Chong Tae Kim

Pediatric rehabilitation: 1. Common medical conditions in children with disabilities.

This self‐directed learning module focuses on the physiatric management of the common morbidities associated with pediatric traumatic brain injury and cerebral palsy. It is part of the study guide on pediatric rehabilitation in the Self‐Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to enhance the learners knowledge regarding current physiatric management of complications related with pediatric traumatic brain injury and cerebral palsy.

Pediatric Rehabilitation: 5. Transitioning Teens With Disabilities Into Adulthood

This self‐directed learning module focuses on preparing adolescent patients with special health care needs for adulthood by promoting their independence in their own self‐care; helping them to navigate issues of sexuality, marriage, and parenting; preparing the patient and family to make guardianship decisions during the transition between childhood and adulthood; and planning for higher education or vocation. Emphasis will be on the role of the physiatrist in providing this guidance and its importance in improving the patients quality of life. It is part of the study guide on pediatric rehabilitation in the Self‐Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to refine the learners knowledge of preparing adolescent patients with special health care needs for adulthood to improve their quality of life.

Pediatric Rehabilitation: 3. Facilitating Family-Centered Treatment Decisions

This self‐directed learning module focuses on the role of accurate diagnosis, psychological support, and family integration of children who have chronic impairments such as pain, spasticity, or cognitive disability. It is part of the study guide on pediatric rehabiliation in the Self‐Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The role of therapeutic, medical (traditional and nontraditional) and psychological interventions that improve family and individual function are emphasized. The goal of this article is to refine a learners knowledge of the impact family‐centered care can have on the medical, psychological, financial, and functional capabilities of families to improve treatment decisions in the context of children with disability.

Pediatric rehabilitation: Trends in length of stay

Length of stay (LOS) is one of the most important pieces of data used to measure clinical rehabilitation outcomes, but there is a paucity of LOS data regarding pediatric acute rehabilitation. The purpose of this study was to predict LOS based on admission diagnosis to an acute pediatric inpatient rehabilitation unit. The hypothesis was that LOS will vary according to admission diagnosis. One thousand one hundred forty-five patients were admitted to our acute inpatient rehabilitation unit from January 1, 2000 to December 31, 2007. Common admission impairment groups were orthopedic conditions (29.3%), brain injury (17.9%), brain tumor (7.9%), pain syndrome (7.5%), complex medical conditions (7.4%), stroke (7.2%), meningoencephalitis (7.2%), and spinal cord injury (4.4%). The distribution of LOS data was significantly skewed to the right (for example, mean 40.6 days and median 26 days, respectively, in brain injury group). The median LOS of patients admitted with orthopedic conditions was the shortest (13 days), compared to patients admitted with spinal cord lesions, which was the longest (32 days). Logarithm-transformed mean LOS was different among the admission impairment groups (F=28.7, p < 0.01). However Tukeys Honestly Significance Difference test further showed that: 1) LOS data was not always statistically different across admission impairment groups, and 2) LOS of patients with orthopedic conditions and spinal cord lesions was the shortest and longest, respectively, compared to other admission impairment groups. No proportional decrease in median LOS was observed across the impairment groups from 2000 to 2007. LOS for pediatric acute inpatient rehabilitation varied according to admission diagnosis. When considering future comprehensive pediatric rehabilitation outcome studies, focusing on a uniform impairment group is suggested. In addition, attention to other factors such as functional status changes, severity of illness, payment types, and psychosocioeconomic status should be considered.

Pediatric rehabilitation: 4. Prescribing assistive technology to promote community integration.

This self‐directed learning module highlights the equipment and assistive technology needs of children and youth with disabilities. This article specifically focuses on preparing families and patients for equipment transitions that occur over the course of childhood and adolescence including progressing from stroller to wheelchair to powerchair, as well as job training and use of augmentative communication. It is part of the study guide on pediatric rehabilitation in the Self‐Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to modify the learners current practice techniques to ensure that assistive technology is used to promote community integration from early childhood through transition and into adulthood.

Pneumatosis intestinalis (PI) following severe traumatic brain injury

Primary objective: To report a case of pneumatosis intestinalis complicated with sorbitol containing medicines. Research design: Case report. Methods and procedures: Clinical course and literature review. Experimental interventions: Chart review. Main outcomes and results: Large amount of sorbital may cause a reversible gastrointestinal complication, pneumatosis intestinalis. Conclusions: In the assessment of enteral abnormalities, all components of medications, active and ‘inactive’, must be evaluated as possible aetiological factors of pneumatosis intestinalis.

Poster 482 Botulinum Toxin A Injections for Drooling Management in Children.

Disclosures: Chong Tae Kim: I Have No Relevant Financial Relationships To Disclose Objective: To evaluate safety and effectiveness of botulinum toxin A for drooling management in children. Design: Retrospective clinical review. Setting: Academic Children’s hospital, inpatient and outpatient clinic. Participants: 154 cases (81 subjects, age: 2 276 months, M:F 1⁄4 107:47). Interventions: Botulinum toxin A was injected to the bilateral parotid and submandibular glands under ultrasound guidance. Drooling was assessed by Visual Analog Scales (VAS, 1-100) and Teacher Drooling Scale (TDS, 5 grades) pre-injection and 3-5 weeks after injections. Adverse effects were reviewed. Main Outcome Measures: Outcomes were classified as nonsignificant (less than 20 point change in VAS or 0-1 grade change in TDS), good (20-39 point change in VAS or 2 grade change in TDS), and excellent more than 40 point change in VAS or 3-4 grade change in TDS). Results: A total of 123 cases (80%) reported satisfactory improvement of drooling (59 good and 64 excellent). The good and excellent outcomes were more significantly found in males (Chisquare, P 1⁄4 .046), the subjects without tracheostomy vs with tracheostomy (Chi-square, P 1⁄4 .042), and those with enteral feeding tubes vs without (Chi-square, P 1⁄4 .0001). Botulinum toxin A injection doses (unit/kg) did not affect the outcome (ANOVA, F 1⁄42.133, P 1⁄4 .122). Age, baclofen, and any oral anticholinergic agents did not affect the outcome. No significant adverse effects were reported. Conclusions: Botulinum toxin A injection to the bilateral parotid and submandibular glands under ultrasound guidance is a safe and effective way to manage drooling in children, however, it seems to be less effective in children with tracheostomy and enteral feeding tube. Level of Evidence: Level II

Isolated Injury of Femoral and Lateral Femoral Cutaneous Nerves

Program Description: He began having neck pain after lifting and moving large boxes. On our evaluation, he reported anterior and posterior shoulder pain and weakness. Physical examination was notable for medial deviation of the inferior border of the right scapula. Setting: Electrodiagnostic clinic at a veterans hospital in an urban setting Results or Clinical Course: Needle electromyography of the rhomboid major muscle on the right demonstrated increased spontaneous activity, large motor unit action potentials and a decreased recruitment pattern. Based on the electrophysiologic findings, he was diagnosed with chronic and ongoing dorsal scapular mononeuropathy as the cause of winged scapula. Discussion: Scapular winging is a fairly uncommon disorder. Patients can complain of shoulder and upper arm pain. A less common cause of a winged scapula is dorsal scapular nerve injury resulting in rhomboid muscle weakness. The lesion has been shown to be due to hypertrophic middle scalene muscle or traction injury of the C5 nerve root associated with heavy lifting or highimpact trauma such as motor vehicle accidents. Our case was unique in that the winged scapula was caused by dorsal scapular nerve injury. Conclusions: Winging of the scapula can present as shoulder pain and weakness due to dorsal scapular mononeuropathy in the setting of heavy lifting.

Poster 71 Belatedly Diagnosed Acute Motor Axonal Neuropathy After Cardiac Surgery: A Case Report

Disclosures: C. M. Roque-Dang, none. Patients or Programs: A 50-year-old man. Program Description: The patient had presented with the chief complaint of dyspnea for several months. He reported that he had chiropractic treatment for cervicalgia and, on the day after cervical manipulation, developed unexplained dyspnea with mild exertional activities. Due to his worsening symptoms, he terminated his chiropractic visits and was evaluated by his primary care physician and a neurologist. Pertinent radiographic imaging included a SNIFF fluoroscopic examination, which revealed left hemidiaphragmatic paralysis and a chest radiograph that demonstrated an elevated left hemidiaphragm. Based on the patient’s history and radiographic imaging a electrodiagnostic testing was then performed to rule out a left phrenic nerve palsy. Setting: Outpatient private practice office. Results: On motor nerve conduction studies, he was found to have delayed distal latencies of the left phrenic nerve. Electromyography revealed reduced recruitment throughout the left hemidiaphragm, rare spontaneous denervation potentials in the left lateral diaphragm, and complex and nascent polyphasic single motor unit potentials in the left anterior diaphragm. The electrodiagnostic findings were consistent a left phrenic nerve segmental demyelinated injury. We referred the patient to a plastic surgeon, who performed a left phrenic nerve reconstruction. After surgery, the patient had improved respiratory function and activity tolerance. Discussion: A phrenic nerve injury that resulted in symptomatic diaphragmatic paralysis is most commonly associated with cardiothoracic surgery or malignancy. There are only a few cases that report phrenic nerve palsies sustained from chiropractic cervical manipulation. In these isolated reports, electrodiagnosis was not routinely used to detect these lesions. Conclusions: Reported is an unusual case of unilateral phrenic nerve palsy sustained after chiropractic manipulation. Before receiving cervical spine manipulation, patients should be counseled of this possible and serious complication. Electrodiagnostic studies are useful in phrenic nerve injury diagnosis and treatment determination.

Pediatric Rehabilitation: 2. Environmental Factors Affecting Participation

This self‐directed learning module highlights the environmental factors that influence the participation of children and youth with disabilities in life situations, including activities of self‐care, mobility, socialization, education, recreation, and community life. It is part of the study guide on pediatric rehabilitation in the Self‐Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. This module emphasizes the participation of children with disabilities in adapted sports and reviews mobility devices to promote function, in the context of the International Classification of Functioning and in reference to the Americans with Disabilities Act. It provides the physiatrist with strategies to promote community participation, functional independence and healthcare transitions for children with disabilities as they approach adulthood. The goal of this article is to improve the learners treatment strategies to maximize the participation of children and youth with disabilities in all settings, particularly schools and communities.