OIF Veterans with Mild TBI

Abstracts / PM R 7 (2015) S83-S222 Participants: 1,376 participants in the SCIRehab Project; 404 (29%) entered rehabilitation within 2 weeks of injury and 972 (71%) received rehabilitation after 2 weeks. (Use of 2 weeks to mark “early” rehabilitation is consistent with prior research.) Interventions: Not applicable Main Outcome Measures: At discharge from rehabilitation: Functional Independence Measure (FIM) Motor Score. At 1 year post-injury: FIM Motor Score, self-rated health status, Satisfaction with Life Scale, and Craig Handicap Assessment and Reporting Technique (CHART) Physical Independence Score. Results or Clinical Course: IPW using propensity scores rendered the earlier vs. later groups comparable on several dozen demographic and clinical characteristics, including severity of illness and the American Spinal Injury Association (ASIA) Impairment Scale at admission. Mean time-to-rehabilitation from injury was 30 days (standard deviation, 27). Earlier rehabilitation was associated with 5.74 (95% confidence interval [CI], 3.54 to 7.93) and 7.31 (95% CI, 4.50 to 10.12) higher FIM Motor Scores at discharge and 1-year post-injury, respectively, and a 13.00 (95% CI, 8.70 to 17.25) higher CHART Physical Independence score. Self-rated health and satisfaction with life were not significantly different across groups (P > .05). Conclusion: Comparing otherwise similar patients with traumatic SCI, earlier rehabilitation was associated with improvements in functional status at discharge from rehabilitation and at 1-year post injury.

Poster 47 A Single Surface EMG Interface to Control Multiple Degrees of Freedom in Stroke Survivors Ethan Rand, MD (New York Presbyterian Hospital, New York, NY, United States), Lyssa Sorkin, MD, Lawrence G. Chang, MPH, Parth Patel, BS, Hilary Armstrong, MA, Lauri Bishop, DPT, Ida M. Skavhaug, PhD, Sanjay S. Joshi, PhD, Joel Stein, MD Disclosures: E. Rand: I Have No Relevant Financial Relationships To Disclose. Objective: To test the use of a novel sEMG (surface electromyography) interface for controlling a computer cursor in two dimensions from a single surface electrode by individuals with hemiparesis after stroke. Design: Feasibility study. Setting: Outpatient medical center. Participants: A total of 14 subjects (n¼8 stroke, n¼6 control). Interventions: Subjects used the interface with electrode placed either at the extensor pollicis longus or biceps brachii to move a computer cursor in two dimensions to randomly presented targets on a tablet screen. Each subject was tested over three sessions, consisting of 90 cursor-to-target trials with each arm (180 total trials per session). Both paretic and non-paretic arms (stroke) were compared to dominant and non-dominant arms (control). Main Outcome Measures: Accuracy (% of targets achieved) was calculated for each session and analyzed over time. Results or Clinical Course: The mean accuracy improved 507 to 5511% for the paretic arm, 6311 to 6610% for the non-paretic arm, 5411 to 6712% for the dominant arm, and 6413 to 748% for the non-dominant arm over three sessions. A two-way repeated measures ANOVA was used to determine the differences between groups, over time, and the interaction between group and time. The dominant and paretic arms significantly changed over the three sessions (P-value¼.05). Significant differences were also noted between the paretic and non-paretic groups as a whole (P-value¼.002). Conclusion: This is the first study comparing performance in stroke survivors to control subjects using this novel sEMG system. Using this interface, healthy subjects and stroke survivors demonstrated multidimensional control of cursor movement using a single sEMG sensor. Overall, accuracy improved in all arms over time. Significant differences in accuracy were noted between groups; however, with the

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current model and design only the non-dominant arm of the control group was able to reliably reach the 70% accuracy standard by session 3. Additional research is warranted to evaluate utility of this technology for enhancing functional independence in individuals with motor impairments.

Poster 48 Treatment of Susac’s (Retinocochleocerebral Vasculopathy) Syndrome in Rehabilitation: A Case Report William Wagner, MD (University of Utah, Salt Lake City, UT, United States), Steven R. Edgley, MD Disclosures: W. Wagner: I Have No Relevant Financial Relationships To Disclose. Case Description: Ms. X is a 27-year-old woman with history of depression, migraines, hypothyroidism, HLD, pre-diabetes who presented with headaches, blurriness of vision and increased confusion. She was admitted to Neurology with initial concern for stroke, although the work up was negative. MRI revealed numerous areas of high diffusion signal within the supratentorial and infratentorial parenchyma, with the majority of the lesions centered around or within the corpus callosum and thalami. Ophthalmology was consulted for the vision changes and she was found to have a left superior temporal branch retinal artery occlusion and evidence of Gass plaques. These combined findings were very suggestive of Susac’s syndrome, which is often characterized by a vision loss, low frequency hearing loss and personality change. She was admitted to acute inpatient rehabilitation for treatment of her cognitive deficits. Setting: Primary/Acute care hospital. Results or Clinical Course: Ms. X had deficits primarily in cognition and had an initial MOCHA of 10/30. She would also experience regular delusions and hallucinations. She was treated with a course of IV Solumedrol, followed by Prednisone and Cellcept. She improved cognitively with speech therapy and her discharge MOCHA was 19/30, but still had deficits specifically in the delayed recall and executive/ visuospatial tasks. Unfortunately, she continued have intermittent delusions leading up to discharge. She was discharged on Prednisone and Cellcept. She continued therapies as an outpatient and had further cognitive testing, which will be fully detailed in the complete case. She followed up with Neurology and Physical Medicine and Rehabilitation. Discussion: Susac’s syndrome is rare condition and this is the first case report outlining specific treatment challenges of the condition. Conclusion: Susac’s syndrome introduces interesting challenges to inpatient rehabilitation, specifically in regards to cognitive deficits. Our patient presented with strong cognitive deficits and benefited from a rehabilitation program that was focused on cognitive recovery.

Poster 49 Moral Injury, Spiritual Health, and PTSD in OEF/OIF Veterans with Mild TBI Ryan O. Stephenson, DO (Denver VAMC- University of Colorado, Denver, CO, United States), Holly R. Gerber, BA, Lisa Brenner, PhD Disclosures: R. O. Stephenson: I Have No Relevant Financial Relationships To Disclose. Objective: This study aims to explore psychological, moral, and spiritual health factors that may contribute to the maintenance of post-concussive symptoms (PCS) in Veterans with mild traumatic brain injury (mTBI). Design: This is an observational study of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans with mTBI. Setting: All participants were recruited from the Veterans Health Administration Eastern Colorado Health Care System.

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Participants: OEF/OIF Veterans with mTBI (N¼57). The majority of participants were male (89.5%) with a mean age of 32.5 and two combat deployments. Interventions: Not applicable Main Outcome Measures: Clinical interviews were used to assess lifetime history of mTBI and PTSD. Questionnaires included the Moral Injury Events Scale (MIES), Spiritual Health and Life-Orientation Measure (SHALOM), and Brief Multidimensional Measure of Religiousness/ Spirituality (BMMRS). Results or Clinical Course: Participants reported high levels of perceived moral transgressions (M¼20.8, SD¼8.1) and perceived moral betrayals (M¼11.1, SD¼4.5), as well as high rates of PTSD diagnoses (86%). Discrepancies were found between ideal (M¼16.2) and current (M¼12.5) levels of spiritual health. Preliminary results suggest a preference for individuals to identify as spiritual rather than religious (M¼ 2.5, 3.1, respectively, SD¼1). Further, 33.4% of the sample identified as atheist, agnostic, or as having no religion, while 50.8% identified as Christian. Conclusion: Preliminary data reveal rates of moral injury, spiritual health, and post-traumatic stress disorder. Veterans with mTBI reported greater moral injury than has been previously reported in other military samples. Discrepancies found between ideal and current states of spiritual health highlight unsatisfactory spiritual well-being. Religious preferences (or rejection thereof) were noteworthy. These findings call attention to potential factors associated with PCS maintenance, and reinforce the need for continued exploration of moral injury and spirituality.

Poster 50 Progressive Lower Extremity Weakness Due to Nitrous Oxide Induced Myelopathy: A Case Report Matthew Jones, MD (William Beaumont Hospital, Royal Oak, MI, United States), Julie A. Ferris, MD, Ronald S. Taylor, MD Disclosures: M. Jones: I Have No Relevant Financial Relationships To Disclose. Case Description: An 18-year-old female presented to the Emergency Department with hand numbness, progressive lower extremity weakness, and bilateral foot drop. Her symptoms began 2-3 weeks prior to presentation and had been getting worse. She denied bulbar symptoms or bowel and bladder dysfunction. On examination, she was found to have 4/5 (Medical Research Council) bilateral proximal lower extremity muscle strength and 2/5 distal strength. Upper extremity strength was normal. Reflexes were absent in the upper extremities, 2+ for the patellar, and 1+ for the achilles. Her gait was ataxic. On discussion with the patient, she revealed that she was a frequent recreational nitrous oxide user. Setting: Tertiary Care Hospital. Results or Clinical Course: Magnetic resonance imaging (MRI) demonstrated extensive, non-enhancing increase of T2 signal involving the dorsal columns of the cervical spinal cord and scattered areas within the dorsal columns of the thoracic cord. Vitamin B12 and methylmalonic acid levels were drawn which were normal, although the patient had been supplemented with vitamin B12 at an outside hospital prior to her presentation at our institution. Other causes of posterior column degeneration including HIV, syphilis, and heavy metals were ruled out. The patient was diagnosed with nitrous oxide induced myelopathy. She was admitted to inpatient rehabilitation (IPR) where her course was complicated by ataxia and lower extremity weakness. At the time of discharge, she was able to ambulate 100 ft with bilateral AFOs. Discussion: Nitrous oxide induced myelopathy is a known consequence of nitrous oxide abuse due to irreversible oxidation and thus inactivation of vitamin B12. Although vitamin B12 levels are frequently low in this condition, this is not always a requirement. Conclusion: Nitrous oxide is a commonly used recreational drug that can result in devastating consequences. Screening for nitrous oxide

use should be performed in young patients presenting with symptoms of myelopathy.

Poster 51 Electrodiagnostic Findings in Anterior Spinal Cord Syndrome: A Case Report Hana F. Azizi, MD (Montefiore Medical Center, New York, NY, United States), Pegah Dehghan, Dennis D. Kim, MD Disclosures: H. F. Azizi: I Have No Relevant Financial Relationships To Disclose. Case Description: A 75-year-old woman with history of DM, hypertension, and hypercholesterolemia, developed sudden onset of weakness in lower extremities, with severe pain in lower back and lower extremities without numbness. MRI showed severe lumbar stenosis and a questionable area of grey matter ischemia between T10 level and conus medullaris. Patient received conservative treatment including steroids with no significant improvement. Five months later, she was referred for electrodiagnostic evaluation of weakness in bilateral lower extremities. Physical examination revealed severe distal weakness in lower extremities with left foot drop. There was decreased appreciation of light touch in lower extremities with preserved vibration and position sense. Setting: Electrodiagnostic laboratory at teaching hospital. Results or Clinical Course: Electrodiagnostic study showed unobtainable bilateral sural sensory nerves action potentials (SNAP), unobtainable left tibial and peroneal nerves compound muscle action potentials (CMAP), and very low CMAP amplitude in the right tibial and peroneal nerves with decreased conduction velocities. F response was recorded only from the right gastrocnemius-soleus complex. The amplitude was slightly decreased in the left ulnar SNAP with mild prolonged latency. Needle EMG showed very small fibrillation potentials with no voluntary motor units in left gastrocnemius, and small fibrillation potentials, positive sharp waves and 1-2 voluntary motor units of high firing rate in left peroneus longus muscle. Needle insertion in these muscles was associated with a gritty feeling signifying fibrotic changes.There was no significant abnormal EMG findings in other muscle groups including para spinal muscles. Discussion: These findings were most likely consistent with anterior spinal cord ischemia. Unobtainable bilateral sural nerves SNAP and decreased SNAP in ulnar nerve could be explained by old age and diabetes. Anterior spinal cord syndrome results from compression of the anterior spinal artery and often occurs in the absence of traumatic injury. It is frequently asymmetrical and may spare the dorsal columns. Conclusion: Anterior spinal cord syndrome has the worst prognosis among incomplete spinal cord injuries. The chance of motor recovery is low, and supportive devices such as ankle foot orthosis should be considered.

Poster 52 Remarkable Motor and Neurocognitive Recovery in H1N1 Hemorrhagic Encephalitis after Acute Rehabilitation Steven Ross, DO (NYU, New York, NY, United States) Disclosures: S. Ross: I Have No Relevant Financial Relationships To Disclose. Case Description: A 38-year-old previously healthy man presented to the ER with new-onset tonic-clonic seizures. History was significant for a recent visit to Nepal. MRI revealed increased T2/FLAIR signal with bilateral hemisphere involvement with associated hemorrhage in the temporal lobes and thalami consistent with hemorrhagic encephalitis. A positive nasal swab for H1N1 RNA confirmed the diagnosis of H1N1 hemorrhagic encephalitis. Though the acute hospital course was