- Email: [email protected]
Poster 90
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.
E21
(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
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.
E21
(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