- Email: [email protected]
Poster 86
A20
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
the Back Builders program designed by the principal author, who used the principles of medical yoga and Pilates to minimize disk pressures. In addition to the exercise program, patients took 200mg of celecoxib with hydrocodone and acetaminophen for breakthrough pain. Group 2 (n⫽25) underwent medication treatment with 200mg of celecoxib with hydrocodone and acetaminophen for breakthrough pain. Both groups were age and sex matched. Main Outcome Measures: Outcome measures included Roland-Morris Disability Questionnaire, numeric pain score, patient satisfaction, and distance from finger to floor (in centimeters). A successful outcome was defined as ⬎50% pain reduction with good or better patient satisfaction. Results: At a minimum of 12 months of follow-up with an average follow-up of 12.3 months (range, 12–14mo), group 1 had 72% (18/25) successful outcomes and group 2 reported 36% (8/22, 3 lost to follow-up) successful outcomes (P⫽.001). In group 1, 16% (y/25) reported recurrence of acute symptoms versus 50% (11/22) in group 2 (P⫽.001). Conclusion: A well-designed program for patients with disk problems that minimizes disk pressures while restoring flexibility, strength, endurance, balance, and posture may yield superior results to oral medications with reduction in recurrence of back pain. Key Words: Low back pain; Rehabilitation. Poster 84 The Utah State University Concussion Protocol. Jonathan T. Finnoff, DO (Utah State University, Logan, UT); Dale P. Mildenberger, MS, ATC, e-mail: [email protected]. Disclosure: None. Objective: To develop and implement an economically feasible and objective concussion identification and return-to-play protocol based on the most recent scientific information. Design: Retrospective study. Setting: US National Collegiate Athletics Association Division I university athletic program. Participants: All university athletes from the men’s football and basketball teams, and from the women’s soccer, volleyball, and gymnastics teams. Interventions: Not applicable. Main Outcome Measure: The number of concussions from August through December 2002, and the duration of time from injury to return-to-play. Results: The Utah State University (USU) concussion protocol employed baseline objective measures including the Standardized Assessment of Concussion™ (SAC) and the Balance Error Scoring System™ (BESS). After a concussion, an athlete was evaluated with a standardized clinical evaluation and repetition of objective tests. If the clinical examination and objective measures were normal, the athlete was allowed to return to competition the same day. If findings were abnormal, the athlete was withheld from competition until objective measures and clinical examination normalized. After a 48-hour asymptomatic period, the athlete began a functional exercise protocol. The athlete was allowed to return to noncontact practice after successful completion of the functional exercise protocol. A minimum of 5 asymptomatic days and completion of the functional exercise protocol was required prior to return to unrestricted competition. 15 concussions were identified during the study. The number of concussions per sport and the incidence were: football 13 (12.4%), soccer 1 (4%), and volleyball 1 (7%). Athletes were returned to competition an average of 7 days after concussion, with the shortest and longest durations being 0 and 13 days, respectively. No adverse outcomes occurred. Conclusion: The USU concussion protocol is an effective and affordable scientifically based guideline for the identification and management of concussed athletes. Key Words: Concussion; Rehabilitation; Sports. Poster 85 Severe Aortoiliac Occlusive Disease Presenting as Suspected Symptomatic High Lumbar Stenosis: A Report of 2 Cases. Jason S. Lipetz, MD (NS-LIJ Health System, East Meadow, NY); Jeffry R. Beer, MD; Jeff S. Silber, MD, e-mail: [email protected]. Disclosure: None. Setting: Outpatient physiatric spine center. Patients: 2 patients with the chief complaint of proximal thigh pain. Case Descriptions: 2 middle-aged female smokers were referred by their primary care physician with bilateral thigh pain that had persisted for several years. Each presented with a lumbar magnetic resonance imaging, which demonstrated upper lumbar stenosis. In each case, bilateral and circumferential thigh pain was described, which prohibited the patient from ambulating extended distances and was relieved through quiet standing. A detailed history and radiographic review were not convincing for a corroborative radicular stressor. Each patient was neurologically intact and had diminished lower-extremity pulses. Segmental arterial Doppler studies were performed. Assessment/Results: In each case, a markedly diminished ankle-brachial index was observed. Although a focal drop in pressure was not observed between lower-limb segments, a significant reduction was appreciated when comparing the high thigh to brachial pressure measurements. Computed tomography (CT) angiograms confirmed severe aortoiliac atherosclerotic disease. Each patient was treated with an antiplatelet agent prior to further considering aortofemoral bypass. One patient’s carotid Doppler image revealed severe bilateral occlusion that led to a prompt endarterectomy. Discussion: Neurogenic claudication can present with proximal and anterior lower-extremity pain arising from a high lumbar and stenotic radicular stressor. Vascular claudication most commonly arises from atherosclerosis obliterans, and smoking remains a primary risk factor. Isolated proximal limb pain with ambulation, Leriche’s syndrome, can arise from aortoiliac occlusive disease. Conclusions: Spine practitioners are often consulted to determine if a patient’s limb complaints are arising from a spinal pain generator. These atypical cases highlight a less common pain distribution in the vascular patient, the symptomatic overlap between neurogenic and vascular claudication, and the challenges that arise when evaluating the patient with combined disease. Key Words: Atherosclerosis; Claudication; Rehabilitation; Spinal stenosis.
Poster 86 Medical Students’ Perspectives on Physical Medicine and Rehabilitation Musculoskeletal Workshops Using Simulated Patients. Patrick M. Foye, MD (UMDNJ: New Jersey Medical School, Newark, NJ); Todd P. Stitik, MD; Scott Nadler, DO; Denise I. Campagnolo, MD, e-mail: [email protected]. Disclosure: None. Objective: To evaluate medical students’ perspectives on the use of simulated patients within musculoskeletal physical exam workshops run by physical medicine and rehabilitation (PM&R)
Arch Phys Med Rehabil Vol 84, September 2003
physicians. Design: A survey administered at the end of the workshop. Setting: A large, state medical school. Participants: 142 second-year medical students. Intervention: Unlike previous years, simulated patients were used to create realism and experience for the students. Main Outcome Measure: Survey. Results: 93% (132/142) expressed that learning via simulated patients was more effective than the traditional lecture format. Their opinions were split, however, on the effectiveness of simulated patients over real patients (yes, 30%; no, 36%; undecided, 34%). Prior to this workshop, only 23% (32/142) were considering PM&R as a potential career. After this workshop, percentage increased to 32% (46/142). 77% (109/142) responded that, as a result of the workshop, they would be more likely to refer patients to physiatrists. Conclusions: Medical students preferred simulated patients to lectures, but were undecided as to how simulated patients compared with real patients for these educational purposes. Physiatry-run musculoskeletal workshops seems to foster an increased interest in entering physiatry and referring patients. Key Words: Medical education; Musculoskeletal system; Rehabilitation. Poster 87 Golf Club Grounding Menace to the Coracobrachialis Muscle: A Report of 2 Cases. Jeffrey J. Fossati, MD (UMDNJ–New Jersey Medical School, Newark, NJ); Todd P. Stitik, MD; Patrick M. Foye, MD. Disclosure: None. Setting: Office-based solo practice. Patients: 2 right-handed patients. Case Descriptions: The patients presented complaining of severe right anterior shoulder pain, particularly with internal rotation, after grounding their golf clubs. By definition, golf grounding occurs when a golf club’s forward motion is halted during the down swing; this is caused by striking the ground prior to striking the ball. This generally occurs due to any combination of poor weather, poor skill level, and/or fatigue. The patients described their pain as having an almost immediate onset after grounding their clubs, and the pain was located in the anterior shoulder and of a burning quality. Assessment/Results: Their physical examinations revealed pain-limited active range of motion pain in all planes. Both patients had slight warmth to palpation in the anterior deltoid area and appeared to have positive Hawkin’s impingement signs but negative drop arm tests. Vague tenderness was noted in the area of the bicipital tendons, but the speed tests were negative. Further examination revealed tenderness with palpation over the coracobrachialis muscle and with manual muscle testing of this muscle. In addition to nonsteriodal anti-inflammatory drugs, rest, and therapeutic modalities, the patients underwent prophylactic coracobrachialis strengthening as part of a home exercise program. Both patients became and remained pain free despite returning to golf and reportedly still grounding their clubs with a similar frequency. Discussion: Careful consideration of the mechanism of injury and assessment for the unusual finding of coracobrachialis tenderness and pain with resisted coracobrachialis muscle contraction avoided erroneously diagnosing the much more common condition, shoulder impingement syndrome. Conclusion: Golf grounding syndrome (Fosti syndrome) can present a diagnostic dilemma unless it is considered in the differential diagnosis of shoulder pain in golfers. Prophylactic coracobrachialis strengthening might help to prevent this disorder in golfers who tend to ground their clubs. Key Words: Coracobrachialis; Golf; Rehabilitation; Shoulder pain. Poster 88 Rehabilitation Risk Assessment Tool: Predicting Length of Stay After Elective Hip and Knee Arthroplasty. James A. Young, MD (Rush Presbyterian St. Luke’s Medical Center, Chicago, IL); Julie Yuen, RN, MS, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care hospital. Program: Elective hip and knee arthroplasties. Program Description: A risk assessment tool was written to anticipate lengths of stay (LOS) in the acute rehabilitation setting for 113 patients. Categories included the home situation (caregiver presence, stairs, living alone), assistive devices, prior hip or knee procedures, neurologic problems, age, other medical concerns. Category scoring was weighted based on expected posthospital complications. The groups included a stay of ⱖ14 days; 10 to 14 days; 7 to 10 days; 4 to 7 days; and ⬍3 days (“fast-tracked patients”). The tool was completed by nurses, usually days to weeks before the procedure. Assessment/Results: 66 of 113 patients were within the expected LOS for 58% accuracy— 63.7% within 1 day and 72.6% within 2 days. The categories most consistently difficult to predict were those ⬍7 days. Discussion: Predicting acute rehabilitation LOS involves many factors. Advising patients and families about the expected duration assists in their time management. With this data, a bed reservation system can be developed by the rehabilitation unit, to assist with staffing issues, vacation needs, and facility maintenance. Weeks to months before the operation, the risk assessment tool and demographics are sent (electronically) to hospital reservations (to the acute facility and the rehabilitation unit as decided by the patient or family). Those patients with the low to mild risk levels were the most consistently difficult to predict. Other factors, including the expected procedure, may need to be added. Conclusions: A risk assessment tool to anticipate acute rehabilitation LOS was developed to aid patients and families and to provide a basis for a reservation system. The latter might streamline the entire hospitalization process for both patients and rehabilitation units. Key Words: Arthroplasty; Assessment; Length of stay; Rehabilitation.
Poster 89 Suprascapular Neuropathy Presenting as Myofascial Pain: A Report of 4 Cases. Robin Gottlieb, MD (Baystate Medical Center, Springfield, MA/Tufts University School of Medicine, Boston, MA, Springfield, MA); Nicholas T. Spellman, MD, e-mail: [email protected]. Disclosure: None. Setting: Outpatient clinic. Patients: 4 women presenting with myofascial pain in the upper trapezius, diffuse shoulder pain, and pain with shoulder abduction above 90°. Case Descriptions: All patients were symptomatic for 6 months to ⬎3 years and had been previously diagnosed and treated for cervicobrachial myofascial pain. Assessment/Results: On clinical exam, asymmetric scapular movements were noted with reversal of abduction including mild lateral displacement and medial winging. No atrophy was noted. Electromyography was notable for chronic denervation in
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
the Back Builders program designed by the principal author, who used the principles of medical yoga and Pilates to minimize disk pressures. In addition to the exercise program, patients took 200mg of celecoxib with hydrocodone and acetaminophen for breakthrough pain. Group 2 (n⫽25) underwent medication treatment with 200mg of celecoxib with hydrocodone and acetaminophen for breakthrough pain. Both groups were age and sex matched. Main Outcome Measures: Outcome measures included Roland-Morris Disability Questionnaire, numeric pain score, patient satisfaction, and distance from finger to floor (in centimeters). A successful outcome was defined as ⬎50% pain reduction with good or better patient satisfaction. Results: At a minimum of 12 months of follow-up with an average follow-up of 12.3 months (range, 12–14mo), group 1 had 72% (18/25) successful outcomes and group 2 reported 36% (8/22, 3 lost to follow-up) successful outcomes (P⫽.001). In group 1, 16% (y/25) reported recurrence of acute symptoms versus 50% (11/22) in group 2 (P⫽.001). Conclusion: A well-designed program for patients with disk problems that minimizes disk pressures while restoring flexibility, strength, endurance, balance, and posture may yield superior results to oral medications with reduction in recurrence of back pain. Key Words: Low back pain; Rehabilitation. Poster 84 The Utah State University Concussion Protocol. Jonathan T. Finnoff, DO (Utah State University, Logan, UT); Dale P. Mildenberger, MS, ATC, e-mail: [email protected]. Disclosure: None. Objective: To develop and implement an economically feasible and objective concussion identification and return-to-play protocol based on the most recent scientific information. Design: Retrospective study. Setting: US National Collegiate Athletics Association Division I university athletic program. Participants: All university athletes from the men’s football and basketball teams, and from the women’s soccer, volleyball, and gymnastics teams. Interventions: Not applicable. Main Outcome Measure: The number of concussions from August through December 2002, and the duration of time from injury to return-to-play. Results: The Utah State University (USU) concussion protocol employed baseline objective measures including the Standardized Assessment of Concussion™ (SAC) and the Balance Error Scoring System™ (BESS). After a concussion, an athlete was evaluated with a standardized clinical evaluation and repetition of objective tests. If the clinical examination and objective measures were normal, the athlete was allowed to return to competition the same day. If findings were abnormal, the athlete was withheld from competition until objective measures and clinical examination normalized. After a 48-hour asymptomatic period, the athlete began a functional exercise protocol. The athlete was allowed to return to noncontact practice after successful completion of the functional exercise protocol. A minimum of 5 asymptomatic days and completion of the functional exercise protocol was required prior to return to unrestricted competition. 15 concussions were identified during the study. The number of concussions per sport and the incidence were: football 13 (12.4%), soccer 1 (4%), and volleyball 1 (7%). Athletes were returned to competition an average of 7 days after concussion, with the shortest and longest durations being 0 and 13 days, respectively. No adverse outcomes occurred. Conclusion: The USU concussion protocol is an effective and affordable scientifically based guideline for the identification and management of concussed athletes. Key Words: Concussion; Rehabilitation; Sports. Poster 85 Severe Aortoiliac Occlusive Disease Presenting as Suspected Symptomatic High Lumbar Stenosis: A Report of 2 Cases. Jason S. Lipetz, MD (NS-LIJ Health System, East Meadow, NY); Jeffry R. Beer, MD; Jeff S. Silber, MD, e-mail: [email protected]. Disclosure: None. Setting: Outpatient physiatric spine center. Patients: 2 patients with the chief complaint of proximal thigh pain. Case Descriptions: 2 middle-aged female smokers were referred by their primary care physician with bilateral thigh pain that had persisted for several years. Each presented with a lumbar magnetic resonance imaging, which demonstrated upper lumbar stenosis. In each case, bilateral and circumferential thigh pain was described, which prohibited the patient from ambulating extended distances and was relieved through quiet standing. A detailed history and radiographic review were not convincing for a corroborative radicular stressor. Each patient was neurologically intact and had diminished lower-extremity pulses. Segmental arterial Doppler studies were performed. Assessment/Results: In each case, a markedly diminished ankle-brachial index was observed. Although a focal drop in pressure was not observed between lower-limb segments, a significant reduction was appreciated when comparing the high thigh to brachial pressure measurements. Computed tomography (CT) angiograms confirmed severe aortoiliac atherosclerotic disease. Each patient was treated with an antiplatelet agent prior to further considering aortofemoral bypass. One patient’s carotid Doppler image revealed severe bilateral occlusion that led to a prompt endarterectomy. Discussion: Neurogenic claudication can present with proximal and anterior lower-extremity pain arising from a high lumbar and stenotic radicular stressor. Vascular claudication most commonly arises from atherosclerosis obliterans, and smoking remains a primary risk factor. Isolated proximal limb pain with ambulation, Leriche’s syndrome, can arise from aortoiliac occlusive disease. Conclusions: Spine practitioners are often consulted to determine if a patient’s limb complaints are arising from a spinal pain generator. These atypical cases highlight a less common pain distribution in the vascular patient, the symptomatic overlap between neurogenic and vascular claudication, and the challenges that arise when evaluating the patient with combined disease. Key Words: Atherosclerosis; Claudication; Rehabilitation; Spinal stenosis.
Poster 86 Medical Students’ Perspectives on Physical Medicine and Rehabilitation Musculoskeletal Workshops Using Simulated Patients. Patrick M. Foye, MD (UMDNJ: New Jersey Medical School, Newark, NJ); Todd P. Stitik, MD; Scott Nadler, DO; Denise I. Campagnolo, MD, e-mail: [email protected]. Disclosure: None. Objective: To evaluate medical students’ perspectives on the use of simulated patients within musculoskeletal physical exam workshops run by physical medicine and rehabilitation (PM&R)
Arch Phys Med Rehabil Vol 84, September 2003
physicians. Design: A survey administered at the end of the workshop. Setting: A large, state medical school. Participants: 142 second-year medical students. Intervention: Unlike previous years, simulated patients were used to create realism and experience for the students. Main Outcome Measure: Survey. Results: 93% (132/142) expressed that learning via simulated patients was more effective than the traditional lecture format. Their opinions were split, however, on the effectiveness of simulated patients over real patients (yes, 30%; no, 36%; undecided, 34%). Prior to this workshop, only 23% (32/142) were considering PM&R as a potential career. After this workshop, percentage increased to 32% (46/142). 77% (109/142) responded that, as a result of the workshop, they would be more likely to refer patients to physiatrists. Conclusions: Medical students preferred simulated patients to lectures, but were undecided as to how simulated patients compared with real patients for these educational purposes. Physiatry-run musculoskeletal workshops seems to foster an increased interest in entering physiatry and referring patients. Key Words: Medical education; Musculoskeletal system; Rehabilitation. Poster 87 Golf Club Grounding Menace to the Coracobrachialis Muscle: A Report of 2 Cases. Jeffrey J. Fossati, MD (UMDNJ–New Jersey Medical School, Newark, NJ); Todd P. Stitik, MD; Patrick M. Foye, MD. Disclosure: None. Setting: Office-based solo practice. Patients: 2 right-handed patients. Case Descriptions: The patients presented complaining of severe right anterior shoulder pain, particularly with internal rotation, after grounding their golf clubs. By definition, golf grounding occurs when a golf club’s forward motion is halted during the down swing; this is caused by striking the ground prior to striking the ball. This generally occurs due to any combination of poor weather, poor skill level, and/or fatigue. The patients described their pain as having an almost immediate onset after grounding their clubs, and the pain was located in the anterior shoulder and of a burning quality. Assessment/Results: Their physical examinations revealed pain-limited active range of motion pain in all planes. Both patients had slight warmth to palpation in the anterior deltoid area and appeared to have positive Hawkin’s impingement signs but negative drop arm tests. Vague tenderness was noted in the area of the bicipital tendons, but the speed tests were negative. Further examination revealed tenderness with palpation over the coracobrachialis muscle and with manual muscle testing of this muscle. In addition to nonsteriodal anti-inflammatory drugs, rest, and therapeutic modalities, the patients underwent prophylactic coracobrachialis strengthening as part of a home exercise program. Both patients became and remained pain free despite returning to golf and reportedly still grounding their clubs with a similar frequency. Discussion: Careful consideration of the mechanism of injury and assessment for the unusual finding of coracobrachialis tenderness and pain with resisted coracobrachialis muscle contraction avoided erroneously diagnosing the much more common condition, shoulder impingement syndrome. Conclusion: Golf grounding syndrome (Fosti syndrome) can present a diagnostic dilemma unless it is considered in the differential diagnosis of shoulder pain in golfers. Prophylactic coracobrachialis strengthening might help to prevent this disorder in golfers who tend to ground their clubs. Key Words: Coracobrachialis; Golf; Rehabilitation; Shoulder pain. Poster 88 Rehabilitation Risk Assessment Tool: Predicting Length of Stay After Elective Hip and Knee Arthroplasty. James A. Young, MD (Rush Presbyterian St. Luke’s Medical Center, Chicago, IL); Julie Yuen, RN, MS, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care hospital. Program: Elective hip and knee arthroplasties. Program Description: A risk assessment tool was written to anticipate lengths of stay (LOS) in the acute rehabilitation setting for 113 patients. Categories included the home situation (caregiver presence, stairs, living alone), assistive devices, prior hip or knee procedures, neurologic problems, age, other medical concerns. Category scoring was weighted based on expected posthospital complications. The groups included a stay of ⱖ14 days; 10 to 14 days; 7 to 10 days; 4 to 7 days; and ⬍3 days (“fast-tracked patients”). The tool was completed by nurses, usually days to weeks before the procedure. Assessment/Results: 66 of 113 patients were within the expected LOS for 58% accuracy— 63.7% within 1 day and 72.6% within 2 days. The categories most consistently difficult to predict were those ⬍7 days. Discussion: Predicting acute rehabilitation LOS involves many factors. Advising patients and families about the expected duration assists in their time management. With this data, a bed reservation system can be developed by the rehabilitation unit, to assist with staffing issues, vacation needs, and facility maintenance. Weeks to months before the operation, the risk assessment tool and demographics are sent (electronically) to hospital reservations (to the acute facility and the rehabilitation unit as decided by the patient or family). Those patients with the low to mild risk levels were the most consistently difficult to predict. Other factors, including the expected procedure, may need to be added. Conclusions: A risk assessment tool to anticipate acute rehabilitation LOS was developed to aid patients and families and to provide a basis for a reservation system. The latter might streamline the entire hospitalization process for both patients and rehabilitation units. Key Words: Arthroplasty; Assessment; Length of stay; Rehabilitation.
Poster 89 Suprascapular Neuropathy Presenting as Myofascial Pain: A Report of 4 Cases. Robin Gottlieb, MD (Baystate Medical Center, Springfield, MA/Tufts University School of Medicine, Boston, MA, Springfield, MA); Nicholas T. Spellman, MD, e-mail: [email protected]. Disclosure: None. Setting: Outpatient clinic. Patients: 4 women presenting with myofascial pain in the upper trapezius, diffuse shoulder pain, and pain with shoulder abduction above 90°. Case Descriptions: All patients were symptomatic for 6 months to ⬎3 years and had been previously diagnosed and treated for cervicobrachial myofascial pain. Assessment/Results: On clinical exam, asymmetric scapular movements were noted with reversal of abduction including mild lateral displacement and medial winging. No atrophy was noted. Electromyography was notable for chronic denervation in