- Email: [email protected]
Poster 9
E8
2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS
exposure or frostbite may be helpful in such cases. Physicians treating patients with cold injury should also be aware of this risk. Early intervention including rehabilitation may limit joint deformity and loss of function. Key Words: Arthritis; Frostbite; Osteoarthritis; Rehabilitation. Poster 6 An Unusual Aspiration Pneumonia Secondary to Diffuse Idiopathic Skeletal Hyperostosis: A Combined Medical and Rehabilitative Approach. Stefano Masiero (University of Padova, Padova, Italy); Raffaele Bottin; Rosario Marchese Ragona, MD; Daniela Volante; Claudio Ferraro; Marco Ortolani, e-mail: [email protected]. Disclosure: None. Setting: Outpatient rehabilitation center. Patient: An 84-year-old man presented with an 8-month history of nonsevere dysphagia that was experienced only with solid foods in a patient with diffuse idiopathic skeletal hyperostosis (DISH) or Forestier’s disease of the cervical spine. An episode of pneumonia occurred in the third and sixth months previously and the patient had been admitted to hospital and treated with antibiotics. Case Description: The patient was treated with nonsteroidal anti-inflammatory drugs (10mg aceclofenac QID, maintained for 2wk/mo), a soft diet, and rehabilitation treatment (active exercises to strengthen the swallowing musculature and effortful swallow, exercises for coordinating swallowing and breathing, for strengthening the respiratory, airflow protection maneuvers to produce safer swallowing, improve airway protection, and pharyngeal and laryngeal function, etc). Assessment/Results: At follow-up 6, 12, 18, 24, and 30 months after starting medical and rehabilitation treatment, the patient was still able to maintain an adequate oral food intake with no signs of aspiration or clinical complications. Discussion: This is the first reported case, to our knowledge, which describes a long follow-up in the dysphagia post-DISH. The dysphagia was hypothesized to be caused by mechanical compression and inflammatory changes accompanied by fibrosis in the esophagus wall. The aspiration pneumonia probably had multifactorial etiology: dysphagia, abnormal cough reflex, colonization of the oropharynx and virulent bacteria, etc. We believe that the durable improvement in our patient dysphagia is due to the combined use of medical and rehabilitation treatment. Conclusions: This case illustrates that cervical spinal abnormalities, such as Forestier’s disease, may be potentially treatable causes of aspiration pneumonia. Key Words: Aspiration pneumonia; Dysphagia; Rehabilitation. Poster 7 A Complication of an Osteoarthritis Medication or a “Rare Bird” of a Diagnosis? A Case Report. Charles J. Buttaci, DO, PT (UMDNJ-NJMS/Kessler Institute for Rehabilitation, Newark, NJ); Todd P. Stitik, MD; Lisa Schoenherr, BA, e-mail: [email protected]. Disclosure: None. Setting: University hospital–affiliated outpatient musculoskeletal physiatry practice. Patient: A 55-year-old woman with knee osteoarthritis enrolled in a phase 3 double-blinded randomized clinical trial assessing the efficacy and cardiovascular side effect profile of an investigational cyclooxygenase-2 inhibitor versus a traditional nonsteroidal anti-inflammatory drug. Case Description: The patient experienced orthopnea, dyspnea on exertion, a nonproductive cough, and lowerextremity edema approximately 3 months after randomization. The study medication was temporarily discontinued (drug holiday), and she was treated for presumed congestive heart failure (CHF) with minimal improvement. A subsequent cardiac evaluation was essentially negative. On a more thorough social history, she revealed that she had a parrot. This raised concern for psittacosis, an infection caused by the obligatory intracellular bacterium chlamydia psittaci. She was treated with moxifloxacin (fourth-generation quinolone) and improved greatly. She subsequently restarted the study medication and did not report any side effects that would suggest reoccurrence of his previous respiratory illness. Assessment/Results: The diagnosis of psittacosis was presumptively made based on symptom resolution after treatment with antibiotics, exclusion of underlying cardiovascular pathology, and absence of symptom recurrence on study medication re-exposure. This case was not an example of an anti-inflammatory–related cardiovascular side effect. Discussion: Psittacosis is a rare infectious disease whose primary site of pathology is the respiratory tract. This disease entity is capable of causing a clinical picture that can be mistaken for CHF. Conclusions: Physiatrists conducting phase 3 clinical trials need to be aware of the process by which to protect patients from potential adverse reactions while these are being investigated without ultimately inappropriately depriving them of benefit from a medication. Thorough investigation of potential adverse medication reactions is important during clinical pharmaceutical trials, as is a working knowledge of internal medicine in order to accurately determine medication side effect profiles. Key Words: Cyclooxygenase-2 inhibitors; Osteoarthritis; Psittacosis; Rehabilitation.
Poster 8 Intra-Articular Injection of Hylan G-F 20 for the Treatment of Hip Osteoarthritis. Victoria Brander, MD (Northwestern University School of Medicine, Chicago, IL); S. David Stulberg, MD; Bonny Galazka, MPH, e-mail: [email protected]. Disclosure: Brander, Research grant from Wyeth/Genzyme, Wyeth/Genzyme Speakers bureau; Other authors: None. Objective: To test the safety and efficacy of hylan G-F 20 for the treatment of hip osteoarthritis (OA). Design: Prospective, observational study. Setting: Orthopedic clinic. Participants: 90 patients with osteoarthritis of the hip who failed to get satisfactory pain relief from standard, conservative methods. Intervention: 3 weekly, fluoroscopically guided injections of 2mL of hylan G-F 20, in addition to customary care. Main Outcome Measures: Visual numeric pain score at rest, with walking, and at night and adverse events were recorded at all visits. Results: 90 hip joints with OA (51 men, 39 women; mean age, 54⫾18y). Mean pain scores at visit 1 (baseline; first injection) were: 58⫾22 at rest, 28⫾24 with walking, and 37⫾28 at night. All mean pain scores at visit 3 (14d after first injection) were significantly lower (P⬍.05) than baseline (23⫾23 at rest, 41⫾27 with walking, 27⫾27 at night). At the final follow-up visit (mean 12 weeks; range, 4 –31wk after first injection), mean pain scores were: 17⫾17 at rest (P⬍.05 vs baseline), 30⫾21 with walking (P⬍.05 vs baseline), and 25⫾26 at night. 82% of patients reported that they were satisfied or very satisfied with the results of the injections. A patient reported pain after injection at the injection site only, and 1 reported hip pain after the second injection, which resolved without treatment. No significant
Arch Phys Med Rehabil Vol 86, September 2005
episodes of increased pain or transient synovitis were observed. The only significant predictor of poor response identified was female sex. Conclusions: This study demonstrates the use of intraarticular hylan-G-F 20 injections as a safe and efficacious option for treatment of painful OA of the hip. Key Words: Hip; Hylan G-F 20; Osteoarthritis; Pain; Rehabilitation. Poster 9 Total Knee Replacement Delayed During 6 Years of Hylan G-F 20 Use in Orthopedic Practice. David D. Waddell, MD (Orthopedic Specialists of Louisiana, Shreveport, LA); DeWayne Bricker, PA-C, e-mail: [email protected]. Disclosure: Waddell, Consultant for Wyeth Pharmaceuticals, Research grant from Genzyme Biosurgery; Bricker, Wyeth Pharmaceuticals Speakers bureau. Objective: To determine the effect of hylan G-F 20 on current patient need for total knee replacement (TKR). Design: Retrospective review. Setting: Clinical orthopedic practice. Participants: Patients who have Kellgren-Lawrence grade IV osteoarthritis (OA) who are TKR candidates. Intervention: 1 or more courses of therapy (3 weekly intra-articular injections, 2mL) of hylan G-F 20 (Synvisc). Main Outcome Measures: Incidence of TKR and time to TKR. Logistic regression analysis to determine factors influencing time to TKR and odds of TKR. Results: TKR incidence in hylan G-F 20 –treated knees (1187 knees; 863 patients) was 19.0%. The median time to TKR in these 19.0% of patients was 1.8 years. For patients in whom a TKR had not yet occurred during the observation time, median time of hylan G-F 20 treatment and patient follow-up was 2.2 years. Survival analysis shows that TKR was delayed by 3.8 years in 75% of patients. Age was the only factor that significantly affected the time to TKR and odds of having a TKR. Conclusions: In patients who are candidates for TKR, the need for TKR can be delayed for approximately 2 years with hylan G-F 20 when used for the treatment of OA knee pain. Key Words: Hylan G-F 20; Osteoarthritis; Rehabilitation; Total knee replacement. Poster 10 Comparative Functional Outcomes for Patients With Rheumatoid Arthritis and Osteoarthritis After Joint Arthroplasty. Mabel E. Caban, MD (UTMB, Houston, TX); Tracy NguyenOghalai, MD; Kenneth J. Ottenbacher, PhD; Rashmi Maganti, MD; Carl V. Granger, MD, e-mail: [email protected]. Disclosure: None. Objective: To determine the impact of rheumatoid arthritis (RA) on functional recovery after rehabilitation for lower-extremity joint arthroplasty. Design: Retrospective cohort analysis. Setting: Large national registry of standardized information on medical rehabilitation inpatients using Uniform Data System for Medical Rehabilitation from 1994 to 2001. Participants: All adult patients admitted for rehabilitation after lower-extremity joint replacement. Interventions: Not applicable. Main Outcome Measures: Length of stay (LOS); functional status (FIM instrument) at admission, discharge, and follow-up; and death at follow-up. Results: There were 39,199 adult patients admitted to inpatient rehabilitation after knee or hip replacement. Of these, 25,973 had osteoarthritis (OA) and 1374 had RA. The univariate analyses comparing outcome between patients with RA and OA showed a lower discharge FIM (105.94⫾12.77 vs 109.98⫾9.13, P⬍.001), lower at follow-up FIM (115.02⫾12.10 vs 118.64, P⬍.001), and a longer length of stay (11.26⫾7.12 vs 10.27⫾6.50, P⬍.001) for patients with RA. Having RA was associated with lower FIM at discharge (⫺4.44, P⬍.001), lower FIM at follow-up (⫺3.73, P⬍.001), and longer LOS (.52d, P⫽.002), after adjusting for age, sex, race, number and type of joint arthroplasty, and admission FIM. However, mortality was not increased among patients with RA. Conclusions: As a group, patients with RA had worse functional outcomes than patients with OA. Key Words: Arthroplasty; Osteoarthritis; Rheumatoid arthritis; Rehabilitation.
Brain Injury Poster 11 Unusual Presentation of Aspiration Following Traumatic Brain Injury: A Case Report. Thomas R. Jackson, MD (Temple University Hospital, Philadelphia, PA); Sooja Cho, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care rehabilitation hospital. Patient: A 69-year-old man with traumatic brain injury (TBI). Case Description: The patient suffered a severe TBI following a motor vehicle accident. The hospital course included prolonged intensive care stay, critical illness neuropathy, tracheostomy, and gastrostomy feeding tube placement. At the time of transfer to the rehabilitation hospital, the patient was minimally responsive. As level of arousal improved, swallowing studies were initiated. Assessment/Results: A bedside methylene blue dye study revealed delayed aspiration. A modified barium swallow study revealed no aspiration. The differential diagnosis included gastroesophageal reflux, micro-aspiration, or gastroparesis. A gastric-emptying study showed no evidence for gastroparesis. An esophagram demonstrated possible stricture of the distal esophagus, and follow-up esophageal endoscopy confirmed early achalasia of the distal esophagus and esophageal-gastric junction. Patient was injected with 100U of botulinum toxin type A (BTX-A) to the distal esophagus under endoscopic technique. Follow-up fluoroscopic study using barium tablets revealed passage of the tablets through the esophagus to the stomach. Oral feeds were started using small, frequent meals. Prior to discharge, the patient no longer required gastrostomy tube feedings. Discussion: Aspiration is an extremely common problem in patients with severe TBI and can limit the patient to a restricted diet or tube feeding only. Animal model research has demonstrated alterations of brain-gut peptides and the effects of motility in the gastrointestinal tract following traumatic brain injury. It is extremely important to fully investigate the cause of a patient’s aspiration or apparent aspiration to promote the least restrictive diet. Conclusions: Esophageal dysmotility must be included in the differential of aspiration particularly in cases where the swallowing function appears normal. Although an uncommon cause, achalasia can lead to aspiration and may be treated with BTX-A. Key Words: Aspiration; Botulinum toxin type A; Brain injuries; Rehabilitation.
2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS
exposure or frostbite may be helpful in such cases. Physicians treating patients with cold injury should also be aware of this risk. Early intervention including rehabilitation may limit joint deformity and loss of function. Key Words: Arthritis; Frostbite; Osteoarthritis; Rehabilitation. Poster 6 An Unusual Aspiration Pneumonia Secondary to Diffuse Idiopathic Skeletal Hyperostosis: A Combined Medical and Rehabilitative Approach. Stefano Masiero (University of Padova, Padova, Italy); Raffaele Bottin; Rosario Marchese Ragona, MD; Daniela Volante; Claudio Ferraro; Marco Ortolani, e-mail: [email protected]. Disclosure: None. Setting: Outpatient rehabilitation center. Patient: An 84-year-old man presented with an 8-month history of nonsevere dysphagia that was experienced only with solid foods in a patient with diffuse idiopathic skeletal hyperostosis (DISH) or Forestier’s disease of the cervical spine. An episode of pneumonia occurred in the third and sixth months previously and the patient had been admitted to hospital and treated with antibiotics. Case Description: The patient was treated with nonsteroidal anti-inflammatory drugs (10mg aceclofenac QID, maintained for 2wk/mo), a soft diet, and rehabilitation treatment (active exercises to strengthen the swallowing musculature and effortful swallow, exercises for coordinating swallowing and breathing, for strengthening the respiratory, airflow protection maneuvers to produce safer swallowing, improve airway protection, and pharyngeal and laryngeal function, etc). Assessment/Results: At follow-up 6, 12, 18, 24, and 30 months after starting medical and rehabilitation treatment, the patient was still able to maintain an adequate oral food intake with no signs of aspiration or clinical complications. Discussion: This is the first reported case, to our knowledge, which describes a long follow-up in the dysphagia post-DISH. The dysphagia was hypothesized to be caused by mechanical compression and inflammatory changes accompanied by fibrosis in the esophagus wall. The aspiration pneumonia probably had multifactorial etiology: dysphagia, abnormal cough reflex, colonization of the oropharynx and virulent bacteria, etc. We believe that the durable improvement in our patient dysphagia is due to the combined use of medical and rehabilitation treatment. Conclusions: This case illustrates that cervical spinal abnormalities, such as Forestier’s disease, may be potentially treatable causes of aspiration pneumonia. Key Words: Aspiration pneumonia; Dysphagia; Rehabilitation. Poster 7 A Complication of an Osteoarthritis Medication or a “Rare Bird” of a Diagnosis? A Case Report. Charles J. Buttaci, DO, PT (UMDNJ-NJMS/Kessler Institute for Rehabilitation, Newark, NJ); Todd P. Stitik, MD; Lisa Schoenherr, BA, e-mail: [email protected]. Disclosure: None. Setting: University hospital–affiliated outpatient musculoskeletal physiatry practice. Patient: A 55-year-old woman with knee osteoarthritis enrolled in a phase 3 double-blinded randomized clinical trial assessing the efficacy and cardiovascular side effect profile of an investigational cyclooxygenase-2 inhibitor versus a traditional nonsteroidal anti-inflammatory drug. Case Description: The patient experienced orthopnea, dyspnea on exertion, a nonproductive cough, and lowerextremity edema approximately 3 months after randomization. The study medication was temporarily discontinued (drug holiday), and she was treated for presumed congestive heart failure (CHF) with minimal improvement. A subsequent cardiac evaluation was essentially negative. On a more thorough social history, she revealed that she had a parrot. This raised concern for psittacosis, an infection caused by the obligatory intracellular bacterium chlamydia psittaci. She was treated with moxifloxacin (fourth-generation quinolone) and improved greatly. She subsequently restarted the study medication and did not report any side effects that would suggest reoccurrence of his previous respiratory illness. Assessment/Results: The diagnosis of psittacosis was presumptively made based on symptom resolution after treatment with antibiotics, exclusion of underlying cardiovascular pathology, and absence of symptom recurrence on study medication re-exposure. This case was not an example of an anti-inflammatory–related cardiovascular side effect. Discussion: Psittacosis is a rare infectious disease whose primary site of pathology is the respiratory tract. This disease entity is capable of causing a clinical picture that can be mistaken for CHF. Conclusions: Physiatrists conducting phase 3 clinical trials need to be aware of the process by which to protect patients from potential adverse reactions while these are being investigated without ultimately inappropriately depriving them of benefit from a medication. Thorough investigation of potential adverse medication reactions is important during clinical pharmaceutical trials, as is a working knowledge of internal medicine in order to accurately determine medication side effect profiles. Key Words: Cyclooxygenase-2 inhibitors; Osteoarthritis; Psittacosis; Rehabilitation.
Poster 8 Intra-Articular Injection of Hylan G-F 20 for the Treatment of Hip Osteoarthritis. Victoria Brander, MD (Northwestern University School of Medicine, Chicago, IL); S. David Stulberg, MD; Bonny Galazka, MPH, e-mail: [email protected]. Disclosure: Brander, Research grant from Wyeth/Genzyme, Wyeth/Genzyme Speakers bureau; Other authors: None. Objective: To test the safety and efficacy of hylan G-F 20 for the treatment of hip osteoarthritis (OA). Design: Prospective, observational study. Setting: Orthopedic clinic. Participants: 90 patients with osteoarthritis of the hip who failed to get satisfactory pain relief from standard, conservative methods. Intervention: 3 weekly, fluoroscopically guided injections of 2mL of hylan G-F 20, in addition to customary care. Main Outcome Measures: Visual numeric pain score at rest, with walking, and at night and adverse events were recorded at all visits. Results: 90 hip joints with OA (51 men, 39 women; mean age, 54⫾18y). Mean pain scores at visit 1 (baseline; first injection) were: 58⫾22 at rest, 28⫾24 with walking, and 37⫾28 at night. All mean pain scores at visit 3 (14d after first injection) were significantly lower (P⬍.05) than baseline (23⫾23 at rest, 41⫾27 with walking, 27⫾27 at night). At the final follow-up visit (mean 12 weeks; range, 4 –31wk after first injection), mean pain scores were: 17⫾17 at rest (P⬍.05 vs baseline), 30⫾21 with walking (P⬍.05 vs baseline), and 25⫾26 at night. 82% of patients reported that they were satisfied or very satisfied with the results of the injections. A patient reported pain after injection at the injection site only, and 1 reported hip pain after the second injection, which resolved without treatment. No significant
Arch Phys Med Rehabil Vol 86, September 2005
episodes of increased pain or transient synovitis were observed. The only significant predictor of poor response identified was female sex. Conclusions: This study demonstrates the use of intraarticular hylan-G-F 20 injections as a safe and efficacious option for treatment of painful OA of the hip. Key Words: Hip; Hylan G-F 20; Osteoarthritis; Pain; Rehabilitation. Poster 9 Total Knee Replacement Delayed During 6 Years of Hylan G-F 20 Use in Orthopedic Practice. David D. Waddell, MD (Orthopedic Specialists of Louisiana, Shreveport, LA); DeWayne Bricker, PA-C, e-mail: [email protected]. Disclosure: Waddell, Consultant for Wyeth Pharmaceuticals, Research grant from Genzyme Biosurgery; Bricker, Wyeth Pharmaceuticals Speakers bureau. Objective: To determine the effect of hylan G-F 20 on current patient need for total knee replacement (TKR). Design: Retrospective review. Setting: Clinical orthopedic practice. Participants: Patients who have Kellgren-Lawrence grade IV osteoarthritis (OA) who are TKR candidates. Intervention: 1 or more courses of therapy (3 weekly intra-articular injections, 2mL) of hylan G-F 20 (Synvisc). Main Outcome Measures: Incidence of TKR and time to TKR. Logistic regression analysis to determine factors influencing time to TKR and odds of TKR. Results: TKR incidence in hylan G-F 20 –treated knees (1187 knees; 863 patients) was 19.0%. The median time to TKR in these 19.0% of patients was 1.8 years. For patients in whom a TKR had not yet occurred during the observation time, median time of hylan G-F 20 treatment and patient follow-up was 2.2 years. Survival analysis shows that TKR was delayed by 3.8 years in 75% of patients. Age was the only factor that significantly affected the time to TKR and odds of having a TKR. Conclusions: In patients who are candidates for TKR, the need for TKR can be delayed for approximately 2 years with hylan G-F 20 when used for the treatment of OA knee pain. Key Words: Hylan G-F 20; Osteoarthritis; Rehabilitation; Total knee replacement. Poster 10 Comparative Functional Outcomes for Patients With Rheumatoid Arthritis and Osteoarthritis After Joint Arthroplasty. Mabel E. Caban, MD (UTMB, Houston, TX); Tracy NguyenOghalai, MD; Kenneth J. Ottenbacher, PhD; Rashmi Maganti, MD; Carl V. Granger, MD, e-mail: [email protected]. Disclosure: None. Objective: To determine the impact of rheumatoid arthritis (RA) on functional recovery after rehabilitation for lower-extremity joint arthroplasty. Design: Retrospective cohort analysis. Setting: Large national registry of standardized information on medical rehabilitation inpatients using Uniform Data System for Medical Rehabilitation from 1994 to 2001. Participants: All adult patients admitted for rehabilitation after lower-extremity joint replacement. Interventions: Not applicable. Main Outcome Measures: Length of stay (LOS); functional status (FIM instrument) at admission, discharge, and follow-up; and death at follow-up. Results: There were 39,199 adult patients admitted to inpatient rehabilitation after knee or hip replacement. Of these, 25,973 had osteoarthritis (OA) and 1374 had RA. The univariate analyses comparing outcome between patients with RA and OA showed a lower discharge FIM (105.94⫾12.77 vs 109.98⫾9.13, P⬍.001), lower at follow-up FIM (115.02⫾12.10 vs 118.64, P⬍.001), and a longer length of stay (11.26⫾7.12 vs 10.27⫾6.50, P⬍.001) for patients with RA. Having RA was associated with lower FIM at discharge (⫺4.44, P⬍.001), lower FIM at follow-up (⫺3.73, P⬍.001), and longer LOS (.52d, P⫽.002), after adjusting for age, sex, race, number and type of joint arthroplasty, and admission FIM. However, mortality was not increased among patients with RA. Conclusions: As a group, patients with RA had worse functional outcomes than patients with OA. Key Words: Arthroplasty; Osteoarthritis; Rheumatoid arthritis; Rehabilitation.
Brain Injury Poster 11 Unusual Presentation of Aspiration Following Traumatic Brain Injury: A Case Report. Thomas R. Jackson, MD (Temple University Hospital, Philadelphia, PA); Sooja Cho, MD, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care rehabilitation hospital. Patient: A 69-year-old man with traumatic brain injury (TBI). Case Description: The patient suffered a severe TBI following a motor vehicle accident. The hospital course included prolonged intensive care stay, critical illness neuropathy, tracheostomy, and gastrostomy feeding tube placement. At the time of transfer to the rehabilitation hospital, the patient was minimally responsive. As level of arousal improved, swallowing studies were initiated. Assessment/Results: A bedside methylene blue dye study revealed delayed aspiration. A modified barium swallow study revealed no aspiration. The differential diagnosis included gastroesophageal reflux, micro-aspiration, or gastroparesis. A gastric-emptying study showed no evidence for gastroparesis. An esophagram demonstrated possible stricture of the distal esophagus, and follow-up esophageal endoscopy confirmed early achalasia of the distal esophagus and esophageal-gastric junction. Patient was injected with 100U of botulinum toxin type A (BTX-A) to the distal esophagus under endoscopic technique. Follow-up fluoroscopic study using barium tablets revealed passage of the tablets through the esophagus to the stomach. Oral feeds were started using small, frequent meals. Prior to discharge, the patient no longer required gastrostomy tube feedings. Discussion: Aspiration is an extremely common problem in patients with severe TBI and can limit the patient to a restricted diet or tube feeding only. Animal model research has demonstrated alterations of brain-gut peptides and the effects of motility in the gastrointestinal tract following traumatic brain injury. It is extremely important to fully investigate the cause of a patient’s aspiration or apparent aspiration to promote the least restrictive diet. Conclusions: Esophageal dysmotility must be included in the differential of aspiration particularly in cases where the swallowing function appears normal. Although an uncommon cause, achalasia can lead to aspiration and may be treated with BTX-A. Key Words: Aspiration; Botulinum toxin type A; Brain injuries; Rehabilitation.