Adrian Cristian

Blast-related mild traumatic brain injury: mechanisms of injury and impact on clinical care.

Mild traumatic brain injury has been called the signature injury of the wars in Iraq and Afghanistan. In both theaters of operation, traumatic brain injury has been a significant cause of mortality and morbidity, with blast-related injury the most common cause. Improvised explosive devices have been the major cause of blast injuries. It is estimated that 10% to 20% of veterans returning from these operations have suffered a traumatic brain injury, and there is concern that blast-related injury may produce adverse long-term health affects and affect the resilience and in-theater performance of troops. Blast-related injury occurs through several mechanisms related to the nature of the blast overpressure wave itself as well as secondary and tertiary injuries. Animal studies clearly show that blast overpressure waves are transmitted to the brain and can cause changes that neuropathologically are most similar to diffuse axonal injury. One striking feature of the mild traumatic brain injury cases being seen in veterans of the wars in Iraq and Afghanistan is the high association of mild traumatic brain injury with posttraumatic stress disorder. The overlap in symptoms between the disorders has made distinguishing them clinically challenging. The high rates of mild traumatic brain injury and posttraumatic stress disorder in the current operations are of significant concern for the long-term health of US veterans with associated economic implications.

Blast-induced Mild Traumatic Brain Injury

Traumatic brain injury (TBI) has been a major cause of mortality and morbidity in the wars in Iraq and Afghanistan. Blast exposure has been the most common cause of TBI, occurring through multiple mechanisms. What is less clear is whether the primary blast wave causes brain damage through mechanisms that are distinct from those common in civilian TBI and whether multiple exposures to low-level blast can lead to long-term sequelae. Complicating TBI in soldiers is the high prevalence of posttraumatic stress disorder. At present, the relationship is unclear. Resolution of these issues will affect both treatment strategies and strategies for the protection of troops in the field.

Evaluation of acupuncture in the treatment of Parkinson's disease: a double-blind pilot study.

As many as 40% of patients with Parkinsons disease (PD) use some form of complementary medicine during the course of their illness, and many try acupuncture. One nonblinded study of the effects of acupuncture in PD suggested that it might be helpful for some aspects of PD. We performed a double‐blind, randomized, pilot study comparing acupuncture to a control nonacupuncture procedure to determine the effects of acupuncture upon a variety of PD‐associated symptoms. Fourteen patients with Stage II or III PD received acupuncture or a control nonacupuncture protocol. Before and after treatment, patients were evaluated using the Motor subscale of the Unified Parkinsons Disease Rating Scale (UPDRS), the Parkinsons Disease Questionnaire (PDQ‐39), and the Geriatric Depression Scale. There were no statistically significant changes for the outcomes measured. In the patients who received acupuncture, nonsignificant trends toward improvement were noted in the Activities of Daily Living score of the PDQ‐39, the PDQ‐39 Summary Index, and the Motor subscale of the UPDRS.

Role of Rehabilitation Medicine in the Management of Pain in Older Adults

Pain management may play an important role in contributing to optimal quality of life in the elderly population. Pain lowers overall quality of life in part by decreasing function and by amplifying the psychologicic stress of aging. A comprehensive, multidisciplinary approach to pain management, with preservation and restoration of function in older adults, is the cornerstone of an effective pain management program.

Poster 340 Analysis of Neurosurgical Patients Acutely Discharged (AD) vs Non-Acutely Discharged (NAD) from an Inpatient Rehabilitation Facility (IRF).

abductor pollicis brevis, and 1st dorsal interosseous. Electromyogram (EMG) of adductor digiti mini (ADM) and pronator teres were within normal limits. NCS was repeated two months later: median motor and sensory showed prolonged latencies and decreased amplitude. Motor responses were obtained at the first dorsal interosseous and ADM by stimulating both the median and ulnar nerves at the wrist. There was evidence of median neuropathy across the wrist as well as a neuropathy affecting the deep terminal ulnar branch distal to the innervation of the hypothenar muscles. Furthermore, this patient demonstrated an anastomosis present in the palm between the median nerve and deep ulnar branch proximal to the hypothenar branch as evidenced by motor response at the ADM when stimulating the median nerve. Discussion: Isolated deep ulnar branch lesions are rare. To our knowledge there is no published literature regarding isolated lesions of the deep ulnar branch and the median nerve along with a palmar median to ulnar anastomosis. Conclusions: Isolated lesions of the deep ulnar branch and rare anastomosis should be considered as potential etiology in complicated cases of hand weakness and numbness. Level of Evidence: Level V

Identification of the most frequent injuries in a variety of fencing competitors: A cross sectional study of fencing clubs in the Northeast tri-state region

Objective: To identify the most common fencing injuries in variety of competitors. Design: Retrospective cohort study. Setting: Athletic fencing clubs in the Tri-State Area. Participants: A total of 115 fencing athletes were provided a survey questionnaire after signing informed consent form (or by parent or guardian for fencers under 18 years old). These athletes included minors as well as adults of different age groups and different levels of training. Interventions: A survey was conducted at several Athletic Clubs in the Tri-State area with fencing athletes in order to identify: the most common fencing injuries in different levels of competitors, most common weapon used and whether injury is consistent with competitors age. Main Outcome measures: Fencing Survey Results: From 115 survey participants, sixty-two participants considered themselves to be experts, 41 considered themselves to be at an intermediate level, and 12 participants were beginners. Ninety-seven participants reported experiencing pain as a result of injury. Mild injuries suffered: 21 knee, 15 wrist, 14 ankle, 13 elbow, 11 foot, 10 lower back, 10 shoulder, 6 neck, 2 hip, 2 hamstring, 1 heel. Moderate injuries suffered: 25 knee 18 ankle, 11 foot, 10 wrist, 10 elbow, 10 lower back, 9 shoulder, 5 hands, 4 hip, 4 neck, 2 hamstring. Severe injuries suffered: 9 knee, 8 lower back, 7 ankle, 5 elbow, 5 shoulder, 2 foot, 2 wrist, 2 hip, 1 hands, 1 hamstring. From the participants 58-seeked treatment vs. 45 who did not. From participants who seeked treatment 45 were from Medical Doctor, 25 were from coach, 13 were self-treated, 3 were by chiropractor, 2 were by trainer and 2 were by physical therapist or in varied combinations. Only 20 participants notified their parents and 64 were educated about their injuries. Out of the participants that received some sort of injury 41 had a setback at practice time or competition and 51 had a reoccurrence of their injury. Conclusions: From 115 participants that participated in the fencing survey the most common injuries whether it was mild, moderate or severe were knee injuries across all 3 categories, followed closely by ankle and elbow. Treatment from medical doctors seemed to be the predominant choice by participants, although a large part of competitors had reoccurrence of injury. Further study will need to focus on what strategies and training are recommended in the prevention of these injuries. Correspondence to: Kirill Alekseyev, Department of Rehabilitation Medicine, Kingsbrook Rehabilitation Institute, Kingsbrook Jewish Medical Center, 585 Schenectady Avenue, Brooklyn, NY 11203, USA, Tel: 1(917)379-8964; E-mail: kirill.alekseyev@gmail.com Received: August 01, 2016; Accepted: August 19, 2016; Published: August 23, 2016 Introduction The goal of this retrospective cohort study is to determine the most common injuries suffered by various fencing competitors in order to establish future preventative measures and treatment modalities. Historically, fencing shifted from being used as military training to a competitive sport in the mid-eighteenth century. In 1896 it had been admitted as an open-skilled combat sport to the first modern Olympics held in Athens [1]. In the modern era fencing is one of only four sports to have been included in every Olympiad [2]. The sport is played between two individuals who attempt to score points by having their weapon contact the opponent’s target area. An international tournament usually lasts between 9-11 hours, but the effective fighting time between two individual opponents is anywhere from 17 to 48 minutes long. There are three weapons utilized in modern fencing: foil, epee, and sabre. The foil is a light-thrusting weapon with a flexible blade. When athletes use the foil, they may only target the torso, back of neck, and groin. The athlete receives a point only when he or she hits “on target,” the body regions mentioned above. The epee is also a thrusting weapon but notably heavier and stiffer compared to the foil. Of distinction, the athlete may target the opponent’s entire body. The last weapon, the sabre, a light cutting and thrusting weapon, targets the entire body above the waist. Since the sabre is a cutting weapon, athletes can score with the edge of their blade as well as their point. The game is simple conceptually in that the athlete who makes contact with the target area is awarded the point; however, if athletes strike each other simultaneously, the referee uses the “right of way” Alekseyev K (2016) Identification of the most frequent injuries in a variety of fencing competitors: A cross sectional study of fencing clubs in the Northeast tri-state region Volume 1(3): 52-55 Phys Med Rehabil Res, 2016 doi: 10.15761/PMRR.1000115 rule, in that the point is awarded to whomever began the attack first. At the Olympics, there are 3 three minute matches during which the winner is the first athlete to score 15 points or whomever has the most points after the entire 3 rounds. Athletes are required to wear protective attire in order to reduce the chance of being injured. These include a mask, helmet that covers the entire head, and a strong mesh on the torso. In addition, athletes wear a fencing jacket, pads, and glove on the weapon hand. With the advancement of protective gear, traumatic acute injury, such as lacerations and punctures are extremely rare. Despite these preventative measures, injuries do occur, though more commonly they are of a chronic nature. Fencing is an asymmetrical sport in terms of utilizing the upper limb. Fencing produces typical functional asymmetries that emphasize the very high level of specific function, strength, and control required in the sport [1]. It involves rapid lunges and retreats, causing increased strain on the legs and as a result, the lower extremity was the most frequent location for fencing injuries. Rapid change of direction and strong lunging place the knee and ankle at risk for injury [2]. The athlete undergoes lengthy periods of extension and quick movements of the weapon using the arm, wrist, and hand. Therefore, some of the most common injuries suffered include overuse injuries, such as sprains and strains, similar to other sports involving rapid change of direction. Traumatic injuries are less common in the sport of fencing, as are time-loss injuries. However, the reports of fencing injuries are scarce in the literature and epidemiological large-scale studies are lacking [1]. Despite a lack of large-scale evidence, it has been found that the majority of fencing injuries include blisters, contusions, and abrasions [2]. In addition tendinopathies and tendon tears, secondary to overuse, are relatively common amongst fencers. However, non-contact injuries, such as ligamentous and muscular strains are the predominant form of injury. Overall, the data indicates that fencing injuries tend to be minor, whether surface trauma (abrasions, contusions) or musculoskeletal damage (sprains, strains), which is expected in any activity with rapid change of direction [2]. Fencing was also found to have one of the lowest rates of timeloss. Athletes were found to be able to return to normal functions and activities rather quickly post-injury. It has been found to be one of the safest sports. Despite this, some fencing athletes do experience reoccurrence of injury, which can be problematic to future performance.

Poster 190 The Warm Hand-Off: Changing the Culture of a Patient Being “Discharged” to Rehab

resident evaluation (62%1⁄4excellent, 37%1⁄4good); a new skill/ patient management approach was learned (50%1⁄4strongly agree; 50%1⁄4agree). Discussion: Tracheostomy management is an essential skill for the practicing physiatrist especially those involved in the care of patients with brain injury, spinal cord injury and stroke. PM&R residents are likely to encounter clinical situations that require re-insertion of tracheostomy tubes in the acute rehabilitation setting. Conclusion: Accidental tracheostomy decannulation is a condition that may be encountered in an acute rehabilitation setting. It is imperative that rehabilitation care providers, such as PM&R residents, who care for patients with tracheostomies be knowledgeable on how to assess and manage this medical emergency to ensure patient safety.

Characterization and Description of Pain Syndromes in a West Indian/Caribbean Population Receiving Rehabilitation Care in an Urban U.S. Setting

Objective: The selection of appropriate candidates for spinal injections remains a challenge particularly for axial low back pain. Our hypotheses are firstly that there will be a correlation between the change in a patient’s subjective pain following either a lumbar epidural steroid injection (ESI) or medial branch block (MBB) which will correlate to the changes in biomarkers of pain (Neuropeptide Y (NPY)) and inflammation (RANTES). Secondly baseline levels of these biomarkers will be predictive of responders to these treatments. Design: Non-randomized prospective study. Setting: Interventional pain clinic in a tertiary referral center. Participants: 19 subjects with axial low back pain, without leg pain who underwent either an epidural steroid injection or medial branch block injection. Interventions: Patients underwent either an ESI or MBB procedure for axial low back pain. The choice of procedure for each patient was made by the physician and not influenced by the study. All research procedures were approved by institutional IRB. Main Outcome Measures: Visual Analog Scale (VAS) pain scores were taken pre-injection, immediately post-injection and at a follow-up visit 1-week later. Serum levels of NPY and RANTES were measured pre-injection and at the 1-week followup visit. Results or Clinical Course: In patients who underwent an ESI, the change in NPY levels between pre-injection and at the 1 week follow-up visit had a strong correlation with the change in pain score (r1⁄40.652, p<.05). In addition, in patients who underwent an MBB, their immediate post-injection pain score had a strong correlation to the levels of NPY at the follow-up visit 1 week later (r1⁄40.770, p<.05). Although not a significant finding, patients who had lower levels of RANTES at baseline, had a higher likelihood to respond to the treatments i.e. had a reduction in their pain score following an MBB (r1⁄40.802 p1⁄4.102) or ESI (r1⁄40.743, p1⁄4.091). Conclusions: The levels of NPY, a pain biomarker in the serum following an ESI or MBB correlated with changes in subjective pain score of the patients and may provide insight into disease mechanisms. The measurement of an inflammatory marker, RANTES has potential in predicting who would benefit from these procedures and deciding which intervention would best match the patient’s particular pathology.

Poster 119 Sensorimotor Peripheral Neuropathy of Bilateral Lower Extremities and Pudendal Nerve: A Case Report

distal latency with preserved distal amplitude and mild partial sensory conduction block at the wrist. 2. Right median thenar CMAP was reduced in amplitude with initial positive deflection; normal amplitude was restored with stimulation over the ulnar nerve. Median CMAP at lumbrical II was mildly delayed with borderline decreased amplitude. 3. Needle EMG examination of the right APB was normal. Impression: 1. Mild to moderate right median neuropathy at the wrist (carpal tunnel syndrome). 2. Right Riche-Cannieu anastomosis. Discussion: Riche-Cannieu anastomosis is a common neuroanatomical variant involving a deep ulnar motor-to-recurrent median branch anastomosis. The “all ulnar hand“ may initially appear on nerve conduction studies to resemble a severe median neuropathy. This misdiagnosis may lead to unnecessary surgical intervention. Conclusions: Riche-Cannieu anastomosis should be included in the differential when median thenar CMAP is severely reduced in the setting of well-preserved thenar musculature.

Poster 276 The Role of Rehabilitation in Improving Hypotonia, Truncal Stability and Motor Functional Skills in a Patient With Joubert Syndrome: A Case Report

Results or Clinical Course: At the TCH he was given baclofen, diazepam, and fentanyl; however, his dystonia progressed to include extreme trunk extension posturing and possible laryngospasms with secondary decline in respiratory function. He was electively intubated and transferred to the ICU for status dystonicus. Toxin screens and brain MRI were negative. He had minimal relief with tizanidine, risperdone, trihexyphenidyl, lidocaine infusion, or dexmedetomidine. A deep brain stimulator (DBS) was eventually placed at the globus pallidus pars interna with significant improvement. Genetic testing and levadopa trials were negative, and he was subsequently diagnosed with idiopathic early onset primary dystonia. Discussion: Early onset dystonia can present as focal dystonia with possible subsequent progression to a more generalized form. Progression may result in extreme posturing and laryngospasms with secondary compromise of the airway. Dystonia is the sole clinical sign with an absence of other disease or exogenous cause and onset before age 20-30 years. In the sports setting, this may be confused with muscle cramping or tremor. Initial treatment is with oral anti-spasmodics, with refractory cases treated with intrathecal baclofen, botulinum toxin chemodenervation, or DBS. Treatment by DBS restricts the athlete from contact sports. Conclusions: Sports Medicine physicians need to be aware of early onset primary dystonia, the signs of generalization, and the possibility of airway compromise.