Cynthia G. Pineda

Prevention of Pressure Ulcers Among People With Spinal Cord Injury: A Systematic Review

To evaluate the literature on the effectiveness of bed and wheelchair positioning and repositioning in the prevention of pressure ulcers (PUs) in both the spinal cord injury (SCI) and non‐SCI populations.

Poster 76 Prevention of Pressure Ulcers Among People with Spinal Cord Injury: A Systematic Review

Objective: To evaluate the feasibility of using a newly developed active-assistive gait device (AAGAD) for locomotion training in hemiplegic stroke patients. Design: Randomized, controlled study. Setting: Gait training with active-assistive system at therapeutic room. Participants: 20 subjects randomly assigned to the AAGAD (n1⁄410) or control (n1⁄410) group. Interventions: Both groups were treated with a standard rehabilitation program, and 20 min of gait training on treadmill for 5 days a week during 4 weeks with AAGAD and without AAGAD in control group Main Outcome Measures: The 10 m walking test, walking speed (m/s), step cycle (cycle/s), and step length (m) were measured as a gait parameter on a treadmill (Gait Trainer, Biodex, USA) before and after gait training. The angle of ankle dorsiflexion in swing phase was also measured (MotionTwin, Simi, Germany). Clinical parameters measured before and after gait training included Korean Modified Barthel Index (K-MBI), Manual Muscle Test (MMT), and Modified Ashworth Scale (MAS) of hemiplegic ankle. Results or Clinical Course: 1) The 10-m walking time was improved in both groups (P<.05), but step length and step cycle were not. Walking speed and angle of dorsiflexion were improved in AAGAD group (P<.05). K-MBI and MMTwere improved after gait training except ankle power (P<.05), but MAS was not in both groups. 2) The 10-m walking test, Walking speed, angle of dorsiflexion, and step length were greater in AAGAD group (P<.05). Conclusion: AAGAD increases speed and posture of gait in hemiplegic patients. It can be a useful device for gait training in hemiplegic patients.

Poster 188 Development of a Hybrid Tracheostomy Management Skills Workshop for Physical Medicine and Rehabilitation Residents: A Case Study

Disclosures: M. Oh-Park: I Have No Relevant Financial Relationships To Disclose. Objective: Delirium, an acute decline in attention and cognition, is the leading complication associated with poor outcomes and increased cost among hospitalized older adults. Implementing practice guidelines for delirium in rehabilitation may improve patient outcomes and quality of care. However, this requires a well-orchestrated effort of multiple disciplines. The objective of this study is to describe the development of strategies, process, and outcomes during implementation of practice guidelines for delirium based on the stages-ofchange model. Design: Descriptive study. Setting: A large rehabilitation hospital. Participants: Patients admitted in inpatient rehabilitation. Interventions: Delirium Initiative Task Force of multiple disciplines (physicians, therapists, nurses, administrators) outlined the strategy: 1) prioritizing delirium as a quality indicator at institutional level based on its impact on quality measure (acute care transfers), 2) increasing awareness of delirium by education, 3) identification of screening (Confusion Assessment Methods: CAM) & development of intervention tool (Institution_Name_Delirium Intervention Protocol: KDIP) based on literature and potential barriers to implementation, 4) small scale trial of tools and feedback analysis, 5) outcome monitoring. Main Outcome Measures: Documentation of delirium status at admission preand postimplementation of guidelines. Usability of intervention protocol. Results or Clinical Course: 30% of patients with acute care transfer due to mental status change had delirium pre-implementation of guidelines. 23 didactic sessions (14 for nursing, 3 for therapists, 6 for MDs) about delirium were provided over 12 months. Barriers for implementation included time, knowledge of staff, administrative support, and patient population (brain injury). Documentation of delirium status at admission improved from 11% to 98% from preto postimplementation. Prevalence of delirium at admission was 15.2%. K-DIP was used by physicians successfully identifying delirium and preventing potential acute care transfers. Conclusion: Implementing practice guidelines for delirium based on the stages-of-change model may improve practice patterns and quality of care in inpatient rehabilitation.

Effective Rehabilitation Management of Central Pontine Myelinolysis: A Case Study

multiple brain ischemic infarcts in the left thalamus, bilateral midbrain, left occipital lobe and right basal ganglia. On admission to Rehabilitation, physical examination showed flaccid quadriplegia with an isolated right thumb movement. Alertness was intact. The patient was able to communicate by opening and closing his eyes. Initial rehabilitation efforts resulted in minimal functional recovery. Around 12 weeks after surgery, volitional movements were noted and this was followed by an exponential gain in function. After 16 weeks of comprehensive rehabilitation, including robot-assisted walking therapy, the patient was able to speak short sentences, propel a wheelchair, don/doff his shirt and ambulate x 20 ft with moderate assistance. Setting: Pediatric Inpatient Rehabilitation Unit Results or Clinical Course: 11-year-old male with Locked-in syndrome for 12 weeks showed unexpected functional gains with comprehensive rehabilitation. Discussion: The most common mechanism of Locked in syndrome is a basis pontis infarction. Based on accepted literature, most functional recovery occurs within the first few weeks after the insult. This presentation reports on an unusual case when a genetic disorder resulted to a cascade of events that led to a pediatric patient in a locked-in state for 3 months. Expectations for appreciable functional recovery seemed unrealistic at that stage. A patient centered multidisciplinary approach with close communication with the parents seemed to have played a key role in the patient’s unexpected gain in function. Conclusions: 11-year-old male with Locked-in syndrome for 12 weeks showed unexpected functional gains with comprehensive rehabilitation.

Use of Virtual Patients and Online Interactive Case-based Scenarios in the Evaluation and Management of Autonomic Dysreflexia in Persons with Spinal Cord Injury: A Case Study on the Perceptions of Physical Medicine and Rehabilitation Residents and Medical Students

Interventions: None. Main Outcome Measures: Cognition and motor functional gains measured by the FIM instrument, and discharge to acute care hospital and community. Results or Clinical Course: The three stroke groups differed significantly in patient characteristics, medical conditions, facility level measures, and IRF LOS, with an average of 8.8, 13.6, and 20.9 days for mildly, moderately, and severely impaired patients, respectively. After controlling for admission FIM and covariates under study, a longer LOS was significantly associated with increased cognition and motor gains for both moderately and severely impaired patients. Patients who had a longer IRF LOS were less likely to be discharged to an acute care hospital (moderately and severely impaired groups) and more likely to be discharged to community (severely impaired group). However, a longer LOS did not associate with better patient outcomes for the mildly impairment group. Conclusions: A longer IRF LOS was associated with favorable rehabilitation outcomes of the moderately and severely impaired stroke patients but not the mildly impaired stroke patients.

Poster 483 Use of Hybrid Simulation to Teach the Evaluation and Management of Autonomic Dysreflexia in Physical Medicine and Rehabilitation Education: A Feasibility Case Study

Disclosures: C. W. Robinson, No Disclosures. Case Description: A 51-year-old man who underwent subtotal resection of spinal astrocytoma at level T7-T9 in April 2007 which resulted in T10 motor and sensory ASIA D classification. Patient developed a deep venous thrombosis (DVT) in lower left extremity, diagnosed by Doppler ultrasound, 8 months after spinal surgery. Patient had been treated with warfarin since December 2007 secondary to the DVT and increased DVT risk associated with cancer. Anticoagulation was initiated and managed by a hematologist/oncologist with International Normalized Ratio (INR) values obtained weekly, then monthly once INR values were stable. INR values for the 2 years previous to this event ranged from 1.8-2.8. Patient developed acute onset of complete, bilateral, lower extremity paralysis in January 2012. Thirty hours after onset of paralysis, patient presented to an emergency department where thoracic MRI revealed intramedullary hematoma extending from the site of the previous surgery (T8) to T10. Documented INR was 2.2. Patient underwent thoracic laminectomy at level T9-T10 with exposure of previous T8 decompression, intramedullary exploration and evacuation of intramedullary hemorrhage. Setting: Tertiary care hospital. Results or Clinical Course: Patient had complete loss of motor function and sensation from level T10 resulting in conversion of incomplete ASIA D to complete ASIA A classification that has persisted at 6 weeks follow-up. Discussion: This is the first reported case, to our knowledge, of an intramedullary hematoma that developed at a previous spinal tumor resection site in a patient on chronic, therapeutic anticoagulation. Conclusions: The risk of spontaneous spinal hemorrhage in one with previous spinal tumor resection and who requires anticoagulation is unknown. However, given the significant consequences of an intramedullary hemorrhage and the increased risk of spontaneous hemorrhage associated with warfarin anticoagulation, risks versus benefits of anticoagulation should be carefully assessed and discussed with a patient, and frequently re-evaluated.

Poster 162 Sonographically Assisted Diagnosis of Left Rectus Femoris Tendon Tear in a Patient with a Total Knee Arthroplasty: A Case Report

Childhood Experience (ACE) Module asks about abuse (physical, sexual, emotional) and family dysfunction (exposure to domestic violence, living with mentally ill, substance abusing, or incarcerated family member). Setting: Six U.S. States: Arkansas, Louisiana, New Mexico, Tennessee, Washington, Wisconsin. Participants: Community-dwelling adults ages 18 (n 30,059). Interventions: Not Applicable. Main Outcome Measures: Self-reported musculoskeletal (MSK) disorder prevalence; MSK-disorderrelated disability measured as: activity limitations, work and social participation restrictions. Results: The prevalence of any ACE was 59% and of 4 ACEs was 15%. The age-adjusted MSK-disorder prevalence increased from 21% for those with no ACEs to 36% for those with 4 ACEs. In those with MSK-disorders (n 9354), the percent reporting activity limitations increased from 46% (no ACEs) to 59% (4 ACEs.). The percent reporting work and social restrictions increased from 25% (no ACEs) to 44% (4 ACEs) and from 40% (no ACEs) to 57% (4 ACEs) respectively. In logistic regression analyses adjusting for demographic factors (sex, age, education, marital status, income), those reporting 1, 2, 3, and 4 ACEs had an increased OR (95% confidence interval) of MSK disorders of 1.14 (1.05-1.24), 1.53 (1.33-1.76), 1.84 (1.58-2.13), 2.43 (2.15-2.74) respectively, compared to those reporting no ACEs. Those with MSK-disorders and 4 ACEs also had an increased adjusted odds of MSK-related activity limitations [1.6 (1.4-2.0)], work [1.9 (1.5-2.4)] and social [1.6 (1.3-2.0)] participation restrictions compared to those with no ACEs. Conclusions: Adverse childhood experiences have a graded effect on musculoskeletal disorder prevalence and also magnify the disability associated with these disorders. A better understanding of this link will help physicians improve functioning in those affected by childhood adversity and musculoskeletal disorders.

Poster 324 Challenges in the Rehabilitation of a Patient With Chronic Inflammatory Demyelinating Polyneuropathy and Allodynia Presenting During Pregnancy: A Case Report

times during the examination due to severe pain in the lateral neck. Physical examination results revealed minimal pain reproduction with opening and closing the mouth. The musculoskeletal and neurologic examination of the head, neck, and upper extremities, as well as HEENT examination, were unremarkable. Magnetic resonance imaging of the brain and cervical spine with and without contrast revealed no space-occupying or demyelinating lesions, normal-appearing spinal cord, and mild degenerative changes within the cervical spine. Electromyography revealed no evidence of left superior or recurrent laryngeal mononeuropathy, left spinal accessory or left C2-3 neuropathy. Laboratory tests, including complete blood cell count, complete metabolic profile, thyroid stimulating hormone, hemoglobin A1c, lyme titer, vitamin B12, and methylmalonic acid, were normal. Setting: Tertiary care hospital. Results: The patient was diagnosed with left glossopharyngeal neuralgia (GN) based on the above history, clinical examination, and workup. Symptoms have improved with the initiation and titration of carbamazepine and baclofen. Magnetic resonance imaging FIESTA and evaluation for surgical decompression are pending and will be discussed. Discussion: This case report presents a case of GN, a rare pain syndrome, presenting as lateral neck pain. Pain from GN is typically felt around the base of tongue, throat, ears, jaw, and/or larynx. GN primarily affects the elderly and occurs more often in men. Conclusions: Cranial neuralgias should be considered in the differential for atypical neck pain.

Poster 232 Ultrasound-guided Diagnosis of Tophaceous Gout Mimicking Rheumatoid Arthritis: A Case Report

Disclosures: M. Skeels, none. Patients or Programs: A healthy 21-year-old right-hand dominant man. Program Description: The patient was attempting to perform an iron cross, which is a gymnastic maneuver in which someone holds onto the still rings with the arms extended away from the body. After a month of attempting this move, he noticed that he was no longer able to adduct the fifth digit of his right hand. He was not aware of any trauma or inciting incident. He had no any sensory loss or paresthesias of his hand. Setting: An outpatient clinic. Results: The patient was a healthy 6 ft 1 in., 170 lb man with normal gross appearance of his right hand. Light touch sensation and 2-point discrimination were intact in the ulnar, median, and radial nerve distributions of the right hand. The patient had a positive Wartenberg sign, negative Froment sign, no clawing of the hand, and other than adduction of the fifth digit; the muscle strength of his hand demonstrated no weakness. The flexor and extensor tendons were intact, there was no instability at the wrist, and he had full range of motion of his wrist and fingers. Electrodiagnostic testing revealed increased latency and decreased amplitude to the first dorsal interosseous muscle on motor nerve conduction testing and motor unit loss on needle electromyography. Magnetic resonance imaging revealed contusion or compression, with soft-tissue swelling surrounding the ulnar nerve at the hamate hook, with the nerve signal slightly edematous, without enlargement or disruption of the ulnar nerve. The patient was treated with rest and discontinuation of provoking activity, and his symptoms resolved after 1 month. Discussion: This is the first case report of ulnar neuropathy at the wrist that was caused by attempting to perform the gymnastic maneuver of the iron cross. Conclusions: The case represents an unusual cause of ulnar neuropathy at the wrist.

Poster 78 The Alpha-numeric Soup: A Systems-based Practice Workshop for the Physical Medicine and Rehabilitation Resident

Disclosures: F. Emamhosseini, none. Objective: To develop a novel quality improvement model and standardize the hand-off system in our institution. Design: Pre-post intervention survey and retrospective chart review. Setting: Acute inpatient rehabilitation hospital. Participants: Twelve physical medicine and rehabilitation residents. Interventions: A novel quality improvement model, the “LIFE Cycle” (L-Learn and highlight the basic tasks associated with patient handoffs; I-Identify opportunities for miscommunication through focus groups and root cause analysis; F-Formulate and implement a standardized hand-off template; E-Evaluate and monitor the initiative), was used to standardize our hand-off system. A color-coding system (RED, critical laboratory values and/or acutely ill patients; YELLOW, routine laboratory values and/or workups; GREEN, general medical check) was used to prioritize patients to be seen during the weekend call for a period of 4 months. Main Outcome Measures: (1) Preand postintervention resident satisfaction and efficiency survey, (2) retrospective chart review of number of patient-related rapid responses, code blue, transfers to acute care, and average length of stay. Results: Statistically significant improvement was noted in (1) residents overnight having a clear idea of what they need to accomplish (P .005, Stuart Maxwell test), (2) issues no longer arising that are directly attributable to an inadequate sign-out (P .05, Stuart Maxwell test), (3) decrease in rapid response rates (P .05, Fisher exact test). There was slight improvement in the residents’ perception of the new hand-off system as being efficient and complete (P .06, Stuart Maxwell test). Overall, there was no statistically significant difference in number of acute care transfers. However, in 1 unit, there was a statistically significant decrease in acute care transfers (P .05, Pearson 2 test). There was no significant change in the number of code blue and length of stay. Conclusions: Use of the “LIFE Cycle” improved the hand-off system in our institution. Future steps include the development of a color-coded electronic hand-off system by using this model to maintain continuity of care across transitions, reduce communication errors and preserve patient safety. Poster 77 Candidate and Interviewer Perceptions of a Novel Multistation Interview Format for Admission to a Physical Medicine and Rehabilitation Residency Training Program. Hernish Acharya (University of Alberta, Edmonton, AB, Canada); Nigel Ashworth, MB ChB, MSc, FRCPC, Curtis Hlushak, Lalith Satkunam.