Colby Hansen

A Normative Dataset of the Balance Error Scoring System in Children Aged Between 5 and 14

Objective:Pediatric head injuries occur commonly and are being reported in increasing numbers. Balance testing is a key component in the evaluation of suspected concussion, and the balance error scoring system (BESS) is likely the most well-known and widely used measure. To date, normative BESS scores for adults have been reported but not for children. Design:Normative data for BESS scores and modified BESS scores were created in a cohort of healthy children. Potential variables were analyzed as predictors of BESS performance. Setting:Local elementary and junior high schools. Participants:A total of 373 healthy children between the ages of 5 and 14. Interventions:The BESS was performed on all children. Assessment of Risk Factors:Gender, body mass index percentile, previous concussions, athletic participation, age, and the parental opinion of childs balance ability were examined as factors associated with the BESS score. Main Outcome Measures:BESS scores. Results:Normative data are reported, stratified by age groups of 5 to 7 years, 8 to 10 years, and 11 to 14 years of age, for both BESS and modified BESS. Median BESS scores are 23 for children aged 5 to 7, 18 for children aged 8 to 10, and 16 for children aged 11 to 14. Median modified BESS scores are 8 for children age 5 to 7, 5 for children age 8 to 10, and 4 for children age 11 to 14. Increasing age and positive parental opinion regarding their childs balance ability were independently correlated with decreasing BESS scores (P < 0.01). Conclusions:The normative data on BESS scores for healthy children reported here provide age-stratified reference values for suspected balance alterations.

Incidence, Severity, and Impact of Hyperhidrosis in People with Lower-Limb Amputation

To assess the incidence and severity of self-reported hyperhidrosis in patients with amputation and understand its effects on prosthetic fit or function, a cross-sectional survey of patients at two amputee clinics was performed. Responses from 121 subjects with lower-limb amputation were analyzed. Of these subjects, 66% reported sweating to a degree that it interfered with daily activities, as measured by the Hyperhidrosis Disease Severity Scale. There was a significant association between sweating and interference with prosthetic fit and function. Sweating was more severe in cases of transtibial amputations, patients under the age of 60, warm weather, and vigorous activity. There was no relationship between severity of sweating and time since amputation, etiology of amputation, duration of daily prosthetic use, or reported ability to perform functional tasks. Subjects reported trying multiple interventions, but the self-reported effectiveness of these treatments was low. Hyperhidrosis, a common problem associated with prosthetic usage, varies in severity and often interferes with daily activities. Sweating severity is associated with poor prosthetic fit and function. Risk factors include younger age and transtibial amputation status. Treatment strategies generally lack efficacy. The results of this study may provide guidance for future interventions and treatment options.

Poster 33: Sports Participation and Return to Play in Children with Mild Traumatic Brain Injury

Objective: The relationships between running kinetics and recent lower extremity injury among runners of different body sizes are not clear, so the purpose of this study was to determine the key kinetic characteristics of running gait among runners across the spectrum of body mass index (BMI in kg/m) values with and without recent history of lower extremity injuries. Design: Cross-sectional experimental design. Setting: Research laboratory associated with a tertiary care medical center. Participants: Recreational competitive runners (N1⁄4278; 46.6% women; 34.8 14.9 yr) were stratified into three BMI groups: healthy weight BMI<24.9, overweight BMI 25-30, obese BMI>30. Interventions: Not applicable. Main Outcome Measures: Recent history of lower extremity bony and soft tissue injuries related to running; peak ground reaction force (GRF) and vertical instantaneous loading rate (VILR). A 3D motion tracking system and instrumented treadmill captured ground reaction forces (GRF) and loading rates at preferred running speed. Results: Injury prevalence (stress fractures, tendonitis, plantar fasciitis, patellofemoral pain) was not different among the three BMI strata (28%-38%). Peak GRFs were highest in the overweight group compared to the healthy weight and obese runners, respectively (1919 282 N vs 1566 318 and 1794 419 N; P < .0001). VILR was also highest in the overweight group compared to the healthy weight and obese runners, respectively (47.9 11.9 kN/s vs 40.7 14.1 kN/s and 39.9 13.3 kN/s; P < .001). Regression results indicated that after accounting for running speed (R21⁄4.123), BMI accounted for an additional 6% of the variance to the model for VILR (B coefficient 0.251). Conclusions: BMI effects on loading rates during running at a preferred speed are relatively small. Progressively heavier runners were not at a higher risk for lower extremity injury, and this may be due to internal motion adjustments that are made to control VILR and peak GRF at slower preferred speeds. Level of Evidence: Level II

Complicated Mild Traumatic Brain Injury at a Level I Pediatric Trauma Center: Burden of Care and Imaging Findings

OBJECTIVE The aims of this study were: (1) to characterize mild traumatic brain injury (mTBI), mTBI with skull fracture, and complicated mTBI in school-aged children seen at a Level I pediatric trauma center and (2) to examine the nature of imaging findings seen in children with mTBI with skull fracture and those with complicated mTBI. METHODS A total of 1777 pediatric patients (male: 1193 or 67.1%; age = 11.1 ± 3.5 years) sustaining mTBI who presented to the Emergency Department or directly to the trauma service in the years 2010 to 2013 were identified and classified into mTBI (n = 1,319 or 74.2%), mTBI with skull fracture (n = 127 or 7.2%), and complicated mTBI (n = 331 or 18.6%). Patient characteristics and imaging findings were analyzed using descriptive statistics, Pearsons χ2 test, Fishers exact test, and logistic regression analysis. RESULTS In children with complicated mTBI, subdural hematoma (36.9%) was the most common finding. Of the 331 children with complicated mTBI, 241 (72.8%) had multiple findings compared with one (0.8%) of 127 children having mTBI with skull fracture (Fishers exact P < 0.001), with logistic regression analysis revealing younger age as a potential risk factor (P < 0.01). Children sustaining a depressed or complex skull fracture were nearly twice as likely as those with simple, linear skull fracture to have intracranial abnormality. CONCLUSIONS Multiple radiographic findings in children sustaining mTBI with skull fracture or complicated mTBI are prevalent (72.8%), with younger age as a potential risk factor.

Reliability of the balance error scoring system in a population with protracted recovery from mild traumatic brain injury

ABSTRACT Objective: This study aimed to identify the Balance Error Scoring System’s (BESS) intraclass reliability in a cohort of patients with prolonged symptoms using variance component analysis and intraclass correlation coefficient (ICC). Setting: Outpatient sports medicine/concussion clinic. Participants: A total of 241 paediatric and 102 adult patients with symptoms lasting longer than 10 days. Interventions: BESS testing. Design: Retrospective review. Main outcome measures: Percent variance for each BESS component and intraclass reliability. A five-component model (including all components except for firm double-leg) and a four- component model (including all components except for firm and foam doubleleg) were also performed to compare ICC values. Results: The largest source of variance came from stance (41.1%). The BESS components firm single (25.5%) and foam tandem (27.5%) stances accounted for the largest percentages of variance, while firm double (1.1%) and foam double (6.9%) accounted for the smallest percentages. The ICC for all patients was 0.800, and increased both if the firm double stance was excluded, or if both double-leg stances were excluded. Conclusion: BESS reliability appears to be high in a concussed cohort, regardless of age. Removing the two double-leg stance portions increases the ICC of the test without failing to identify balance deficits.

Residual Limb Hyperhidrosis Managed by Botulinum Toxin Injections, Enhanced by the Iodine-Starch Test: A Case Report.

Hyperhidrosis of the residual limb is a common condition affecting patients with amputations. The iodine‐starch test is used by dermatologists to identify focal areas of hyperhidrosis before treatment with botulinum toxin. Here, we describe a case of a patient with a transtibial amputation with moderate‐to‐severe hyperhidrosis who received intradermal botulinum toxin injections to treat residual limb hyperhidrosis, with particular emphasis given to the utility of the iodine‐starch test in managing this common condition. The iodine‐starch test successfully identified hyperhidrotic areas before treatment as well as confirmed the physiologic anhidrotic effect of the botulinum toxin treatment.

Poster 140: Descriptive Cohort Study of Children Sustaining Mild or Complicated Mild TBI

Disclosures: Denesh Ratnasingam: I Have No Relevant Financial Relationships To Disclose Objective: To determine if pediatric patients with cerebral palsy (CP) with a quadriplegic type of CP have a stronger correlation of developing scoliosis compared to other types of CP. Design: Retrospective cross-sectional study. Setting: Tertiary pediatric rehabilitation outpatient clinic. Participants: 494 participants were analyzed to determine factors associated with increased radiographic Cobb angle measurements. Interventions: Not applicable. Main Outcome Measures: Cobb angle measurement analysis by radiographic imaging of spine and orthopedic surgery evaluation, location of CP involvement, age, weight, and Gross Motor Functional Classification System (GMFCS) scores were collection. Results: Using an analysis of variance, a statistically significant difference in Cobb angle (p<.0001) was found between quadriplegic patients (mean 42.7*, standard deviation 32.9*) compared to hemiplegic (9.1*, 3.9*), diplegic (13.5*, 6.9*), and triplegic (17.7*, 16.2*) patients after controlling for both weight and age. Individually, there is a moderately strong correlation observed (p< .001, r1⁄40.40) between increasing age and increased Cobb angle; however, no statistically significant correlation related to weight. Patients with GMFCS level V had greater Cobb angles compared to all other GMFCS levels (p<.05). Conclusions: In comparing patients with CP, those with quadriplegic involvement or GMFCS level V patients had an increased amount of scoliosis compared to those with different locations of involvement or improved functional mobility. Level of Evidence: Level III

Iodine–Starch test for assessment of hyperhidrosis in amputees, evaluation of different methods of application*

Abstract Purpose: Hyperhidrosis is a common problem for amputees. The iodine–starch test is frequently used to assess hyperhidrosis, but a method for its application has not been described for amputees. Methods: We performed an unblinded comparison of the iodine–starch test using various methods to protect the prosthesis in 10 prosthetic limb users with hyperhidrosis. Results: Plastic wrap produced a diffuse pattern of sweating in 70% of subjects. Forty percent had complaints about this method, and 50% experienced leakage of iodine stain onto prosthetic liners. The prosthetic sheath produced a focal or multifocal reaction in 100% of subjects after 10 min of ambulation. Eighty percent had minor leakage onto the liner, and complaints were noted in 10%. The proportion that experienced diffuse sweating was significantly higher in the plastic wrap condition (p = 0.016; difference in proportions = 70%; 95% confidence interval = 32–100%). The prosthetic sock was tested in four subjects and all had at least mild complaints; three had minor leakage onto the liner. Repeated complaints and lack of stain prevention led to discontinuation with this method. Conclusions: Of the three methods, the sheath produces a focal or multifocal reaction after 10 min of ambulation and tends to cause less subject complaints. It should be the preferred method to apply the iodine–starch test to amputees. Implications for rehabilitation Hyperhidrosis is a common problem in amputees which negatively affects quality of life. The iodine–starch test is commonly used to guide treatment decisions for hyperhidrosis, but a preferred method for applying it in amputees has not been described. This study describes different methods for applying the iodine–starch test. A prosthetic sheath covering should be the preferred method for the iodine–starch test in amputees.

Poster 173 Concussions Presenting with Conversion Disorder: A Case Series.

Case/Program Description: A 52-year-old woman with right gluteal pain for 1 year. Patient presents after exhausting multiple treatment approaches such as physical therapy, right hip and right ischial bursa corticosteroid injections. MRI and EMG findings were not helpful in identifying cause. Physical exam noted tenderness at the right middle lower gluteal region, but otherwise normal. In a prone position, ultrasound imaging the maximal local tender point demonstrated imaging of right obturator internus (OI) and its underlying bursa. Identification of the tendon of OI muscle and OI bursa transtendinosus injection technique was based on the detailed description by J Smith. A 22-gauge 3.5-inch needle was then inserted through the sterilized skin using in-plane to transducer and longitudinal to the OI from lateral to medial direction until the tip of needle touching the ischium just underneath the tendon of obturator internus muscle. The patient reported severe pain when needle was advanced to this location where a mixture of 2.5cc 0.5% lidocaine mixed with 20mg kenalog was injected. Patient reported immediate complete relief of pain following the injection. Results: Patient returned to office at 3 months after the injection. She continued to report significant pain relief in the right gluteal region. She reported sleeping much better and no longer took pain medications. Discussion: This case report is to stress the success of US guided injection of obturator internus bursa at the ischial region. To our knowledge, there has no been prior documented case report utilizing this approach. Conclusions: Ultrasound guided injection of obturator internus bursa utilizing the OI bursa trans-tendinosus technique as described by J Smith may be an effective approach for successful treatment for patients with gluteal pain from OI bursitis. Setting: Outpatient Clinic Level of Evidence: Level V

Poster 466 Hyperhidrosis in Amputee Populations: Self-Reported Incidence and Impact on Prosthetic Use and Function

Disclosures: H. Lax, No Disclosures. Case Description: The objective of this case study was to report the functional gains found following physical therapy intervention in an independent individual who received new prosthetic components. The subject was a 54-year-old man with a 32-year history of left hip disarticulation secondary to trauma. The subject had utilized his previous prosthesis at a K3 modified independent level. The components were as follows: Canadian hip disarticulation hard socket, Otto Bock 7E7 hip joint, Otto Bock 3R60 knee joint, and Otto Bock Axtion LP energy storing foot. The subject was deemed appropriate for, prescribed, and issued a new prosthesis consisting of the following components: Ischial containment hip disarticulation socket with a flexible inner liner and micro carbon fiber frame, Otto Bock Helix hip joint, Otto Bock C-Leg knee joint with Otto Bock 4R57 axial rotator, and Ossur LP Variflex foot. Setting: Hospital based outpatient rehabilitation center. Interventions: The subject underwent 11 physical therapy treatment sessions focusing on prosthetic training. Main Outcome Measures: Subjective and objective measurements were recorded on initial evaluation and at discharge. Subjective measurements included: pain, Activities-Specific Balance Scale (ABC), and RAND medical outcomes study: 36-item short form survey instrument (SF-36). Objective measurements included: gait analysis, standing balance (single limb stance and Sharpened Romberg positions), 6 and 12 minute walk tests, and timed stair mobility. Results or Clinical Course: By discharge, pain was eliminated, the ABC score was improved, the SF-36 score was improved, standing balance was improved, the 6 and 12 minute walk test distances were improved, and the time to ascend and descend steps was decreased. Discussion: This case study justifies the need for physical therapy interventions throughout an amputee patient’s life. Conclusions: While a good prosthetic design is essential, physical therapy treatment may be required to help the amputee patient learn to utilize the components appropriately and help the patient achieve their highest functional and social outcomes.