Agnes Wallbom

Paraspinal electromyography that compares concentric with monopolar needles: A blinded study

Tong HC, Young IA, Koch J, Haig AJ, Yamakawa KSJ, Wallbom A: Paraspinal electromyography that compares concentric with monopolar needles: A blinded study. Am J Phys Med Rehabil 2003;82:917–924. ObjectiveTo establish interrater reliability for paraspinal muscle needle electromyography study with both monopolar and concentric needles in symptomatic and asymptomatic persons and to further establish normative data for paraspinal needle study. DesignAt a university spine center, participants with and without radiating low back pain were evaluated with the mini–paraspinal mapping paraspinal needle technique by an unblinded and a blinded electromyographer. ResultsIn the symptomatic group, the intraclass correlation coefficient between concentric and monopolar needles was 0.793; between monopolar needles, it was 0.876; and between concentric needles, it was 0.966. In the asymptomatic group, the mean total score was 0.25. ConclusionsThe good interrater reliability with the same needle type helps support the validity of the needle electromyography study of the paraspinal muscles. The good correlation between the concentric and monopolar needles shows the data published using monopolar needle data also apply to studies using paraspinal needle electromyography with concentric needles. The low score with the asymptomatic group reaffirms that using a cutoff score of >2 as abnormal has a false-positive rate of <5%.

Lumbar flexion and dynamic EMG among persons with single level disk herniation pre- and postsurgery with radicular low-back pain.

Wallbom AS, Geisser ME, Koch J, Haig AJ, Guido C, Hoff JT: Lumbar flexion and dynamic EMG among persons with single level disk herniation pre- and postsurgery with radicular low-back pain. Am J Phys Med Rehabil 2009;88:302–307. Objective:The paraspinal muscles often fail to relax on forward flexion in many persons with low-back pain. The goal of this prospective study was to determine whether this abnormal lack of a flexion-relaxation phenomenon corrects after lumbar diskectomy for symptoms of radiculopathy with low-back pain. Design:Electromyographic testing was performed on 17 patients before and 30 days after lumbar diskectomy. Results:Although pain improved significantly (P < 0.05), the flexion-relaxation phenomenon did not improve. Conclusions:Failure to recover muscle relaxation while pain is relieved suggests another mechanism for paraspinal activity.

Interactive teaching, medical students, and substance abuse university and community come together in a new endeavor

The authors present an innovative approach for providing freshman and sophomore medical students with their initial exposure to the problems of alcohol and other drug abuse. Students in small interactive group seminars teach each other about the major areas of substance abuse: treatment, prevention/education, research, and law enforcement. They are aided by group moderators, by resource professionals, and by recovery teachers as they make field trips, attend 12-step meetings, and get background material. They utilize audiovisuals, role-plays, and programmed patients in a report/debate format. Effects of this seminar on their attitudes have been measured and are presented.

False-Negative Triple-Phase Bone Scans in Spinal Cord Injury to Detect Clinically Suspect Heterotopic Ossification: A Case Series

Abstract Background/Objective: Heterotopic ossification (HO) is a complication seen in patients after spinal cord injury (SCI). Triple-phase nuclear bone scanning is the most sensitive test for the detection of HO. This retrospective study assesses whether patients with clinically suspected HO but negative triple-phase nuclear bone scans develop delayed positive nuclear bone scans. Methods: Case series: A cohort of patients with SCI and clinically suspected HO who underwent triple phase nuclear bone scans over a period of 2 years was identified from retrospective chart review of an acute inpatient SCI rehabilitation service. A subgroup of 7 patients with initially negative but subsequently positive triple-phase nuclear bone scans was identified, and the following data were collected: date, mechanism, admission level, and admission completeness of injury as well as date, number, and results of bone scans. Laboratory studies were also collected during the time of imaging. Results: Over a 2-year period, 343 patients were admitted to the SCI rehabilitation service; 60 patients were suspected of having HO and underwent a total of 85 triple-phase nuclear bone scans. Seven patients were identified with initially negative but subsequently positive bone scans. Conclusions: In patients with clinically suspicious HO but negative bone scans, follow-up scans are indicated to identify initial false-negative studies.

Alterations of F wave parameters after exercise in symptomatic lumbar spinal stenosis.

Wallbom AS, Geisser ME, Haig AJ, Koch J, Guido C: Alterations of F wave parameters after exercise in symptomatic lumbar spinal stenosis. Am J Phys Med Rehabil 2008;87:270–274. Objectives:The purpose of the study is to investigate changes in F wave parameters after exercise in subjects with symptomatic lumbar spinal stenosis. Design:A total of 19 older patients with lumbar spinal stenosis and neurogenic claudication participated in this cohort study. No one withdrew for adverse effects. All subjects underwent physical therapy, with half performing additional interval-walking exercises. Groups were treated for eight sessions, returning for follow-up at weeks 4 and 8. Changes in F wave indices—minimal latency, chronodispersion, and persistence—were calculated. The treatment group demonstrated worsening of F wave persistence at 8-wk follow-up (P < 0.01). Conclusions:F wave indices worsened after an interval-walking exercise program. Subjects in the treatment group demonstrated worsening of F wave persistence at 8-wk follow-up.

Poster 413 A Case Study Investigating Opioid Medication Utilization in Patients with Complex Regional Pain Syndrome Before and After Ketamine Infusion Therapy

Disclosures: Sheena Aurora: Consulting fees or other remuneration (payment) Allergan, eNeura, Merck, Teva, Speakers bureau Allergan Objective: To evaluate the effect of onabotulinumtoxinA on headache-day severity in patients with chronic migraine (CM). Design: Two multicenter, phase 3, double-blind, parallel-group, placebo-controlled, 24-week studies. Setting: 122 global sites from the PREEMPT (Phase 3 Research Evaluating Migraine Prophylaxis Therapy) Study. Participants: Participants had a history of migraine and met International Classification of Headache Disorders (2nd edition) migraine diagnostic criteria, with headaches 15 days/month. Interventions: OnabotulinumtoxinA (155 U e 195 U) or placebo every 12 weeks for 2 treatment cycles. Main Outcome Measures: Headache-day severity was assessed at baseline and 24 weeks. Treatment responders were defined as those achieving 1-grade improvement in average daily headache severity (ADHS) score at week 24 compared with baseline. Results: 1384 patients received onabotulinumtoxinA (n1⁄4688) or placebo (n1⁄4696). At baseline, the percentage of severe + moderate headache days was 37.3% + 27.3% in the onabotulinumtoxinA group and 37.0% + 27.3% in the placebo group (P1⁄4.58 and P1⁄4.97 for severe and moderate days, respectively). At week 24, the proportion of patients with severe + moderate headache days was significantly lower for onabotulinumtoxinA (21.3% + 15.6%) compared with placebo (26.3% + 17.3%; P<.001 for both comparisons). OnabotulinumtoxinA produced a significant decrease in the number of severe headache days per 28-day period at week 24 (onabotulinumtoxinA, e4.5; placebo, e3.0; P<.001). Responder analyses indicated that significantly more patients receiving onabotulinumtoxinA than placebo demonstrated 1-grade improvement from baseline in ADHS score (35.8% vs 23.1%, P<.001) at week 24. Conclusions: Among patients with CM, use of onabotulinumtoxinA significantly reduced the number of severe and moderate headache days. In conjunction, significantly more patients treated with onabotulinumtoxinA had 1-grade improvements in ADHS scores compared with placebo. This is consistent with previously reported benefit of onabotulinumtoxinA in reducing daily headache severity in patients with CM. Level of Evidence: Level I

Poster 393 C5 Palsy After Cervical Laminectomy and Fusion: 2 Case Reports

Disclosures: Alexander Tucker: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Proximal upper extremity weakness is a poorly understood complication of cervical spine surgery. The cause of this complication is unknown, although most patients recover completely over weeks to months with conservative treatment. We present two cases of postoperative, transient C5 palsy after laminectomy and fusion. Electrodiagnostic (EDX) studies performed after surgery revealed active denervation of the deltoid and biceps muscles on the symptomatic side, however the rhomboid muscles appeared unaffected. Setting: Tertiary care hospital. Results: By 6 months postoperatively, both patients had clinically improved strength in all previously affected muscle groups. We suggest that the current models of postoperative C5 palsy pathogenesis may be inadequate to explain our findings and propose an alternative theory of watershed ischemia distal to the origin of the dorsal scapular nerve as a contributing factor to the etiology of this surgical complication. Discussion: The cases described above illustrate postoperative C5 palsy, a notorious and under-recognized complication of cervical decompressive surgery, that was diagnosed clinically and correlated with EDX evidence. This description is the first to present the results of preoperative and postoperative electrophysiological studies; confirming deltoid and biceps weakness with rhomboid sparing. Conclusions: Serial EDX studies, as were performed on the patients presented here, may be used to assist with diagnosis, confirmation of involved root levels, prognostication, to follow recovery or to offer clues into the pathophysiology of the condition. Level of Evidence: Level V

Poster 24 Age Matched Control Subjects for Comparison in the Evaluation of Balance Dysfunction: A Case Series

were unsuccessful. Symptoms had persisted for 41 days when an intrathecal baclofen trial was performed. The initial bolus 50 mcg flush trial resulted in temporary improvement in hypertension and agitation. A second trial was performed wherein an intrathecal catheter was externalized and infusion of baclofen solution was titrated. Setting: Tertiary care pediatric hospital and inpatient rehabilitation center. Results or Clinical Course: After reaching a rate of 550 mcg/ day, the symptoms of hyperhidrosis, agitation, hypertension, and fever improved. Intrathecal baclofen pump was implanted. Less spasticity was present by day 5 post-implantation at a rate of 150 mcg/day, choreaform dystonia improved by day 6 at 249.76 mcg/ mL, and vital signs normalized after 2 weeks of treatment at 349.85 mcg/day. Patient had a GCS of 10T during implantation of the pump. She was discharged from acute hospital being dependent for all care. She underwent inpatient rehabilitation for 8 weeks and was discharged ambulating 20 feet with Swedish walker with 2 moderate to maximal assistance and is set-up for feeding. Discussion: There are only a few reported cases on the use of continuous intrathecal baclofen pump in acquired brain injury. There is also limited literature on its effect on the muscle tone, spasticity, and remaining functional strength in the upper extremities. Our study reports on the use of intrathecal baclofen in an adolescent brain injury patient in facilitating improvement in motor function of upper and lower limbs. Conclusions: Intrathecal baclofen facilitates recovery in motor function, thus improving quality of life in brain injury patients.

Poster 23: Balance Dysfunction in Operation Enduring Freedom/Operation Iraqi Freedom Veterans With Mild Traumatic Brain Injury: A Case Series

Disclosures: A. E. Gallagher, None. Patients or Programs: Hemicraniectomy patients are not often seen in acute rehabilitation due to limited postoperative functional status. Their postoperative course is often complicated by infection, hydrocephalus, and seizure. This case series evaluates functional gains made post-hemicraniectomy. Program Description: Three hemicraniectomy patients were evaluated. Patient 1 is a 23-year-old man status post allogenic bone marrow transplant, who developed an intracranial hemorrhage requiring a hemicraniectomy due to an uncal herniation. Patient 2 is a 67-year-old man who underwent a burr hole evacuation complicated by empyema, necessitating a craniotomy with unsuccessful debridement, and ultimately requiring a hemicraniectomy. Patient 3 is a 39year-old man who underwent a hemicraniectomy for cerebral edema after an MCA embolic stroke. These patients initially needed total to minimal assistance for bed mobility. Setting: Cases were cared for at a tertiary care center. Results: With acute rehabilitation, each patient made functional gains with improvements in FIM scores of 1-2 points, depending on their initial functional status. Patient 1 ambulated 50 feet with maximum assistance using a prone walker. Patient 2 ambulated 15 feet with hand-held assistance. Patient 3 was able to tolerate standing for 5 minutes. Discussion: Diagnoses requiring hemicraniectomy significantly impact patients’ functional abilities. Proper precautions must be taken when such patients engage in physical and occupational therapy. Syndrome of the trephined is a complication that should be avoided by wearing a helmet. Although some functional gains were lost after cranioplasty, losses were regained, along with further improvement after bone flap placement. Conclusions: Functional gains in hemicraniectomy patients during acute neurorehabilitation can be similar to the functional gains in post-stroke and TBI patients. Therefore, hemicraniectomy patients should qualify for acute rehabilitation, as they can equally benefit from intensive therapy to improve their quality of life and to achieve their goal of going home. Rehabilitation goals and parameters for hemicraniectomy patients may also be incorporated into the rehabilitation of soldiers returning from duty, who have sustained severe blast injuries affecting the brain.