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Poster 366 Admission Screening for Obstructive Sleep Apnea during Inpatient Stroke Rehabilitation, A New Standard of Care: A Case Report
PM&R
seeking medical attention. Computed tomography of the brain was performed and did not show any signs of acute intracranial changes. He was subsequently discharged home and advised to see his primary care physician. His primary care physician advised him to start physical therapy, however before he could start, he fell again. After his third fall, he returned to the ED and was admitted. His physical examination revealed 4/5 motor scores in bilateral upper extremities, 3/5 motor score in left lower extremity, and 2/5 motor score in right lower extremity. Sensation to light touch and pain was decreased in bilateral lower extremities. Magnetic resonance imaging of both cervical and lumbar spine was performed which showed C6-C7 right paracentral herniation deforming the cord anteriorly with acute cord compression. No myelopathy was observed in the lumbar spine however patient showed multi level degenerative disc disease from L1/L2 to L5/S1. Patient received a course of intravenous steroids and an emergent surgical decompression was performed. Setting: Tertiary care hospital. Results or Clinical Course: His surgery was successful and without complication. The patient reported resolution of numbness as well as regaining strength in his bilateral lower extremities after the decompression. He later was discharged home with home physical therapy. Discussion: Cervical cord compressions usually present with upper extremity symptoms. However there are a few documented cases of cervical cord compressions presenting with lumbar radicular symptoms. One must be careful not to dismiss higher level spinal cord lesions despite absence of upper extremity symptoms. Conclusions: Although rare, cervical cord compressions can occur with a presentation similar to lumbar radiculopathy. Poster 365 Evaluation of Health Utility in Patients Receiving OnabotulinumtoxinA (BotoxÒ) for the Treatment of Adult Focal Spasticity: Results from MOBILITYÒ, a Prospective Observational Cohort Study. Farooq Ismail (Westpark Healthcare Centre, Toronto, ON, Canada); Theodore Wein, MD; Meetu Bhogal, M.Sc.; Grace Trentin, PhD. Disclosures: F. Ismail, Allergan, Inc., Other Objective: To evaluate health utility related to the clinical use of onabotulinumtoxinA in adult patients with focal spasticity. Design: A prospective, multi-center, observational cohort study collecting patient reported outcomes data across several indications (adult focal spasticity [AFS], blepharospasm, cerebral palsy, cervical dystonia, hemifacial spasm, and hyperhidrosis). Setting: Multiple physician sites across Canada. Participants: 440 patients with AFS who were initiating (naïve) or receiving ongoing (maintenance) onabotulinumtoxinA treatment, were enrolled. Interventions: Not applicable. Main Outcome Measures: Health utility was the primary outcome measure obtained from the SF-12Ò Health Survey using the SF-6D. The SF-12Ò was collected at baseline, week four posttreatment and up to five subsequent injection visits. Results or Clinical Course: A total of 440 patients with AFS (mean age, 52.7 years) were enrolled in MOBILITYÒ. The most common etiologies reported were stroke (n¼222), multiple sclerosis (MS; n¼61), and spinal cord injury (SCI; n¼45). Eighty-seven
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percent (86.8%) of patients were Caucasian, 50.2% female and 39.8% were naïve to treatment. The highest mean baseline health utility scores were in traumatic brain injury patients (0.655) vs. stroke (0.634), SCI (0.604), and MS (0.589). Improvements in health utility scores from baseline were seen in all cohorts across all visits. Baseline scores were generally higher in maintenance vs. naïve; however, mean changes from baseline were greatest in naïve patients. A total of 37 adverse events in 21 patients were reported in the AFS safety cohort. Of the 37 adverse events, 16 (43.2%) were serious and 17 (45.9%) were considered unrelated to treatment. Conclusions: MS patients have the lowest health utility scores compared to patients with other neurological lesions. OnabotulinumtoxinA treatment can improve health utility over time in adult patients with focal spasticity due to various etiologies. Poster 366 Admission Screening for Obstructive Sleep Apnea during Inpatient Stroke Rehabilitation, A New Standard of Care: A Case Report. Jennifer R. Knowlton, MD (Vidant Medical Center, Winterville, NC, United States); Jessica Hanson, MD; William Doss, MD. Disclosures: J. R. Knowlton, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: Patient is a 58-year-old Caucasian woman with a history of hypertension, hypercholesterolemia, diabetes, and obesity who presented with right hemiplegia and aphasia who was found to have an acute left MCA infarct with resultant oropharyngeal dysphagia. Patient was without any prior known diagnosis of Obstructive Sleep Apnea (OSA). She reported a positive history of nighttime snoring and daytime fatigue. Observational Apneic OSA screening tool was utilized during initial stroke admission and revealed positive screen for OSA. CPAP was ordered during inpatient rehabilitation with improvements noted in expected FIM gains. Setting: Inpatient Stroke Rehabilitation. Results or Clinical Course: Outcomes were measured using the APNEIC OSA screening tool which evaluates patient’s Age, Mallampati Pharynx grade, Neck circumference, Body Mass Index, Incisors forward/overbite, and Cricomental distance. Measurements were conducted at bedside to obtain neck circumference and the cricomental distance, BMI and age were acquired via chart review. Patient was positive for all APNEIC OSA screen measures. Discussion: Research has demonstrated that having a cricomental distance of less than 1.5 cm, a Mallampati pharyngeal grade of III or IV, and an overbite prompted a positive predictive value of approximately 95% for OSA. Our patient was positive for all five screening measures. Research reveals that undiagnosed OSA in stroke patients correlates with poorer functional outcomes and less functional independence measure (FIM) gains. Conclusions: Currently, over 80% of people with OSA are undiagnosed and the prevalence of OSA in stroke patients is approximately 70%. Statistics highlight the fact that all patients admitted to inpatient rehabilitation with a stroke diagnosis should be screened for OSA, as it is a modifiable risk factor for stroke and subsequent repeat strokes. Patients typically are discharged home prior to their formal polysomography, thus apnea interventions occur after discharge. OSA screening should be performed in all stroke patients admitted to inpatient rehabilitation as standard of
S314
care which may decrease risk of mortality from subsequent strokes, decrease post-stroke morbidity, and also maximize functional gains during their post-acute inpatient rehabilitation stay. Further expanded research is warranted and in process. Poster 367 Early Physical Medicine and Rehabilitation Consultation Leads to Decreased Length of Stay for Patients Admitted with a Stroke. Andrew J. Chrisman, MD (William Beaumont Hospital, Royal Oak, MI, United States); Myron Laban, MD; Ronald S. Taylor, MD; Justin Riutta, MD. Disclosures: A. J. Chrisman, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To determine if the timing of consults placed to Physical Medicine and Rehabilitation (PM&R) for patients admitted with a stroke in an acute medical center affects acute hospitalization Length of Stay (LOS). Design: Restrospective cohort study. Setting: Tertiary Care Hospital. Participants: All patients age 18-99 admitted from 2/2009-12/ 2013 with one of the following ICD-9 codes listed as their primary diagnosis: 430, 431, 432.1, 432.9, 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, and 434.91. Interventions: Not applicable. Main Outcome Measures: Acute hospitalization Length of Stay (LOS). Results or Clinical Course: The hospital’s database was queried to illicit all patients admitted with the above ICD-9 codes and separated into two groups: those who received a PM&R consult and those who did not. Patients were excluded if the ICD-9 code diagnosis was not the primary reason for admission. Acute hospitalization LOS was compared between the two groups and the data was further analyzed to determine if LOS differed based on timing of the consult. LOS was significantly shorter in patients with early PM&R consults. Conclusions: This is the first documented study using Electronic Medical Records to investigate how the timing of PM&R consultation affects acute hospitalization length of stay for patients with strokes that has been reported in the literature to date. Our data indicate that early consultation of PM&R in patients admitted with acute strokes reduces acute hospitalization LOS. Given that Physical Medicine and Rehabilitation focuses on function we are uniquely qualified to both determine and facilitate appropriate disposition plans for patients admitted with strokes. Poster 368 Excessive Eructation in Post Mild Traumatic Brain Injury: A Case Report of a 76-year-old Man with Concussion after Motor Vehicle Collision Post Concussive Symptoms. Yevgeny Zadov, DO (Penn State Hershey Medical Center, Hershey, PA, United States). Disclosures: Y. Zadov, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: Patient was involved in a motor vehicle collision, resulting in mild traumatic brain injury. He was treated
PRESENTATIONS
at an emergency department and released home. He subsequently developed post concussive symptoms including balance dysfunction, cognitive dysfunction, headaches, and nausea. In addition, he developed excessive and uncontrolled eructation (belching). He finds relief when in a recumbent position. Patient reports severe eructation any time he is not supine or recumbent for more than 2-3 minutes. He is symptomatic several times per 2-5 minutes. He denies any associated symptoms. He has seen gastroenterology and has had upper and lower endoscopies which were negative. He was trialed on medications for bowel discomfort such as simethicone. He was been trialed on oral baclofen but this also failed. Review of records from primary care and gastroenterology found no further treatment or diagnostic modalities being investigated. Our belief at this point is that the patient has aerophagia, a type of eructation where excess gas does not enter the stomach but instead is released almost as soon as it enters the vocal cords. Assessment: This patient will undergo speech and behavioral cognitive therapy targeting his excessive eructation, in this case thought to be aerophagia. At the conclusion of therapies we will evaluate for relief given that excessive eructation is known to have both physiological and psychological components. Setting: Outpatient concussion clinic. Results or Clinical Course: This patient will undergo speech and behavioral cognitive therapy targeting his excessive eructation, in this case thought to be aerophagia. At the conclusion of therapies we will evaluate for relief given that excessive eructation is known to have both physiological and psychological components. Discussion: This patient displays unusual symptoms within the post concussive realm. There is no prior literature discussing treatment of such a case and therefore we are exploring a novel treatment for his specific complaint. Conclusions: The diagnoses of post concussive syndrome is based on common symptoms that appear after a mild traumatic brain injury. Neuropsychological changes are common and in this case the unusual eructation may have a neuropsychological cause rather than a physiological cause. Poster 369 Development of a Picture Guide to Identify Common Postures of Spasticity. Ib Odderson (University of Washington, Seattle, WA, United States); Todd Bentley, MD, MS; Jörg Wissel; Khashayar Dashtipour, MD, PhD; Nathan Johnson, MPh; Christopher Evans, PhD; Patrick J. Gillard, PharmD, MS; Richard D. Zorowitz, MD. Disclosures: I. Odderson, Allergan Inc. and Sawbones Inc.,Consulting fees or other remuneration (payment) Objective: To develop an illustrative picture guide to identify common postures of upper and lower limb spasticity for use by clinicians and patients. Design: Five specialists in spasticity management provided guidance on the most common postures observed in patients with spasticity. A photo-shoot with patients was held to capture photos of these spasticity postures across four etiologies (stroke, traumatic brain injury, multiple sclerosis, and cerebral palsy). Setting: Physician office
seeking medical attention. Computed tomography of the brain was performed and did not show any signs of acute intracranial changes. He was subsequently discharged home and advised to see his primary care physician. His primary care physician advised him to start physical therapy, however before he could start, he fell again. After his third fall, he returned to the ED and was admitted. His physical examination revealed 4/5 motor scores in bilateral upper extremities, 3/5 motor score in left lower extremity, and 2/5 motor score in right lower extremity. Sensation to light touch and pain was decreased in bilateral lower extremities. Magnetic resonance imaging of both cervical and lumbar spine was performed which showed C6-C7 right paracentral herniation deforming the cord anteriorly with acute cord compression. No myelopathy was observed in the lumbar spine however patient showed multi level degenerative disc disease from L1/L2 to L5/S1. Patient received a course of intravenous steroids and an emergent surgical decompression was performed. Setting: Tertiary care hospital. Results or Clinical Course: His surgery was successful and without complication. The patient reported resolution of numbness as well as regaining strength in his bilateral lower extremities after the decompression. He later was discharged home with home physical therapy. Discussion: Cervical cord compressions usually present with upper extremity symptoms. However there are a few documented cases of cervical cord compressions presenting with lumbar radicular symptoms. One must be careful not to dismiss higher level spinal cord lesions despite absence of upper extremity symptoms. Conclusions: Although rare, cervical cord compressions can occur with a presentation similar to lumbar radiculopathy. Poster 365 Evaluation of Health Utility in Patients Receiving OnabotulinumtoxinA (BotoxÒ) for the Treatment of Adult Focal Spasticity: Results from MOBILITYÒ, a Prospective Observational Cohort Study. Farooq Ismail (Westpark Healthcare Centre, Toronto, ON, Canada); Theodore Wein, MD; Meetu Bhogal, M.Sc.; Grace Trentin, PhD. Disclosures: F. Ismail, Allergan, Inc., Other Objective: To evaluate health utility related to the clinical use of onabotulinumtoxinA in adult patients with focal spasticity. Design: A prospective, multi-center, observational cohort study collecting patient reported outcomes data across several indications (adult focal spasticity [AFS], blepharospasm, cerebral palsy, cervical dystonia, hemifacial spasm, and hyperhidrosis). Setting: Multiple physician sites across Canada. Participants: 440 patients with AFS who were initiating (naïve) or receiving ongoing (maintenance) onabotulinumtoxinA treatment, were enrolled. Interventions: Not applicable. Main Outcome Measures: Health utility was the primary outcome measure obtained from the SF-12Ò Health Survey using the SF-6D. The SF-12Ò was collected at baseline, week four posttreatment and up to five subsequent injection visits. Results or Clinical Course: A total of 440 patients with AFS (mean age, 52.7 years) were enrolled in MOBILITYÒ. The most common etiologies reported were stroke (n¼222), multiple sclerosis (MS; n¼61), and spinal cord injury (SCI; n¼45). Eighty-seven
Vol. 6, Iss. 9S, 2014
S313
percent (86.8%) of patients were Caucasian, 50.2% female and 39.8% were naïve to treatment. The highest mean baseline health utility scores were in traumatic brain injury patients (0.655) vs. stroke (0.634), SCI (0.604), and MS (0.589). Improvements in health utility scores from baseline were seen in all cohorts across all visits. Baseline scores were generally higher in maintenance vs. naïve; however, mean changes from baseline were greatest in naïve patients. A total of 37 adverse events in 21 patients were reported in the AFS safety cohort. Of the 37 adverse events, 16 (43.2%) were serious and 17 (45.9%) were considered unrelated to treatment. Conclusions: MS patients have the lowest health utility scores compared to patients with other neurological lesions. OnabotulinumtoxinA treatment can improve health utility over time in adult patients with focal spasticity due to various etiologies. Poster 366 Admission Screening for Obstructive Sleep Apnea during Inpatient Stroke Rehabilitation, A New Standard of Care: A Case Report. Jennifer R. Knowlton, MD (Vidant Medical Center, Winterville, NC, United States); Jessica Hanson, MD; William Doss, MD. Disclosures: J. R. Knowlton, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: Patient is a 58-year-old Caucasian woman with a history of hypertension, hypercholesterolemia, diabetes, and obesity who presented with right hemiplegia and aphasia who was found to have an acute left MCA infarct with resultant oropharyngeal dysphagia. Patient was without any prior known diagnosis of Obstructive Sleep Apnea (OSA). She reported a positive history of nighttime snoring and daytime fatigue. Observational Apneic OSA screening tool was utilized during initial stroke admission and revealed positive screen for OSA. CPAP was ordered during inpatient rehabilitation with improvements noted in expected FIM gains. Setting: Inpatient Stroke Rehabilitation. Results or Clinical Course: Outcomes were measured using the APNEIC OSA screening tool which evaluates patient’s Age, Mallampati Pharynx grade, Neck circumference, Body Mass Index, Incisors forward/overbite, and Cricomental distance. Measurements were conducted at bedside to obtain neck circumference and the cricomental distance, BMI and age were acquired via chart review. Patient was positive for all APNEIC OSA screen measures. Discussion: Research has demonstrated that having a cricomental distance of less than 1.5 cm, a Mallampati pharyngeal grade of III or IV, and an overbite prompted a positive predictive value of approximately 95% for OSA. Our patient was positive for all five screening measures. Research reveals that undiagnosed OSA in stroke patients correlates with poorer functional outcomes and less functional independence measure (FIM) gains. Conclusions: Currently, over 80% of people with OSA are undiagnosed and the prevalence of OSA in stroke patients is approximately 70%. Statistics highlight the fact that all patients admitted to inpatient rehabilitation with a stroke diagnosis should be screened for OSA, as it is a modifiable risk factor for stroke and subsequent repeat strokes. Patients typically are discharged home prior to their formal polysomography, thus apnea interventions occur after discharge. OSA screening should be performed in all stroke patients admitted to inpatient rehabilitation as standard of
S314
care which may decrease risk of mortality from subsequent strokes, decrease post-stroke morbidity, and also maximize functional gains during their post-acute inpatient rehabilitation stay. Further expanded research is warranted and in process. Poster 367 Early Physical Medicine and Rehabilitation Consultation Leads to Decreased Length of Stay for Patients Admitted with a Stroke. Andrew J. Chrisman, MD (William Beaumont Hospital, Royal Oak, MI, United States); Myron Laban, MD; Ronald S. Taylor, MD; Justin Riutta, MD. Disclosures: A. J. Chrisman, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To determine if the timing of consults placed to Physical Medicine and Rehabilitation (PM&R) for patients admitted with a stroke in an acute medical center affects acute hospitalization Length of Stay (LOS). Design: Restrospective cohort study. Setting: Tertiary Care Hospital. Participants: All patients age 18-99 admitted from 2/2009-12/ 2013 with one of the following ICD-9 codes listed as their primary diagnosis: 430, 431, 432.1, 432.9, 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, and 434.91. Interventions: Not applicable. Main Outcome Measures: Acute hospitalization Length of Stay (LOS). Results or Clinical Course: The hospital’s database was queried to illicit all patients admitted with the above ICD-9 codes and separated into two groups: those who received a PM&R consult and those who did not. Patients were excluded if the ICD-9 code diagnosis was not the primary reason for admission. Acute hospitalization LOS was compared between the two groups and the data was further analyzed to determine if LOS differed based on timing of the consult. LOS was significantly shorter in patients with early PM&R consults. Conclusions: This is the first documented study using Electronic Medical Records to investigate how the timing of PM&R consultation affects acute hospitalization length of stay for patients with strokes that has been reported in the literature to date. Our data indicate that early consultation of PM&R in patients admitted with acute strokes reduces acute hospitalization LOS. Given that Physical Medicine and Rehabilitation focuses on function we are uniquely qualified to both determine and facilitate appropriate disposition plans for patients admitted with strokes. Poster 368 Excessive Eructation in Post Mild Traumatic Brain Injury: A Case Report of a 76-year-old Man with Concussion after Motor Vehicle Collision Post Concussive Symptoms. Yevgeny Zadov, DO (Penn State Hershey Medical Center, Hershey, PA, United States). Disclosures: Y. Zadov, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: Patient was involved in a motor vehicle collision, resulting in mild traumatic brain injury. He was treated
PRESENTATIONS
at an emergency department and released home. He subsequently developed post concussive symptoms including balance dysfunction, cognitive dysfunction, headaches, and nausea. In addition, he developed excessive and uncontrolled eructation (belching). He finds relief when in a recumbent position. Patient reports severe eructation any time he is not supine or recumbent for more than 2-3 minutes. He is symptomatic several times per 2-5 minutes. He denies any associated symptoms. He has seen gastroenterology and has had upper and lower endoscopies which were negative. He was trialed on medications for bowel discomfort such as simethicone. He was been trialed on oral baclofen but this also failed. Review of records from primary care and gastroenterology found no further treatment or diagnostic modalities being investigated. Our belief at this point is that the patient has aerophagia, a type of eructation where excess gas does not enter the stomach but instead is released almost as soon as it enters the vocal cords. Assessment: This patient will undergo speech and behavioral cognitive therapy targeting his excessive eructation, in this case thought to be aerophagia. At the conclusion of therapies we will evaluate for relief given that excessive eructation is known to have both physiological and psychological components. Setting: Outpatient concussion clinic. Results or Clinical Course: This patient will undergo speech and behavioral cognitive therapy targeting his excessive eructation, in this case thought to be aerophagia. At the conclusion of therapies we will evaluate for relief given that excessive eructation is known to have both physiological and psychological components. Discussion: This patient displays unusual symptoms within the post concussive realm. There is no prior literature discussing treatment of such a case and therefore we are exploring a novel treatment for his specific complaint. Conclusions: The diagnoses of post concussive syndrome is based on common symptoms that appear after a mild traumatic brain injury. Neuropsychological changes are common and in this case the unusual eructation may have a neuropsychological cause rather than a physiological cause. Poster 369 Development of a Picture Guide to Identify Common Postures of Spasticity. Ib Odderson (University of Washington, Seattle, WA, United States); Todd Bentley, MD, MS; Jörg Wissel; Khashayar Dashtipour, MD, PhD; Nathan Johnson, MPh; Christopher Evans, PhD; Patrick J. Gillard, PharmD, MS; Richard D. Zorowitz, MD. Disclosures: I. Odderson, Allergan Inc. and Sawbones Inc.,Consulting fees or other remuneration (payment) Objective: To develop an illustrative picture guide to identify common postures of upper and lower limb spasticity for use by clinicians and patients. Design: Five specialists in spasticity management provided guidance on the most common postures observed in patients with spasticity. A photo-shoot with patients was held to capture photos of these spasticity postures across four etiologies (stroke, traumatic brain injury, multiple sclerosis, and cerebral palsy). Setting: Physician office