management used in this population. Further research to assess the relationship between clinical characteristics and management with patient outcomes is warranted. Key Words: Pneumonia; Rehabilitation; Spinal cord injuries; Treatment outcome. Poster 32 Rehabilitative Outcome After Simultaneous Bilateral Hip Replacement: A Case Report. John A. Walter, DO (Ohio State University Medical Center, Columbus, OH); Vivek Kadyan, MD, e-mail: [email protected]. Disclosure: None. Setting: Acute Midwestern medical center and university-based rehabilitation hospital. Patient: 55-year-old postmenopausal woman with a medical history remarkable for L4-5 laminectomy. Case Description: Bilateral total hip arthroplasty (THA) was performed. Postoperative course was complicated by anemia and pain. The patient was admitted to acute rehabilitation 4 days after surgery. We report on the rehabilitation outcome after simultaneous bilateral THA. Assessment/ Results: On admission, the patient ambulated 50ft using a standard walker at a maximum assist level and total assistance for stairs. She did quite well and had a rather short inpatient course. On day 7 of rehabilitation admission, the patient was discharged and was ambulating 400ft using a rolling walker with supervision and was climbing 6 stairs with maximum assistance. At 1-month follow-up, she was ambulating with a cane approximately 0.5 mile daily. At 6 months, she is ambulating without a cane over 1 mile daily, swimming 1 mile daily, and participating in low-impact aerobics twice weekly. Discussion: Osteoarthritis is a major cause of pain and disability in the United States with hip involvement often leading to significant functional impairment. THA, undertaken after conservative management failure, involves invasive surgery followed by a long and demanding rehabilitation program. THA is invariably performed unilaterally and sequentially if both hips are involved. Orthopedic surgical literature reports cases of simultaneous bilateral THA, but provides little information about rehabilitation outcome. Conclusions: This case illustrates that simultaneous THA can be performed with favorable surgical and functional outcome. Our patient had an excellent outcome and this could be attributed, in part, to her age, limited comorbidities, and good physical conditioning prior to surgery. Further prospective research needs to be performed to help determine exact patient criteria, surgical approach, and rehabilitative techniques when performing simultaneous bilateral THA. Key Words: Osteoarthritis; Rehabilitation; Total hip replacement.
Electrodiagnosis Poster 33 Isolated Laryngeal Myokymia Causing Voice Dysfunction: A Case Report. Michael C. Munin, MD (University of Pittsburgh, Pittsburgh, PA); Clark A. Rosen, MD; Colleen Powell, MD; George Small, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care outpatient voice center. Patient: A 48-year-old women with isolated laryngeal myokymia causing dysphonia. Case Description: The patient presented with a 2-year history of increasing dysphonia and pain with vocalization. Physical examination, including cranial nerve testing, was normal. Assessment/Results: Indirect laryngoscopy, performed by a boardcertified otolaryngologist, showed focal, nonfatigable, left vocal cord tremor with phonation and at rest. A board-certified electromyographer performed laryngeal electromyography, which demonstrated abundant myokymic potentials within the left thyroarytenoid muscle. Other muscles of vocalization were normal on electromyographic testing, as was limb electromyography performed separately. Magnetic resonance imaging (MRI) of the brain demonstrated a loop of the left vertebral artery compressing the left medulla. No demyelinating plaques were observed. An MRI from the posterior fossa to the upper chest excluded compression of the vagus tree as well as other neck pathology. The symptoms did not respond to the oral anticonvulsants carbamazepine (Tegretol) or phenytoin (Dilantin), which were then discontinued. Discussion: Laryngeal myokymia has been previously described only in Isaacs’ syndrome. Isolated myokymia has been reported in facial and trochlear nerve brainstem lesions. Medullary compression may be the cause of focal laryngeal myokymia in this patient. Conclusion: To our knowledge, this is the first report of isolated laryngeal myokymia. Isolated laryngeal myokymia should be considered in the differential diagnosis of dysphonia. Key Words: Dysphonia; Electromyography; Larynx; Myokymia; Rehabilitation. Poster 34 Spinal Cord Injury Patient With Compressive Neuropathy From Normal Tourniquet Pressure: A Case Report. Andre C. Hobbs, MD (Temple University, Philadelphia, PA); Michael Weinik, DO, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care pediatric hospital. Patient: A 19-year-old man with an incomplete C5 spinal cord injury (SCI). Case Description: This patient underwent a tendon-lengthening procedure of the right brachioradialis and biceps secondary to severe spasticity and the onset of contractures. Prior to surgery, he was able to extend his right wrist and fingers without assistance. A decline in his functional status (inability to extend his wrist and fingers) was noted postoperatively. A radial neuropathy was suspected and an electrodiagnostic evaluation was performed. Assessment/Results: The electrodiagnostic evaluation was performed 4 weeks after surgery and revealed severe acute axonal loss (fibrilations, positive waves) in muscles that are innervated distal to deltoid, including the musculocutaneous, ulnar, median, and radial nerves. The axillary nerve was spared. Discussion: It was suspected that the patient suffered a compressive neuropathy from tourniquet pressure during surgery. After discussing this with the surgeon, he agreed but mentioned that the tourniquet time was standard. To our knowledge, this is the first reported case of a patient with SCI with a compressive
Arch Phys Med Rehabil Vol 84, September 2003
Poster 31 Community-Acquired Pneumonia in Veterans With Spinal Cord Injury. Charlesnika T. Evans, MPH (Department of Veterans Affairs, Hines, IL); Frances M. Weaver, PhD; Heidi T. Chang, MPH; Raquel Hampton, MS; Stephen Burns, MD, e-mail: [email protected]. Disclosure: None. Objective: To describe the characteristics of community-acquired pneumonia (CAP) in persons with spinal cord injury (SCI) and how management is related to outcomes. Design: Cross-sectional retrospective review of administrative and clinical data. Setting: Department of Veterans Affairs (VA) facilities, and for substudy, 3 VA SCI centers (October 1998 –September 2000). Participants: Veterans with SCI: 260 inpatients with CAP; in the substudy, 41 inpatients and outpatients with CAP from 3 sites. Interventions: Not applicable. Main Outcome Measures: Percentage of patients with an etiologic diagnosis, mortality rate, mean length of stay (LOS), and number and types of procedures and treatments. Results: Of the 260 inpatients with SCI identified from administrative data with CAP, only 24% had an etiologic diagnosis. Etiologic diagnosis was not associated with mortality after adjusting for several factors (OR⫽1.38; CI, 0.45– 4.20), however, it was associated with an increase in LOS (P⫽.024). For the substudy, almost 75% of the 41 patients were hospitalized (mean LOS⫽16.3d) and 3 patients died. Most received chest radiographs (85%), but up
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to 54% did not receive other tests standard for management of CAP during the first day of care (eg, blood cultures, CHEM 7). Of the 16 patients with sputum cultures, an organism was identified in 44% through microbiology testing. Over 90% received antibiotics within 24 hours of admission. Conclusions: Many patients do not receive the minimum recommended testing. Empiric treatment appears to have been the predominant type of management used in this population. Further research to assess the relationship between clinical characteristics and management with patient outcomes is warranted. Key Words: Pneumonia; Rehabilitation; Spinal cord injuries; Treatment outcome. Poster 32 Rehabilitative Outcome After Simultaneous Bilateral Hip Replacement: A Case Report. John A. Walter, DO (Ohio State University Medical Center, Columbus, OH); Vivek Kadyan, MD, e-mail: [email protected]. Disclosure: None. Setting: Acute Midwestern medical center and university-based rehabilitation hospital. Patient: 55-year-old postmenopausal woman with a medical history remarkable for L4-5 laminectomy. Case Description: Bilateral total hip arthroplasty (THA) was performed. Postoperative course was complicated by anemia and pain. The patient was admitted to acute rehabilitation 4 days after surgery. We report on the rehabilitation outcome after simultaneous bilateral THA. Assessment/ Results: On admission, the patient ambulated 50ft using a standard walker at a maximum assist level and total assistance for stairs. She did quite well and had a rather short inpatient course. On day 7 of rehabilitation admission, the patient was discharged and was ambulating 400ft using a rolling walker with supervision and was climbing 6 stairs with maximum assistance. At 1-month follow-up, she was ambulating with a cane approximately 0.5 mile daily. At 6 months, she is ambulating without a cane over 1 mile daily, swimming 1 mile daily, and participating in low-impact aerobics twice weekly. Discussion: Osteoarthritis is a major cause of pain and disability in the United States with hip involvement often leading to significant functional impairment. THA, undertaken after conservative management failure, involves invasive surgery followed by a long and demanding rehabilitation program. THA is invariably performed unilaterally and sequentially if both hips are involved. Orthopedic surgical literature reports cases of simultaneous bilateral THA, but provides little information about rehabilitation outcome. Conclusions: This case illustrates that simultaneous THA can be performed with favorable surgical and functional outcome. Our patient had an excellent outcome and this could be attributed, in part, to her age, limited comorbidities, and good physical conditioning prior to surgery. Further prospective research needs to be performed to help determine exact patient criteria, surgical approach, and rehabilitative techniques when performing simultaneous bilateral THA. Key Words: Osteoarthritis; Rehabilitation; Total hip replacement.
Electrodiagnosis Poster 33 Isolated Laryngeal Myokymia Causing Voice Dysfunction: A Case Report. Michael C. Munin, MD (University of Pittsburgh, Pittsburgh, PA); Clark A. Rosen, MD; Colleen Powell, MD; George Small, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care outpatient voice center. Patient: A 48-year-old women with isolated laryngeal myokymia causing dysphonia. Case Description: The patient presented with a 2-year history of increasing dysphonia and pain with vocalization. Physical examination, including cranial nerve testing, was normal. Assessment/Results: Indirect laryngoscopy, performed by a boardcertified otolaryngologist, showed focal, nonfatigable, left vocal cord tremor with phonation and at rest. A board-certified electromyographer performed laryngeal electromyography, which demonstrated abundant myokymic potentials within the left thyroarytenoid muscle. Other muscles of vocalization were normal on electromyographic testing, as was limb electromyography performed separately. Magnetic resonance imaging (MRI) of the brain demonstrated a loop of the left vertebral artery compressing the left medulla. No demyelinating plaques were observed. An MRI from the posterior fossa to the upper chest excluded compression of the vagus tree as well as other neck pathology. The symptoms did not respond to the oral anticonvulsants carbamazepine (Tegretol) or phenytoin (Dilantin), which were then discontinued. Discussion: Laryngeal myokymia has been previously described only in Isaacs’ syndrome. Isolated myokymia has been reported in facial and trochlear nerve brainstem lesions. Medullary compression may be the cause of focal laryngeal myokymia in this patient. Conclusion: To our knowledge, this is the first report of isolated laryngeal myokymia. Isolated laryngeal myokymia should be considered in the differential diagnosis of dysphonia. Key Words: Dysphonia; Electromyography; Larynx; Myokymia; Rehabilitation. Poster 34 Spinal Cord Injury Patient With Compressive Neuropathy From Normal Tourniquet Pressure: A Case Report. Andre C. Hobbs, MD (Temple University, Philadelphia, PA); Michael Weinik, DO, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care pediatric hospital. Patient: A 19-year-old man with an incomplete C5 spinal cord injury (SCI). Case Description: This patient underwent a tendon-lengthening procedure of the right brachioradialis and biceps secondary to severe spasticity and the onset of contractures. Prior to surgery, he was able to extend his right wrist and fingers without assistance. A decline in his functional status (inability to extend his wrist and fingers) was noted postoperatively. A radial neuropathy was suspected and an electrodiagnostic evaluation was performed. Assessment/Results: The electrodiagnostic evaluation was performed 4 weeks after surgery and revealed severe acute axonal loss (fibrilations, positive waves) in muscles that are innervated distal to deltoid, including the musculocutaneous, ulnar, median, and radial nerves. The axillary nerve was spared. Discussion: It was suspected that the patient suffered a compressive neuropathy from tourniquet pressure during surgery. After discussing this with the surgeon, he agreed but mentioned that the tourniquet time was standard. To our knowledge, this is the first reported case of a patient with SCI with a compressive
Arch Phys Med Rehabil Vol 84, September 2003