- Email: [email protected]
Poster 84
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2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Geriatrics Poster 79 Virtual Therapy: Efficacy of Video-Teleconferencing to Provide Rehabilitation Interventions to Veterans at Home. Helen M. Hoenig, MD (Duke University & Durham VA Medical Centers, Durham, NC); Jon A. Sanford, MArch. Disclosure: None. Objective: To compare in-home therapy via wireless televideo (telerehab) with in-person therapy. Design: Randomized trial. Setting: A Veterans Affairs medical center and a private rehabilitation hospital. Participants: Community-dwelling adults recently prescribed a walker or a wheelchair. Intervention: 4 therapy sessions, either in-person or via wireless televideo, including home hazard assessment and prescription of adaptive strategies. Main Outcome Measures: Number and type of problems identified, number and type of recommendations, proportion of recommendations implemented. Functional outcomes at 6 and 26 weeks (data collection ongoing). Results: To date, 21 subjects have been randomized to the telerehab (n⫽11) or in-person (n⫽12) interventions, with a mean age of 62 (range, 43– 86y), 92% veterans, 87% male, 39% white, and 13% live alone. Total number of problems identified: 195 in-person, 136 telerehab; similar number of problems were identified for transfer tasks for both groups, but more problems with room-to-room mobility were identified in-person (mean problems/person, 3.4 in-person vs 1.8 telerehab; P⫽.05). Total number of recommendations: 185 in-person, 141 telerehab; a similar number of recommendations were made for transfer tasks, but there was a trend toward more recommendations for room-to-room mobility in-person (mean recommendations/person, 2.75 in-person vs 1.36 telerehab; P⫽.08). Proportion of all recommendations implemented: 60% in-person; 52% telerehab, with no significant differences between the 2 groups for any of the tasks. Conclusions: Equivalent numbers of problems were detected and interventions recommended for transfer tasks, but somewhat more problems were detected in-person for room-to-room mobility. Implementation of recommendations appears to be equivalent for the 2 groups. It is feasible to use wireless televideo technology to carry out home hazard assessment and to prescribe adaptive strategies. Key Words: Assistive technology; Exercise; Home health; Telemedicine.
Poster 80 Evaluating Submaximal Exercise Tolerance Testing Designed to be Appropriate for MobilityLimited Older Adults. Ronald E. Hirschberg, MD (Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA); Dan K. Kiely, MPH, MA; Sharon Cyberey, BS; Eloy Cardenas-Montemayor, MD; Walter R. Frontera, MD, PhD; Jonathan F. Bean, MD, MS, e-mail: [email protected]. Disclosure: None. Objective: To evaluate the validity of a submaximal exercise tolerance testing (ETT) protocol designed for use among older adults with limitations in mobility. Design: A cross-sectional analysis. Setting: An outpatient rehabilitation center. Participants: 67 mobility-limited, community-dwelling adults, ages 65 and older with mobility limitations as manifested by the Short Physical Performance Battery (SPPB). Interventions: Not applicable. Main Outcome Measures: Exercise duration was quantified via treadmill ETT. Testing speed was based on subject’s habitual gait speed, with uniform progression of both incline and speed across all subjects. Results: Subjects had a mean age of 75 (range, 65-93), were 67% female, and had an average of 5 active chronic medical conditions. Subjects manifested moderate mobility limitation as defined by SPPB mean score of 8.6 (maximal score, 12). Subjects were stratified into 3 groups based on their baseline mobility performance and risk for subsequent morbidity and mortality, as determined by the SPPB. Habitual gait speed declined significantly with declining SPPB groupings. There was no significant difference in exercise duration among these 3 groups. Conclusions: Among older adults with varying severity of mobility limitations, the ETT protocol employed appears to be a useful means of evaluating individuals at similar relative exercise intensities. This appears to be a valid means of evaluating submaximal exercise capacity among frail older adults at risk for subsequent disability. Key Words: Aged; Exercise tolerance; Rehabilitation; Task performance.
D7. Significant changes from baseline pain and spasm scores were detected after 3 and 7 days of therapy in all 3 treatment groups (P⬍.001). No significant differences were detected among the 3 treatment groups. Changes from baseline were significantly greater after 7 days than after 3 days of therapy for all 3 treatments (P⬍.001). Conclusions: Data support the hypothesis that 5mg TID of cyclobenzaprine plus ibuprofen (400 or 800mg TID) is not superior to 5mg TID of cyclobenzaprine alone in the treatment of acute muscle spasm and pain. Key Words: Back; Musculoskeletal; Neck; Pain.
Poster 82 The Effect of Playing Ball Sports on Prevention of Future Stress Fractures in Runners. Michael Fredericson, MD (Stanford University, Stanford, CA); Jessica Ngo, MD; Elizabeth Heilman, MD; Kristin Cobb, PhD. Disclosure: None. Objective: To evaluate whether playing ball sports during childhood and adolescence helps to prevent stress fractures in runners later in life. Design: Retrospective cohort study. Setting: National track and field championships. Participants: 156 female and 118 elite male distance runners (age range, 18 – 44y). Intervention: A 1-page questionnaire was used to collect data regarding ages of participation in basketball, soccer, or both, as well as other important covariates and outcomes. Main Outcome Measures: Age(s) when stress fracture(s) occurred. Time-to-event was defined as the number of years from initiation of competitive running to the first stress fracture or to current age, if no fracture had occurred. Results: In both men and women, playing ball sports in youth reduced stress fracture incidence by almost one half, controlling for possible confounders. In men, each additional year of participation in ball sports conferred a 13% decrease in incidence of stress fracture (adjusted hazard ratio [HR], .87; 95% CI, .79 –.95). Among women with regular menses, the HR for each additional year of ball sport participation was similar: .87 (95% CI, 0.75–1.00); however, there was no effect of length of time played among women with irregular menses (HR⫽1.03; 95% CI, 0.92–1.16). In men, younger age of ball sport participation conferred greater protection against stress fractures (HR for each 1-y older age at first exposure: 1.29; 95% CI, 1.14 –1.45). Conclusions: Participation during adolescence in activities generating high strain on the bone in different planes, such as basketball and soccer, is known to enhance bone mass and bone symmetry and may help prevent future stress fractures in runners. Key Words: Prevention; Rehabilitation; Running; Soccer; Stress fractures.
Poster 83 How Is the Spatial Information in a Dynamic Task Such as Throwing Processed? Correlating Multiple Measures of Spatial Cognition. Gary P. Chimes, MD, PhD (UMDNJ-NJMS, Newark, NJ); Elie P. Elovic, MD. Disclosure: None. Objective: To determine whether spatial information as processed in a dynamic task such as throwing is correlated with standard measures of spatial cognition described in the literature or whether they represent distinct domains of spatial cognition. Design: Correlational design. Setting: Indoor exercise facility in a university setting Participants: 160 women (average age, 23.7y; range, 18-47y). Women under 18, postmenopausal, or left-handed were excluded, as these were considered potential confounders. Intervention: Administration of a battery of tests for a total of approximately 90 minutes of participant time. Main Outcome Measures: Multiple measures of spatial perception and cognition including: overhand throwing accuracy, underhand throwing accuracy, the Viewfinding task (participant estimates rotation of a 3-dimensional figurine), the Vandenberg test of spatial cognition (matching a 3-dimensional drawing to images that represent the original drawing rotated in 3-dimensions), and the Purdue pegboard test (a timed test to place small pegs into holes). Results: Pearson product moment correlations were performed to determine the correlations among the different measures of spatial cognition. The only statistically significant correlation was between overhand throwing and underhand throwing (R⫽.326, P⬍.001). Conclusions: The 2 measures of throwing accuracy were correlated with one another, suggesting that both tasks depend on similar underlying cognitive skills. The other measures, however, did not correlate with either throwing or one another. This suggests that spatial cognition is a complex process and thus is additional evidence that the skills involved in processing spatial information is highly task specific. Key Words: Female; Perception; Rehabilitation; Sports.
Musculoskeletal Poster 81 Comparison of Cyclobenzaprine Alone Versus Cyclobenzaprine Plus Ibuprofen in Patients With Acute Musculoskeletal Spasm and Pain. Martin K. Childers, DO, PhD (University of Missouri, Columbia, MO); Michelle Petri, MD, MPH; Charles Laudadio, MD, MBA; Diane D. Harrison, MD, MPH, e-mail: [email protected]. Disclosure: Childers, Consultant for McNeil Pharma; Petri, Consultant for McNeil Pharma; Laudadio, McNeil Pharma employee; Harrison, McNeil Pharma employee. Objective: To test the hypothesis that 5mg TID of cyclobenzaprine (Flexeril) alone (Cyc5) or in combination with 400mg TID of ibuprofen (Cyc5/Ibu400) or 800mg TID of ibuprofen (Cyc5/ Ibu800) is not superior to Cyc5 in the treatment of acute muscle spasm and pain. Design: Prospective, randomized, open-label, multicenter, 7-day study. Setting: U.S. community medical facilities. Participants: 1000 adult men and women with acute back or neck pain of ⬍14 days in duration. Intervention: Cyc5 versus Cyc5/Ibu400 or Cyc5/Ibu800 given over 7 days. Main Outcome Measures: Pain and spasm were assessed using an 11-point (0 –10) patient-rated numeric pain rating score collected via an interactive voice recognition system after 3 and 7 days of therapy. Results: Spasm and pain scores of 867 patients with acute muscle spasm and pain who completed up to 7 days of therapy (Cyc5, n⫽288; Cyc5/Ibu400, n⫽286; Cyc5/Ibu800, n⫽293) were assessed at baseline and after 3 days (D3) and 7 days (D7) of therapy. The percentage changes from baseline for muscle spasm and pain scores were: spasm score changes: Cyc5: ⫺37% D3, ⫺57% D7; Cyc5/Ibu400: ⫺37% D3, ⫺57% D7; Cyc5/Ibu800: ⫺33% D3, ⫺52% D7. Pain score changes: Cyc5: ⫺33% D3, ⫺53% D7; Cyc5/Ibu400: ⫺36% D3, ⫺54% D7; Cyc5/Ibu800: ⫺33% D3, ⫺49%
Arch Phys Med Rehabil Vol 86, September 2005
Poster 84 Tumor Necrosis Factor-Alpha Levels in Herniated Intervertebral Disks. Alfred G. Campbell, MD Candidate (University of Pennsylvania, Philadelphia, PA); Curtis Slipman, MD; Serge Mencken, MD; Beth Winkelstein, PhD; Christian Fras, MD; Kingsley Chin, MD, e-mail: [email protected]. Disclosure: None. Objective: To determine if tumor necrosis factor-alpha (TNF-␣) is present in elevated concentrations within the central aspect of the disk in patients with symptomatic disk herniations. Design: Controlled immunochemical study. Setting: University academic center. Participants: Consecutive subjects undergoing percutaneous disk decompression (PDD) for radicular pain (n⫽20) and undergoing fusion for axial pain (n⫽20), serving as controls. Intervention: Nuclear material was removed from the central part of the disk using a fluoroscopically guided percutaneous decompression probe. Tissue was homogenized in a protease inhibitor buffer and assayed for the presence of TNF-␣ using a colorimetric enzyme linked immunosorbent assay. Control samples were taken from disks of surgical patients undergoing fusion and analyzed in the same manner. Main Outcome Measure: TNF-␣ concentration. Results: TNF-␣ was detected in the disk nucleus of patients who presented with a herniated disk and radicular pain in a statistically greater concentration than in disks from patients presenting with axial pain. Mean concentration of TNF-␣ was 411.2pg/mg tissue in the PDD group, which was significantly higher (Wilcoxon rank-sum test, P⬍.05) than TNF-␣ levels detected in the fusion group. Conclusions: TNF-␣ is a potent inflammatory cytokine that has been implicated in the pathophysiology of disk degeneration as well as radicular pain resulting from herniated disks. Prior studies have demonstrated the presence of TNF-␣ at the interface between the
2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS herniated disk tissue and the nerve root. In addition, the ability of nucleus pulposus cells to synthesize TNF-␣ in culture has been demonstrated. We report the novel observation that TNF-␣ is present in significantly higher concentrations in vivo in the nucleus pulposus of patients with herniated discs than in nonherniated control discs and at a site remote from the disk-nerve root interface. Key Words: Intervertebral disk; Percutaneous diskectomy; Rehabilitation; Tumor necrosis factor-alpha.
Poster 85: Cancelled.
Poster 86 Bone Mineral Metabolism in Patients With Myelomeningocele. Esther Page`s, MD, PhD (Spina Bifida Unit. Vall d’Hebron Hospitals, Barcelona, Spain); Jordi Iborra, MD, PhD; Judith Sa´nchez, MD; Georgia Romero, MD; Susana Rodrı´guez, MD, PhD; Ampar Cuxart, MD, PhD, e-mail: [email protected]. Disclosure: Iborra, Novartis Farmace´utica employee. Other authors: None. Objectives: To examine bone mineral metabolism in patients with myelomeningocele. Design: A cross-sectional study. Setting: A multidisciplinary spina bifida unit within a third-level university hospital. Participants: 80 patients with myelomeningocele. Patients with known metabolic acidosis, renal insufficiency, or other metabolic bone disease were excluded from this study. Intervention: BMD with total-body dual x-ray absorptiometry scan with subregional area values, the biochemical markers of bone mineral metabolism, and the main parameters of calcium phosphate metabolism in blood and/or urine. Main Outcome Measures: Bone mineral density (BMD) and biochemical bone markers. Results: 52% of the patients were in the normal range of BMD, 31.6% were osteopenic and 15.8% were osteoporotic. The only determinant for leg BMD was type of gait (P⫽.012; 95% CI, .042–.229); When we use total-body BMD as dependent variable, the model showed as determinants: type of gait (P⫽.003; 95% CI, .031–.88) and sex (P⫽.044; 95% CI, .003–.155). The formation bone markers were into the normal values, while the resorption bone markers were higher than normal values. Bone-specific alkaline phosphatase levels were determinate by body mass index (P⫽.002), urinary deoxypyridinolines (P⫽.002), and neurologic level (P⫽.013). Osteocalcine levels were determinate by calcium intake (P⫽.001) and sex (P⫽.008). Urinary deoxypyridolines levels were determinate by urea (P⫽.001) and hip flexion contractures (P⫽.009). Finally, NTx levels were determinate by calcium intake (P⫽.001). Conclusions: Fatter (body mass index, ⬎25) patients had less osteopenia or osteoporosis than normal or thin patients. The higher neurologic level, the worse the BMD. Although type of gait is determinate by neurologic level, this study suggests that the type of gait is the most important determinant of leg and total-body BMD. Biochemical markers of bone mineral metabolism in myelomeningocele could be a good tool to evaluate the bone metabolism. Key Words: Bone mineral density; Bone mineral metabolism; Myelomeningocele; Rehabilitation.
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(25[OH]D3 ⬍20ng/mL) was 49.1% (46.7% of men, 52.2% of women) with 41.4% white and 58.3% minority patients affected. The prevalence of osteopenia (T score, ⬍⫺1) was 52.8% (men, 53.3%; women, 52.2%); osteoporosis (T score, ⬍⫺2.5) was 17.0% (men, 20.0%; women, 13%). 51.7% of white and 54.2% of minority patients had osteopenia; 6.9% of white and 29.2% of minority patients had osteoporosis. CTX (bone resorption marker) was elevated in 41.5% of patients. Osteocalcin (bone formation marker) was elevated in 11.3% of patients. Measurements of bone resorption and formation positively correlated (R2⫽.22) indicating increased bone remodeling. Conclusions: Vitamin D deficiency and osteopenia and osteoporosis was highly prevalent in both men and women admitted for rehabilitation. Elevated bone resorption and remodeling were evident. This could be due to vitamin D deficiency that should be corrected before antiresorptive therapy is considered. The study emphasizes the need for vigilance for vitamin D status and bone mineral density testing in patients admitted to rehabilitation facilities. Key Words: Bone density; Osteoporosis; Rehabilitation; Vitamin D deficiency. Poster 89 Study of Neurotransmission Pathway for Diskogenic Low Back Pain: FluroGold Particles Are Transferred From the Rabbit L5-6 Intervertebral Disk to Primary Sensory Neurons and Primary Sensory Fibers at Multiple Levels. Yejia Zhang, MD, PhD (Thomas Jefferson University, Philadelphia, PA); Youngsang Lee, MD; Howard S. An, MD, e-mail: [email protected]. Disclosure: None. Objective: To establish the neurotransmission pathway from the intervertebral disk (IVD) to the spinal cord in rabbit. Design: Gold crystals injected into the IVD will be traced and quantified by examining gold positive neurons in the dorsal root ganglion (DRG) and the spinal cord. Animals: New Zealand-White rabbits. 25-hydroxyvitamin D FluoroGold crystals were injected into the dorsal portion of the L5-6 IVD disk. Intervention: 7 days after the injection, the spinal cord, with bilateral DRGs attached, were isolated. FluroGold-positive neurons were quantified in the DRGs under fluorescence microscopy. Main Outcome Measure: Data were expressed as percentage of positive neurons ⫾ SD. Results: FluoroGold-labeled neurons were present in the bilateral primary afferent neurons within DRGs from L5 through T12. No neurons in DRGs from C1 through T11 were labeled. At the L5 level, labeled neurons were predominantly present in the DRGs on the left side (34.94%⫾9.98%), with clearly less on the right side (8.08%⫾5.58%). At the L4 and L3 levels, the left-side predominance persisted but clearly decreased (L4: left, 5.84%⫾2.28%; right, 2.88%⫾1.22%; L3: left, 2.24%⫾2.05%; right, 2.75%⫾2.32%). Gold particle distribution was similar on both sides of the DRGs at the L2 and L1 levels. In the posterior horn of the spinal cord, gold particles were detected in the fibers within primary afferent sensory fibers within laminae I-II at L4 and L3 levels on both sides. Conclusions: We have shown, for the first time, that FluroGold particles are transferred from the rabbit L5-6 IVD to primary sensory neurons in the DRG and primary sensory fibers in the posterior horn of the spinal cord at multiple levels. If the neurotransmission pathway is similar in humans, it may explain why mechanical back pain is often poorly localized. Key Words: Low back pain; Rehabilitation.
Poster 87 Pulsed Electromagnetic Field Stimulation for the Treatment of Knee Osteoarthritis. Shane Mangrum, MD (University of Utah, Salt Lake City, UT); Stuart E. Willick, MD, e-mail: [email protected]. Disclosure: None. Objective: To investigate the effectiveness of a novel device delivering pulsed electromagnetic field stimulation (PEFS) in the treatment of knee osteoarthritis (OA). Design: A double-blind, randomized, placebo-controlled trial was designed to evaluate the effectiveness of PEFS. Setting: Single tertiary referral center. Participants: Patients with clinically defined OA according to the criteria of the American College of Rheumatology. Intervention: Delivery of 12 active or placebo treatment sessions in 16 patients with knee OA. The study treatment sessions were each 30 minutes in duration, delivered 3 times a week over the course of 4 weeks. Main Outcome Measures: The primary outcome measure for this investigation was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Secondary outcome measures include the 100-mm visual analog scale (VAS), WOMAC global score, WOMAC functional disability score, and WOMAC stiffness score. Outcome measurements were assessed at baseline and after each of 4 subsequent weeks of treatment. Results: Although there were no significant differences between active and placebo treatment groups in respect of any the outcome measures in this pilot study, analysis demonstrated trends in the treatment group towards improvement in WOMAC stiffness scale (P⫽.09), 100-mm VAS (P⫽.15), and the WOMAC global scale (P⫽.16). Conclusions: The small sample size in this pilot study limits any conclusions about treatment effect. However, the observed trends toward improvement in the active treatment group in the areas of pain and function are potentially clinically significant and suggest that further investigation is warranted in a larger, multicenter, randomized controlled trial to evaluate this novel PEMF delivery system for the treatment of knee OA. Key Words: Electromagnetic stimulation; Osteoarthritis; Rehabilitation.
Poster 90 Biologic Treatment of Degenerative Disk Diseases: Gene Therapy Approaches. Yejia Zhang, MD, PhD (Thomas Jefferson University, Philadelphia, PA); Frank M. Phillips, MD; Howard S. An, MD, e-mail: [email protected]. Disclosure: None. Objective: To directly compare the effects of adenovirus expressing bone morphogenetic proteins (AdBMPs) on proteoglycan accumulation by nucleus pulposus (NP) cells in vitro. Design: NP cells were transduced with recombinant adenoviruses expressing human BMP-2, -3, -4, -5, -7, -8, -10, -11, -12, -13, -14, and -15 and cultured in monolayer. In the co-culture approach, articular chondrocytes were transduced with some of these BMPs and co-cultured with NP cells maintained in alginate. Interventions: Not applicable. Main Outcome Measure: In both cases, proteoglycan accumulation by NP cells was measured after 6 days of culture. Results: AdBMP-2, -4, -5, -7, -8, -10, or -13 effectively stimulated proteoglycan accumulation by NP cells (P⬍.05). Articular chondrocytes transduced with AdBMP-7 or -10 and cocultured with NP cells markedly stimulated proteoglycan accumulation by the NP cells (P⬍.05). Conclusions: For treatment of mild to moderate intervertebral disk (IVD) degeneration, genes expressing BMPs could be directly injected into the disks. In contrast, for treatment of advanced IVD degeneration, where viable cells are reduced in number in the IVD, transplantation of articular chondrocytes transduced with BMP genes ex vivo is more appropriate. Based on our findings, future in vivo study with direct gene transfer of native IVD cells should focus on AdBMP-2, -4, -5, -7, -8, -10, and -13; in contrast, while studying the paracrine effects of articular chondrocytes on native intervertebral disk cells in vivo, efforts should focus on treatment with AdBMP-7 or -10. Key Words: Gene therapy; Intervertebral disk; Low back pain; Rehabilitation.
Poster 88 Vitamin D Deficiency and Metabolic Bone Disease in Rehabilitation Inpatients. Leonid M. Shinchuk, MD (Boston University Medical Center, Boston, MA); Leslie R. Morse, DO; Nadia Huancahuari; Seth Arum, MD; Tai C. Chen, PhD; Michael F. Holick, MD, PhD, e-mail: [email protected]. Disclosure: None. Objective: To determine vitamin D status and bone mineral density in patients admitted to a subacute rehabilitation facility. Design: Cross-sectional cohort study. Setting: Subacute rehabilitation facility. Participants: 53 patients admitted from June through February. Intervention: We determined the vitamin D status, bone mineral density, and bone turnover markers. A dietary questionnaire for vitamin D intake was collected. Main Outcome Measures: 25-hydroxyvitamin D (25[OH]D3); bone mineral density, C-telopeptide (CTX), and osteocalcin. Results: Enrolled patients had a mean age of 60.2⫾14.1, 30 men (56.6%), 23 women (43.4%), 29 white (54.7%), 20 African Americans (37.7%), 2 Hispanic (5.7%), and 1 Asian (1.9%) that was comparable to the demographics of the entire unit over the same period of time. Prevalence of vitamin D deficiency
Poster 91 Prevalence of Components of the Female Athlete Triad. Anne Z. Hoch, DO (Medical College of Wisconsin, Milwaukee, WI); Christopher A. Taylor, MD, e-mail: [email protected]. Disclosure: None. Objective: To determine the prevalence of female athlete triad characteristics: disordered eating, menstrual dysfunction, and osteopenia and/or stress fracture. Design: Retrospective study from a standard questionnaire used in an academic sports medicine center. Setting: Hospital sports medicine center and women’s sports medicine program. Participants: 1027 female subjects (513 under 25y, 342 between 26 and 45y, 172 were ⱖ46y) who exercised aerobically an average of 5d/wk for 78 minutes. Intervention: Standardized questionnaire for female subjects. Results: (1) Disordered eating: results from the questionnaire revealed that 6.0% and 4.9% of the subjects had a history of anorexia and bulimia, respectively, with 44% having been on a diet at some point in their life. At the time of the survey, 4% were using laxatives and 3.5% were taking diet pills. On average, subjects wanted to lose 13lb. (2) Menstrual status: the mean age of menarche was 12.8 years. Average number of menstrual periods in the last year was 8 (oligomenorrheic). 39% of subjects had
Arch Phys Med Rehabil Vol 86, September 2005
2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Geriatrics Poster 79 Virtual Therapy: Efficacy of Video-Teleconferencing to Provide Rehabilitation Interventions to Veterans at Home. Helen M. Hoenig, MD (Duke University & Durham VA Medical Centers, Durham, NC); Jon A. Sanford, MArch. Disclosure: None. Objective: To compare in-home therapy via wireless televideo (telerehab) with in-person therapy. Design: Randomized trial. Setting: A Veterans Affairs medical center and a private rehabilitation hospital. Participants: Community-dwelling adults recently prescribed a walker or a wheelchair. Intervention: 4 therapy sessions, either in-person or via wireless televideo, including home hazard assessment and prescription of adaptive strategies. Main Outcome Measures: Number and type of problems identified, number and type of recommendations, proportion of recommendations implemented. Functional outcomes at 6 and 26 weeks (data collection ongoing). Results: To date, 21 subjects have been randomized to the telerehab (n⫽11) or in-person (n⫽12) interventions, with a mean age of 62 (range, 43– 86y), 92% veterans, 87% male, 39% white, and 13% live alone. Total number of problems identified: 195 in-person, 136 telerehab; similar number of problems were identified for transfer tasks for both groups, but more problems with room-to-room mobility were identified in-person (mean problems/person, 3.4 in-person vs 1.8 telerehab; P⫽.05). Total number of recommendations: 185 in-person, 141 telerehab; a similar number of recommendations were made for transfer tasks, but there was a trend toward more recommendations for room-to-room mobility in-person (mean recommendations/person, 2.75 in-person vs 1.36 telerehab; P⫽.08). Proportion of all recommendations implemented: 60% in-person; 52% telerehab, with no significant differences between the 2 groups for any of the tasks. Conclusions: Equivalent numbers of problems were detected and interventions recommended for transfer tasks, but somewhat more problems were detected in-person for room-to-room mobility. Implementation of recommendations appears to be equivalent for the 2 groups. It is feasible to use wireless televideo technology to carry out home hazard assessment and to prescribe adaptive strategies. Key Words: Assistive technology; Exercise; Home health; Telemedicine.
Poster 80 Evaluating Submaximal Exercise Tolerance Testing Designed to be Appropriate for MobilityLimited Older Adults. Ronald E. Hirschberg, MD (Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA); Dan K. Kiely, MPH, MA; Sharon Cyberey, BS; Eloy Cardenas-Montemayor, MD; Walter R. Frontera, MD, PhD; Jonathan F. Bean, MD, MS, e-mail: [email protected]. Disclosure: None. Objective: To evaluate the validity of a submaximal exercise tolerance testing (ETT) protocol designed for use among older adults with limitations in mobility. Design: A cross-sectional analysis. Setting: An outpatient rehabilitation center. Participants: 67 mobility-limited, community-dwelling adults, ages 65 and older with mobility limitations as manifested by the Short Physical Performance Battery (SPPB). Interventions: Not applicable. Main Outcome Measures: Exercise duration was quantified via treadmill ETT. Testing speed was based on subject’s habitual gait speed, with uniform progression of both incline and speed across all subjects. Results: Subjects had a mean age of 75 (range, 65-93), were 67% female, and had an average of 5 active chronic medical conditions. Subjects manifested moderate mobility limitation as defined by SPPB mean score of 8.6 (maximal score, 12). Subjects were stratified into 3 groups based on their baseline mobility performance and risk for subsequent morbidity and mortality, as determined by the SPPB. Habitual gait speed declined significantly with declining SPPB groupings. There was no significant difference in exercise duration among these 3 groups. Conclusions: Among older adults with varying severity of mobility limitations, the ETT protocol employed appears to be a useful means of evaluating individuals at similar relative exercise intensities. This appears to be a valid means of evaluating submaximal exercise capacity among frail older adults at risk for subsequent disability. Key Words: Aged; Exercise tolerance; Rehabilitation; Task performance.
D7. Significant changes from baseline pain and spasm scores were detected after 3 and 7 days of therapy in all 3 treatment groups (P⬍.001). No significant differences were detected among the 3 treatment groups. Changes from baseline were significantly greater after 7 days than after 3 days of therapy for all 3 treatments (P⬍.001). Conclusions: Data support the hypothesis that 5mg TID of cyclobenzaprine plus ibuprofen (400 or 800mg TID) is not superior to 5mg TID of cyclobenzaprine alone in the treatment of acute muscle spasm and pain. Key Words: Back; Musculoskeletal; Neck; Pain.
Poster 82 The Effect of Playing Ball Sports on Prevention of Future Stress Fractures in Runners. Michael Fredericson, MD (Stanford University, Stanford, CA); Jessica Ngo, MD; Elizabeth Heilman, MD; Kristin Cobb, PhD. Disclosure: None. Objective: To evaluate whether playing ball sports during childhood and adolescence helps to prevent stress fractures in runners later in life. Design: Retrospective cohort study. Setting: National track and field championships. Participants: 156 female and 118 elite male distance runners (age range, 18 – 44y). Intervention: A 1-page questionnaire was used to collect data regarding ages of participation in basketball, soccer, or both, as well as other important covariates and outcomes. Main Outcome Measures: Age(s) when stress fracture(s) occurred. Time-to-event was defined as the number of years from initiation of competitive running to the first stress fracture or to current age, if no fracture had occurred. Results: In both men and women, playing ball sports in youth reduced stress fracture incidence by almost one half, controlling for possible confounders. In men, each additional year of participation in ball sports conferred a 13% decrease in incidence of stress fracture (adjusted hazard ratio [HR], .87; 95% CI, .79 –.95). Among women with regular menses, the HR for each additional year of ball sport participation was similar: .87 (95% CI, 0.75–1.00); however, there was no effect of length of time played among women with irregular menses (HR⫽1.03; 95% CI, 0.92–1.16). In men, younger age of ball sport participation conferred greater protection against stress fractures (HR for each 1-y older age at first exposure: 1.29; 95% CI, 1.14 –1.45). Conclusions: Participation during adolescence in activities generating high strain on the bone in different planes, such as basketball and soccer, is known to enhance bone mass and bone symmetry and may help prevent future stress fractures in runners. Key Words: Prevention; Rehabilitation; Running; Soccer; Stress fractures.
Poster 83 How Is the Spatial Information in a Dynamic Task Such as Throwing Processed? Correlating Multiple Measures of Spatial Cognition. Gary P. Chimes, MD, PhD (UMDNJ-NJMS, Newark, NJ); Elie P. Elovic, MD. Disclosure: None. Objective: To determine whether spatial information as processed in a dynamic task such as throwing is correlated with standard measures of spatial cognition described in the literature or whether they represent distinct domains of spatial cognition. Design: Correlational design. Setting: Indoor exercise facility in a university setting Participants: 160 women (average age, 23.7y; range, 18-47y). Women under 18, postmenopausal, or left-handed were excluded, as these were considered potential confounders. Intervention: Administration of a battery of tests for a total of approximately 90 minutes of participant time. Main Outcome Measures: Multiple measures of spatial perception and cognition including: overhand throwing accuracy, underhand throwing accuracy, the Viewfinding task (participant estimates rotation of a 3-dimensional figurine), the Vandenberg test of spatial cognition (matching a 3-dimensional drawing to images that represent the original drawing rotated in 3-dimensions), and the Purdue pegboard test (a timed test to place small pegs into holes). Results: Pearson product moment correlations were performed to determine the correlations among the different measures of spatial cognition. The only statistically significant correlation was between overhand throwing and underhand throwing (R⫽.326, P⬍.001). Conclusions: The 2 measures of throwing accuracy were correlated with one another, suggesting that both tasks depend on similar underlying cognitive skills. The other measures, however, did not correlate with either throwing or one another. This suggests that spatial cognition is a complex process and thus is additional evidence that the skills involved in processing spatial information is highly task specific. Key Words: Female; Perception; Rehabilitation; Sports.
Musculoskeletal Poster 81 Comparison of Cyclobenzaprine Alone Versus Cyclobenzaprine Plus Ibuprofen in Patients With Acute Musculoskeletal Spasm and Pain. Martin K. Childers, DO, PhD (University of Missouri, Columbia, MO); Michelle Petri, MD, MPH; Charles Laudadio, MD, MBA; Diane D. Harrison, MD, MPH, e-mail: [email protected]. Disclosure: Childers, Consultant for McNeil Pharma; Petri, Consultant for McNeil Pharma; Laudadio, McNeil Pharma employee; Harrison, McNeil Pharma employee. Objective: To test the hypothesis that 5mg TID of cyclobenzaprine (Flexeril) alone (Cyc5) or in combination with 400mg TID of ibuprofen (Cyc5/Ibu400) or 800mg TID of ibuprofen (Cyc5/ Ibu800) is not superior to Cyc5 in the treatment of acute muscle spasm and pain. Design: Prospective, randomized, open-label, multicenter, 7-day study. Setting: U.S. community medical facilities. Participants: 1000 adult men and women with acute back or neck pain of ⬍14 days in duration. Intervention: Cyc5 versus Cyc5/Ibu400 or Cyc5/Ibu800 given over 7 days. Main Outcome Measures: Pain and spasm were assessed using an 11-point (0 –10) patient-rated numeric pain rating score collected via an interactive voice recognition system after 3 and 7 days of therapy. Results: Spasm and pain scores of 867 patients with acute muscle spasm and pain who completed up to 7 days of therapy (Cyc5, n⫽288; Cyc5/Ibu400, n⫽286; Cyc5/Ibu800, n⫽293) were assessed at baseline and after 3 days (D3) and 7 days (D7) of therapy. The percentage changes from baseline for muscle spasm and pain scores were: spasm score changes: Cyc5: ⫺37% D3, ⫺57% D7; Cyc5/Ibu400: ⫺37% D3, ⫺57% D7; Cyc5/Ibu800: ⫺33% D3, ⫺52% D7. Pain score changes: Cyc5: ⫺33% D3, ⫺53% D7; Cyc5/Ibu400: ⫺36% D3, ⫺54% D7; Cyc5/Ibu800: ⫺33% D3, ⫺49%
Arch Phys Med Rehabil Vol 86, September 2005
Poster 84 Tumor Necrosis Factor-Alpha Levels in Herniated Intervertebral Disks. Alfred G. Campbell, MD Candidate (University of Pennsylvania, Philadelphia, PA); Curtis Slipman, MD; Serge Mencken, MD; Beth Winkelstein, PhD; Christian Fras, MD; Kingsley Chin, MD, e-mail: [email protected]. Disclosure: None. Objective: To determine if tumor necrosis factor-alpha (TNF-␣) is present in elevated concentrations within the central aspect of the disk in patients with symptomatic disk herniations. Design: Controlled immunochemical study. Setting: University academic center. Participants: Consecutive subjects undergoing percutaneous disk decompression (PDD) for radicular pain (n⫽20) and undergoing fusion for axial pain (n⫽20), serving as controls. Intervention: Nuclear material was removed from the central part of the disk using a fluoroscopically guided percutaneous decompression probe. Tissue was homogenized in a protease inhibitor buffer and assayed for the presence of TNF-␣ using a colorimetric enzyme linked immunosorbent assay. Control samples were taken from disks of surgical patients undergoing fusion and analyzed in the same manner. Main Outcome Measure: TNF-␣ concentration. Results: TNF-␣ was detected in the disk nucleus of patients who presented with a herniated disk and radicular pain in a statistically greater concentration than in disks from patients presenting with axial pain. Mean concentration of TNF-␣ was 411.2pg/mg tissue in the PDD group, which was significantly higher (Wilcoxon rank-sum test, P⬍.05) than TNF-␣ levels detected in the fusion group. Conclusions: TNF-␣ is a potent inflammatory cytokine that has been implicated in the pathophysiology of disk degeneration as well as radicular pain resulting from herniated disks. Prior studies have demonstrated the presence of TNF-␣ at the interface between the
2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS herniated disk tissue and the nerve root. In addition, the ability of nucleus pulposus cells to synthesize TNF-␣ in culture has been demonstrated. We report the novel observation that TNF-␣ is present in significantly higher concentrations in vivo in the nucleus pulposus of patients with herniated discs than in nonherniated control discs and at a site remote from the disk-nerve root interface. Key Words: Intervertebral disk; Percutaneous diskectomy; Rehabilitation; Tumor necrosis factor-alpha.
Poster 85: Cancelled.
Poster 86 Bone Mineral Metabolism in Patients With Myelomeningocele. Esther Page`s, MD, PhD (Spina Bifida Unit. Vall d’Hebron Hospitals, Barcelona, Spain); Jordi Iborra, MD, PhD; Judith Sa´nchez, MD; Georgia Romero, MD; Susana Rodrı´guez, MD, PhD; Ampar Cuxart, MD, PhD, e-mail: [email protected]. Disclosure: Iborra, Novartis Farmace´utica employee. Other authors: None. Objectives: To examine bone mineral metabolism in patients with myelomeningocele. Design: A cross-sectional study. Setting: A multidisciplinary spina bifida unit within a third-level university hospital. Participants: 80 patients with myelomeningocele. Patients with known metabolic acidosis, renal insufficiency, or other metabolic bone disease were excluded from this study. Intervention: BMD with total-body dual x-ray absorptiometry scan with subregional area values, the biochemical markers of bone mineral metabolism, and the main parameters of calcium phosphate metabolism in blood and/or urine. Main Outcome Measures: Bone mineral density (BMD) and biochemical bone markers. Results: 52% of the patients were in the normal range of BMD, 31.6% were osteopenic and 15.8% were osteoporotic. The only determinant for leg BMD was type of gait (P⫽.012; 95% CI, .042–.229); When we use total-body BMD as dependent variable, the model showed as determinants: type of gait (P⫽.003; 95% CI, .031–.88) and sex (P⫽.044; 95% CI, .003–.155). The formation bone markers were into the normal values, while the resorption bone markers were higher than normal values. Bone-specific alkaline phosphatase levels were determinate by body mass index (P⫽.002), urinary deoxypyridinolines (P⫽.002), and neurologic level (P⫽.013). Osteocalcine levels were determinate by calcium intake (P⫽.001) and sex (P⫽.008). Urinary deoxypyridolines levels were determinate by urea (P⫽.001) and hip flexion contractures (P⫽.009). Finally, NTx levels were determinate by calcium intake (P⫽.001). Conclusions: Fatter (body mass index, ⬎25) patients had less osteopenia or osteoporosis than normal or thin patients. The higher neurologic level, the worse the BMD. Although type of gait is determinate by neurologic level, this study suggests that the type of gait is the most important determinant of leg and total-body BMD. Biochemical markers of bone mineral metabolism in myelomeningocele could be a good tool to evaluate the bone metabolism. Key Words: Bone mineral density; Bone mineral metabolism; Myelomeningocele; Rehabilitation.
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(25[OH]D3 ⬍20ng/mL) was 49.1% (46.7% of men, 52.2% of women) with 41.4% white and 58.3% minority patients affected. The prevalence of osteopenia (T score, ⬍⫺1) was 52.8% (men, 53.3%; women, 52.2%); osteoporosis (T score, ⬍⫺2.5) was 17.0% (men, 20.0%; women, 13%). 51.7% of white and 54.2% of minority patients had osteopenia; 6.9% of white and 29.2% of minority patients had osteoporosis. CTX (bone resorption marker) was elevated in 41.5% of patients. Osteocalcin (bone formation marker) was elevated in 11.3% of patients. Measurements of bone resorption and formation positively correlated (R2⫽.22) indicating increased bone remodeling. Conclusions: Vitamin D deficiency and osteopenia and osteoporosis was highly prevalent in both men and women admitted for rehabilitation. Elevated bone resorption and remodeling were evident. This could be due to vitamin D deficiency that should be corrected before antiresorptive therapy is considered. The study emphasizes the need for vigilance for vitamin D status and bone mineral density testing in patients admitted to rehabilitation facilities. Key Words: Bone density; Osteoporosis; Rehabilitation; Vitamin D deficiency. Poster 89 Study of Neurotransmission Pathway for Diskogenic Low Back Pain: FluroGold Particles Are Transferred From the Rabbit L5-6 Intervertebral Disk to Primary Sensory Neurons and Primary Sensory Fibers at Multiple Levels. Yejia Zhang, MD, PhD (Thomas Jefferson University, Philadelphia, PA); Youngsang Lee, MD; Howard S. An, MD, e-mail: [email protected]. Disclosure: None. Objective: To establish the neurotransmission pathway from the intervertebral disk (IVD) to the spinal cord in rabbit. Design: Gold crystals injected into the IVD will be traced and quantified by examining gold positive neurons in the dorsal root ganglion (DRG) and the spinal cord. Animals: New Zealand-White rabbits. 25-hydroxyvitamin D FluoroGold crystals were injected into the dorsal portion of the L5-6 IVD disk. Intervention: 7 days after the injection, the spinal cord, with bilateral DRGs attached, were isolated. FluroGold-positive neurons were quantified in the DRGs under fluorescence microscopy. Main Outcome Measure: Data were expressed as percentage of positive neurons ⫾ SD. Results: FluoroGold-labeled neurons were present in the bilateral primary afferent neurons within DRGs from L5 through T12. No neurons in DRGs from C1 through T11 were labeled. At the L5 level, labeled neurons were predominantly present in the DRGs on the left side (34.94%⫾9.98%), with clearly less on the right side (8.08%⫾5.58%). At the L4 and L3 levels, the left-side predominance persisted but clearly decreased (L4: left, 5.84%⫾2.28%; right, 2.88%⫾1.22%; L3: left, 2.24%⫾2.05%; right, 2.75%⫾2.32%). Gold particle distribution was similar on both sides of the DRGs at the L2 and L1 levels. In the posterior horn of the spinal cord, gold particles were detected in the fibers within primary afferent sensory fibers within laminae I-II at L4 and L3 levels on both sides. Conclusions: We have shown, for the first time, that FluroGold particles are transferred from the rabbit L5-6 IVD to primary sensory neurons in the DRG and primary sensory fibers in the posterior horn of the spinal cord at multiple levels. If the neurotransmission pathway is similar in humans, it may explain why mechanical back pain is often poorly localized. Key Words: Low back pain; Rehabilitation.
Poster 87 Pulsed Electromagnetic Field Stimulation for the Treatment of Knee Osteoarthritis. Shane Mangrum, MD (University of Utah, Salt Lake City, UT); Stuart E. Willick, MD, e-mail: [email protected]. Disclosure: None. Objective: To investigate the effectiveness of a novel device delivering pulsed electromagnetic field stimulation (PEFS) in the treatment of knee osteoarthritis (OA). Design: A double-blind, randomized, placebo-controlled trial was designed to evaluate the effectiveness of PEFS. Setting: Single tertiary referral center. Participants: Patients with clinically defined OA according to the criteria of the American College of Rheumatology. Intervention: Delivery of 12 active or placebo treatment sessions in 16 patients with knee OA. The study treatment sessions were each 30 minutes in duration, delivered 3 times a week over the course of 4 weeks. Main Outcome Measures: The primary outcome measure for this investigation was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Secondary outcome measures include the 100-mm visual analog scale (VAS), WOMAC global score, WOMAC functional disability score, and WOMAC stiffness score. Outcome measurements were assessed at baseline and after each of 4 subsequent weeks of treatment. Results: Although there were no significant differences between active and placebo treatment groups in respect of any the outcome measures in this pilot study, analysis demonstrated trends in the treatment group towards improvement in WOMAC stiffness scale (P⫽.09), 100-mm VAS (P⫽.15), and the WOMAC global scale (P⫽.16). Conclusions: The small sample size in this pilot study limits any conclusions about treatment effect. However, the observed trends toward improvement in the active treatment group in the areas of pain and function are potentially clinically significant and suggest that further investigation is warranted in a larger, multicenter, randomized controlled trial to evaluate this novel PEMF delivery system for the treatment of knee OA. Key Words: Electromagnetic stimulation; Osteoarthritis; Rehabilitation.
Poster 90 Biologic Treatment of Degenerative Disk Diseases: Gene Therapy Approaches. Yejia Zhang, MD, PhD (Thomas Jefferson University, Philadelphia, PA); Frank M. Phillips, MD; Howard S. An, MD, e-mail: [email protected]. Disclosure: None. Objective: To directly compare the effects of adenovirus expressing bone morphogenetic proteins (AdBMPs) on proteoglycan accumulation by nucleus pulposus (NP) cells in vitro. Design: NP cells were transduced with recombinant adenoviruses expressing human BMP-2, -3, -4, -5, -7, -8, -10, -11, -12, -13, -14, and -15 and cultured in monolayer. In the co-culture approach, articular chondrocytes were transduced with some of these BMPs and co-cultured with NP cells maintained in alginate. Interventions: Not applicable. Main Outcome Measure: In both cases, proteoglycan accumulation by NP cells was measured after 6 days of culture. Results: AdBMP-2, -4, -5, -7, -8, -10, or -13 effectively stimulated proteoglycan accumulation by NP cells (P⬍.05). Articular chondrocytes transduced with AdBMP-7 or -10 and cocultured with NP cells markedly stimulated proteoglycan accumulation by the NP cells (P⬍.05). Conclusions: For treatment of mild to moderate intervertebral disk (IVD) degeneration, genes expressing BMPs could be directly injected into the disks. In contrast, for treatment of advanced IVD degeneration, where viable cells are reduced in number in the IVD, transplantation of articular chondrocytes transduced with BMP genes ex vivo is more appropriate. Based on our findings, future in vivo study with direct gene transfer of native IVD cells should focus on AdBMP-2, -4, -5, -7, -8, -10, and -13; in contrast, while studying the paracrine effects of articular chondrocytes on native intervertebral disk cells in vivo, efforts should focus on treatment with AdBMP-7 or -10. Key Words: Gene therapy; Intervertebral disk; Low back pain; Rehabilitation.
Poster 88 Vitamin D Deficiency and Metabolic Bone Disease in Rehabilitation Inpatients. Leonid M. Shinchuk, MD (Boston University Medical Center, Boston, MA); Leslie R. Morse, DO; Nadia Huancahuari; Seth Arum, MD; Tai C. Chen, PhD; Michael F. Holick, MD, PhD, e-mail: [email protected]. Disclosure: None. Objective: To determine vitamin D status and bone mineral density in patients admitted to a subacute rehabilitation facility. Design: Cross-sectional cohort study. Setting: Subacute rehabilitation facility. Participants: 53 patients admitted from June through February. Intervention: We determined the vitamin D status, bone mineral density, and bone turnover markers. A dietary questionnaire for vitamin D intake was collected. Main Outcome Measures: 25-hydroxyvitamin D (25[OH]D3); bone mineral density, C-telopeptide (CTX), and osteocalcin. Results: Enrolled patients had a mean age of 60.2⫾14.1, 30 men (56.6%), 23 women (43.4%), 29 white (54.7%), 20 African Americans (37.7%), 2 Hispanic (5.7%), and 1 Asian (1.9%) that was comparable to the demographics of the entire unit over the same period of time. Prevalence of vitamin D deficiency
Poster 91 Prevalence of Components of the Female Athlete Triad. Anne Z. Hoch, DO (Medical College of Wisconsin, Milwaukee, WI); Christopher A. Taylor, MD, e-mail: [email protected]. Disclosure: None. Objective: To determine the prevalence of female athlete triad characteristics: disordered eating, menstrual dysfunction, and osteopenia and/or stress fracture. Design: Retrospective study from a standard questionnaire used in an academic sports medicine center. Setting: Hospital sports medicine center and women’s sports medicine program. Participants: 1027 female subjects (513 under 25y, 342 between 26 and 45y, 172 were ⱖ46y) who exercised aerobically an average of 5d/wk for 78 minutes. Intervention: Standardized questionnaire for female subjects. Results: (1) Disordered eating: results from the questionnaire revealed that 6.0% and 4.9% of the subjects had a history of anorexia and bulimia, respectively, with 44% having been on a diet at some point in their life. At the time of the survey, 4% were using laxatives and 3.5% were taking diet pills. On average, subjects wanted to lose 13lb. (2) Menstrual status: the mean age of menarche was 12.8 years. Average number of menstrual periods in the last year was 8 (oligomenorrheic). 39% of subjects had
Arch Phys Med Rehabil Vol 86, September 2005