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Poster 35: Association Between Body Mass Index and Gain in FIM Scores
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Clinical Outcomes Poster 35 Association Between Body Mass Index and Gain in FIM Scores. Nitin B. Jain, MD, MSPH (Spaulding Rehabilitation Hospital, Boston, MA); David T. Burke, MD. Disclosure: D.T. Burke, none; N.B. Jain, none. Objective: To assess whether body mass index (BMI) was associated with change in FIM scores of patients receiving acute rehabilitation. Design: Retrospective cross-sectional study. Setting: Rehabilitation hospital. Participants: In-patients undergoing acute rehabilitation. Interventions: Not applicable. Main Outcome Measures: Change in FIM scores from admission to discharge. Results: Patients were classified into underweight (BMI⬍18.5 kg/m2); normative range (BMI⫽18.5–24.9kg/m2); overweight (BMI⫽25.0 –2 9.9kg/ m2); obese class I (BMI⫽30.0 –34.9kg/m2); obese class II (BMI⫽35.0 –39.9kg/m2); and obese class III (BMIⱖ40kg/m2). The median gain in FIM scores from admission to discharge was highest for obese class I patients (27 points), followed by obese class II patients (26 points). Adjusting for age, sex, and length of in-hospital stay, obese class I patients had a 1.8 point (95% confidence limits, 0.2–3.5) higher gain in FIM scores as compared with patients with BMI in the normative range. Underweight patients had the least gain in FIM scores (⫽⫺2.8; 95% confidence limits, ⫺5.3 to⫺0.4). Conclusions: In an acute rehabilitation setting, obese patients did not have suboptimal outcomes, as determined by changes in FIM scores, when compared with normative range BMI patients. Although the differences in gain of FIM scores between BMI categories were small, obese class I patients had better improvement than normative BMI individuals. Key Words: Body mass index; Rehabilitation. Poster 36 Cauda Equina Syndrome After Interlaminar Epidural Corticosteroid Injection: A Case Report. Matthew Pingree, MD (Mayo Clinic, Rochester, MN); Mark B. Hurdle, MD; Terrance McNamara. Disclosure: M.B. Hurdle, none; T. McNamara, none; M. Pingree, none. Setting: Outpatient pain clinic. Patient: 24-year-old female physical therapy student with a 2-year history of back pain with multiple acute exacerbations. Her symptoms and examination were consistent with a left S1 radiculitis. Magnetic resonance imaging (MRI) revealed a very large central disk extrusion at the L5-S1 level effacing the subarachnoid space entirely, with no impingement on the exiting L5 nerve roots bilaterally. Her pain was rated 6 out of 10 on a numeric rating scale. After failing conservative treatment, an L5-S1 interlaminar epidural steroid injection was obtained. Program Description: Tertiary care academic center. Results: Interlaminar epidural steroid L5-S1 injection was completed. Lateral view revealed unintentional dural puncture. 2 days postinjection the patient reported to the pain clinic reporting left leg numbness, saddle anesthesia, and an inability to walk on her toes. Repeat MRI imaging revealed that the volume of disk material within the spinal canal had increased. 3 days postinjection, the patient was evaluated by neurosurgey and was found to have a progressive cauda equina syndrome and she was urgently decompressed. After removal of the yellow ligament, 2 small needle-size holes were identified within the dura. These holes were consistent with prior epidural injections. 2 months after surgery, she reports almost complete resolution of her saddle and leg anesthesia and leg weakness. Conclusions: These findings raise the concern that the epidural space at the level of a disk extrusion, which occupies a large amount of the central canal, may be compromised and therefore difficult to access. In light of the above case, one may consider approaching the epidural
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space at an adjacent level. Key Words: Cauda equina syndrome; Epidural injections; Rehabilitation. Poster 37 Comparative Outcomes of Discontinuing Anticoagulation Therapy Following Intramuscular Hemorrhage: A Case Report. Christina Hughes, MD (Wm Beaumont Hospital, Royal Oak, MI); Myron M. LaBan, BA, MD, MMsc. Disclosure: C. Hughes, none; M.M. LaBan, none. Setting: 1000-bed community academic hospital. Patients: A 67year-old male on Coumadin for atrial fibrillation and an 88-year-old female on Coumadin for atrial fibrillation and Heparin for an acute myocardial infarction (MI). Case Descriptions: We describe 2 cases of intramuscular hemorrhage, the first within the rectus abdominal sheath and the other in the iliopsoas. The 67-year-old experienced a spontaneous bilateral rectus abdominal sheath hematoma. His anticoagulation therapy was discontinued. 10 days later he developed a left hemiparesis from a right middle cerebral artery thromboembolic occlusion emanating from a left atrial intracardiac thrombus. Alternatively, the 88-year-old developed a large right iliopsoas hematoma. Her anticoagulation was discontinued. Despite risk factors for thromboemboli (atrial fibrillation, acute MI, recent femur open reduction, and internal fixation), she experienced no additional problems. Assessment/Results: Spontaneous intramuscular hematomas are a risk associated with anticoagulation therapy and should always be considered in the differential diagnosis of acute abdominal and/or flank pain. Although rarely fatal, these bleeds are capable of producing significant morbidity. In the instance of a rectus abdominal sheath hemorrhage, a patient may complain of abdominal and/or scrotal pain and pressure. Symptoms of a bleed into the iliopsoas include, among others, flank and proximal leg pain as well as weakness secondary to femoral and/or obturator nerve neuropathy. Later, an ecchymosis may develop in the flank, for example, the Gray Turner’s sign. Conclusions: These case reports contrast the variability by which intramuscular hemorrhage can present and the effect of withdrawing anticoagulation. Early diagnosis is essential for immediate and appropriate treatment. The literature with regard to terminating anticoagulation therapy remains controversial; however, there is growing evidence that continuing this treatment does not increase the risk of additional bleeding. Discontinuing anticoagulation must be balanced with regard to the risk of thromboembolism. Key Words: Hematoma; Rehabilitation; Stroke. Poster 38: Cancelled. Poster 39 Congestive Heart Failure Exerts a Limited Influence on Lower Extremity Joint Replacement Rehabilitation Outcomes. Heather K. Vincent, PhD, MS (University of Florida, Gainesville, FL); Kevin R. Vincent, MD, PhD. Disclosure: H.K. Vincent, none; K.R. Vincent, none. Objective: To determine whether congestive heart failure (CHF) influences the magnitude and rate of motor and cognitive functional improvement, and specific rehabilitation outcomes after lower-extremity joint replacement. Design: Retrospective, comparative study. Setting: Freestanding inpatient rehabilitation facility. Participants: A total of 7817 total hip replacement (THR) and 14,995 total knee replacement (TKR) patients from 14 independent inpatient rehabilitation facilities were included (70.1⫾0.1y, 66.9% women). Interventions: Not applicable. Main Outcome Measures: FIM scores (motor, cognition subscores) at admission and discharge, rate of FIM change, length of stay (LOS), comorbidity type, and discharge destination. Results: Patients with CHF had 6% to 10% more cases of chronic Arch Phys Med Rehabil Vol 89, November 2008
Clinical Outcomes Poster 35 Association Between Body Mass Index and Gain in FIM Scores. Nitin B. Jain, MD, MSPH (Spaulding Rehabilitation Hospital, Boston, MA); David T. Burke, MD. Disclosure: D.T. Burke, none; N.B. Jain, none. Objective: To assess whether body mass index (BMI) was associated with change in FIM scores of patients receiving acute rehabilitation. Design: Retrospective cross-sectional study. Setting: Rehabilitation hospital. Participants: In-patients undergoing acute rehabilitation. Interventions: Not applicable. Main Outcome Measures: Change in FIM scores from admission to discharge. Results: Patients were classified into underweight (BMI⬍18.5 kg/m2); normative range (BMI⫽18.5–24.9kg/m2); overweight (BMI⫽25.0 –2 9.9kg/ m2); obese class I (BMI⫽30.0 –34.9kg/m2); obese class II (BMI⫽35.0 –39.9kg/m2); and obese class III (BMIⱖ40kg/m2). The median gain in FIM scores from admission to discharge was highest for obese class I patients (27 points), followed by obese class II patients (26 points). Adjusting for age, sex, and length of in-hospital stay, obese class I patients had a 1.8 point (95% confidence limits, 0.2–3.5) higher gain in FIM scores as compared with patients with BMI in the normative range. Underweight patients had the least gain in FIM scores (⫽⫺2.8; 95% confidence limits, ⫺5.3 to⫺0.4). Conclusions: In an acute rehabilitation setting, obese patients did not have suboptimal outcomes, as determined by changes in FIM scores, when compared with normative range BMI patients. Although the differences in gain of FIM scores between BMI categories were small, obese class I patients had better improvement than normative BMI individuals. Key Words: Body mass index; Rehabilitation. Poster 36 Cauda Equina Syndrome After Interlaminar Epidural Corticosteroid Injection: A Case Report. Matthew Pingree, MD (Mayo Clinic, Rochester, MN); Mark B. Hurdle, MD; Terrance McNamara. Disclosure: M.B. Hurdle, none; T. McNamara, none; M. Pingree, none. Setting: Outpatient pain clinic. Patient: 24-year-old female physical therapy student with a 2-year history of back pain with multiple acute exacerbations. Her symptoms and examination were consistent with a left S1 radiculitis. Magnetic resonance imaging (MRI) revealed a very large central disk extrusion at the L5-S1 level effacing the subarachnoid space entirely, with no impingement on the exiting L5 nerve roots bilaterally. Her pain was rated 6 out of 10 on a numeric rating scale. After failing conservative treatment, an L5-S1 interlaminar epidural steroid injection was obtained. Program Description: Tertiary care academic center. Results: Interlaminar epidural steroid L5-S1 injection was completed. Lateral view revealed unintentional dural puncture. 2 days postinjection the patient reported to the pain clinic reporting left leg numbness, saddle anesthesia, and an inability to walk on her toes. Repeat MRI imaging revealed that the volume of disk material within the spinal canal had increased. 3 days postinjection, the patient was evaluated by neurosurgey and was found to have a progressive cauda equina syndrome and she was urgently decompressed. After removal of the yellow ligament, 2 small needle-size holes were identified within the dura. These holes were consistent with prior epidural injections. 2 months after surgery, she reports almost complete resolution of her saddle and leg anesthesia and leg weakness. Conclusions: These findings raise the concern that the epidural space at the level of a disk extrusion, which occupies a large amount of the central canal, may be compromised and therefore difficult to access. In light of the above case, one may consider approaching the epidural
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space at an adjacent level. Key Words: Cauda equina syndrome; Epidural injections; Rehabilitation. Poster 37 Comparative Outcomes of Discontinuing Anticoagulation Therapy Following Intramuscular Hemorrhage: A Case Report. Christina Hughes, MD (Wm Beaumont Hospital, Royal Oak, MI); Myron M. LaBan, BA, MD, MMsc. Disclosure: C. Hughes, none; M.M. LaBan, none. Setting: 1000-bed community academic hospital. Patients: A 67year-old male on Coumadin for atrial fibrillation and an 88-year-old female on Coumadin for atrial fibrillation and Heparin for an acute myocardial infarction (MI). Case Descriptions: We describe 2 cases of intramuscular hemorrhage, the first within the rectus abdominal sheath and the other in the iliopsoas. The 67-year-old experienced a spontaneous bilateral rectus abdominal sheath hematoma. His anticoagulation therapy was discontinued. 10 days later he developed a left hemiparesis from a right middle cerebral artery thromboembolic occlusion emanating from a left atrial intracardiac thrombus. Alternatively, the 88-year-old developed a large right iliopsoas hematoma. Her anticoagulation was discontinued. Despite risk factors for thromboemboli (atrial fibrillation, acute MI, recent femur open reduction, and internal fixation), she experienced no additional problems. Assessment/Results: Spontaneous intramuscular hematomas are a risk associated with anticoagulation therapy and should always be considered in the differential diagnosis of acute abdominal and/or flank pain. Although rarely fatal, these bleeds are capable of producing significant morbidity. In the instance of a rectus abdominal sheath hemorrhage, a patient may complain of abdominal and/or scrotal pain and pressure. Symptoms of a bleed into the iliopsoas include, among others, flank and proximal leg pain as well as weakness secondary to femoral and/or obturator nerve neuropathy. Later, an ecchymosis may develop in the flank, for example, the Gray Turner’s sign. Conclusions: These case reports contrast the variability by which intramuscular hemorrhage can present and the effect of withdrawing anticoagulation. Early diagnosis is essential for immediate and appropriate treatment. The literature with regard to terminating anticoagulation therapy remains controversial; however, there is growing evidence that continuing this treatment does not increase the risk of additional bleeding. Discontinuing anticoagulation must be balanced with regard to the risk of thromboembolism. Key Words: Hematoma; Rehabilitation; Stroke. Poster 38: Cancelled. Poster 39 Congestive Heart Failure Exerts a Limited Influence on Lower Extremity Joint Replacement Rehabilitation Outcomes. Heather K. Vincent, PhD, MS (University of Florida, Gainesville, FL); Kevin R. Vincent, MD, PhD. Disclosure: H.K. Vincent, none; K.R. Vincent, none. Objective: To determine whether congestive heart failure (CHF) influences the magnitude and rate of motor and cognitive functional improvement, and specific rehabilitation outcomes after lower-extremity joint replacement. Design: Retrospective, comparative study. Setting: Freestanding inpatient rehabilitation facility. Participants: A total of 7817 total hip replacement (THR) and 14,995 total knee replacement (TKR) patients from 14 independent inpatient rehabilitation facilities were included (70.1⫾0.1y, 66.9% women). Interventions: Not applicable. Main Outcome Measures: FIM scores (motor, cognition subscores) at admission and discharge, rate of FIM change, length of stay (LOS), comorbidity type, and discharge destination. Results: Patients with CHF had 6% to 10% more cases of chronic Arch Phys Med Rehabil Vol 89, November 2008