Ira G. Rashbaum

Length of Stay in Rehabilitation is Associated with Admission Neurologic Deficit and Discharge Destination

This study explores the link between neurologic deficit as measured by the National Institutes of Health Stroke Scale (NIHSS), and its relationship to length of stay (LOS) and discharge destination.

Motor planning poststroke: impairment in vector‐coded reach plans

Healthy individuals appear to use both vector‐coded reach plans that encode movements in terms of their desired direction and extent, and target‐coded reach plans that encode the desired endpoint position of the effector. We examined whether these vector and target reach‐planning codes are differentially affected after stroke. Participants with stroke and healthy controls made blocks of reaches that were grouped by target location (providing target‐specific practice) and by movement vector (providing vector‐specific practice). Reach accuracy was impaired in the more affected arm after stroke, but not distinguishable for target‐ versus vector‐grouped reaches. Reach velocity and acceleration were not only impaired in both the less and more affected arms poststroke, but also not distinguishable for target‐ versus vector‐grouped reaches. As previously reported in controls, target‐grouped reaches yielded isotropic (circular) error distributions and vector‐grouped reaches yielded error distributions elongated in the direction of the reach. In stroke, the pattern of variability was similar. However, the more affected arm showed less elongated error ellipses for vector‐grouped reaches compared to the less affected arm, particularly in individuals with right‐hemispheric stroke. The results suggest greater impairment to the vector‐coded movement‐planning system after stroke, and have implications for the development of personalized approaches to poststroke rehabilitation: Motor learning may be enhanced by practice that uses the preserved code or, conversely, by retraining the more impaired code to restore function.

Occupational Therapy in Pulmonary Rehabilitation

Comprehensive rehabilitation of the pulmonary patient requires the consideration of functional capacity and daily life activities. Occupational therapists are vital members of the rehabilitation team who help patients to strive toward the goal of functional independence. Interventions include breathing retraining, increased patient awareness, activity modifications, patient compensation, self-care training, and stress management. This article focuses on the theory, goals, evaluation, and treatment aspects of occupational therapy in pulmonary rehabilitation. A case study is included.

Cardiopulmonary rehabilitation in a patient with Noonan syndrome

Noonan syndrome, an autosomal dominant disease occurring with an incidence of 1 in 1,000 to 1 in 2,500 live births, is characterized by its particular cardiovascular abnormalities, including pulmonic valve stenosis, pulmonary artery stenosis, and, more rarely, septal defects and coarctation of the aorta. The case of a 20-year-old man admitted for inpatient cardiopulmonary rehabilitation after pulmonic valve repair, left pulmonary artery angioplasty, and pectus excavatum repair is presented. His endurance was markedly decreased, thus limiting his ability to perform activities of daily living and reducing his exercise tolerance. With participation in a comprehensive cardiopulmonary rehabilitation program, he experienced marked improvement with independence in his activities of daily living and an increase in his metabolic equivalent levels from to 2.8 to 5.4. After inpatient rehabilitation, he underwent left pulmonary stent placement before being discharged home. Subsequent outpatient cardiopulmonary rehabilitation has continued to improve significantly his overall exercise tolerance. Given that Noonan syndrome is viewed as the most common syndrome associated with congenital heart disease after Down syndrome, physiatrists must be familiar with its presentation, its associated abnormalities, and the treatment approach to optimize the patients cardiopulmonary, musculoskeletal, and psychological status.

Poster 484 Embolic Cerebrovascular Accident After Carotid Sinus Massage of a Previously Endarterectomized Carotid Artery: A Case Report

was initiated. Although his expressive aphasia and superior quadrantanopia resolved, his ability to read was still hindered. Discussion: Alexia without agraphia is a rare disconnection syndrome in which patients retain the ability to write but are unable to process visual input into language due to damage of the splenium of the corpus callosum. Although hand printing is a skill that is ingrained early in life, cursive handwriting is acquired at a later age and requires additional fine motor control, which suggests that hand printing can be functionally dissociated from cursive writing. Although most cases depicted in the current medical literature lose the ability for cursive writing, our case presents with intact expression through cursive rather than hand-printed writing, which makes this the first case described in the medical literature. Conclusions: Because multiple areas of the brain affect different aspects of writing, alexia without agraphia could present in various forms. Given that current rehabilitation therapies have not been consistently successful in the treatment of this condition, further studies that assess the effectiveness of rehabilitation techniques for this population should be conducted.

Refractory venous thrombus propagation in the setting of therapeutic anticoagulation.

A 68-yr-old gentleman with atrial fibrillation, hypertension, and diabetes mellitus sustained an acute ischemic stroke involving the left posterior cerebellar artery. Lower limb venous duplex revealed deep venous thromboses in the right common iliac vein and bilateral popliteal veins. He was started on warfarin and intravenous heparin; however, he developed heparin-induced thrombocytopenia. An inferior vena cava (IVC) filter was placed. He was subsequently admitted for acute inpatient stroke rehabilitation. He continued warfarin, and his international normalized ratio remained within the therapeutic range. His bilateral lower limb swelling increased. Repeat lower limb venous duplex revealed progression of the left lower limb thrombus from the popliteal to the common femoral and saphenous veins. The thrombus in the right lower limb progressed from being nonocclusive to being occlusive. Computerized tomography of the chest, abdomen, and pelvis revealed thrombotic extension above the IVC filter (Fig. 1). Given the patient’s worsening thromboses while on therapeutic warfarin, his anticoagulation was changed to fondaparinux. One week after initiating fondaparinux, repeat computed tomography demonstrated minimal retraction of the proximal end of the thrombus that extended above the IVC filter (Fig. 2). The patient was discharged on fondaparinux in stable condition to a subacute rehabilitation facility. Anticoagulants, whether oral or parenteral, have limitations. Warfarin requires international normalized ratio monitoring and may be affected by genetic polymorphisms, vitamin K dietary intake, and drug interactions. New oral anticoagulants, including dabigatran (direct thrombin inhibitor) and apixaban (antifactor X), demonstrate a dose-efficacy relationship and have a fast onset of activity and short duration of action but require twicedaily dosing. Parenteral anticoagulation includes heparin, low-molecular-weight heparin, and fondaparinux. Lowmolecular-weight heparin and fondaparinux require daily injection, are metabolized by the kidney, and may accumulate in renally impaired patients. IVC filters are used as an alternative to anticoagulation. Complications include pneumothorax, hemorrhage, and vessel injury. Anticoagulation, used with IVC filter, has been recommended for selected patients, although a study found that asymptomatic IVC filter thrombi rarely progress to complete occlusion, FIGURE 1 Arrow denotes thrombus while on therapeutic coumadin.

Poster 415: Vertebral Artery Dissection After Diving into Shallow Waters: A Case Report

Disclosures: J. Chung, None. Patients or Programs: A 24-year-old healthy man. Program Description: The patient dove in the water near Athens, Greece. Before reaching the bottom, and without trauma, he experienced sudden left-sided neck pain. He then developed left hemiplegia within several minutes. Brain magnetic resonance imaging (MRI) demonstrated left medullary infarction involving the pyramid, extending posteriorly towards the floor of the 4th ventricle. Neck and brain magnetic resonance angiography (MRA) showed dissection of the left vertebral artery, tapering to total occlusion at the vertebrobasilar junction. Patient was started on enoxaparin, and subsequently placed on warfarin. Physical examination revealed mild dysarthria, right eye nystagmus, normal cranial nerve function, normal sensation with mild proprioceptive deficit in his fingers, hyperreflexia on the left, and significant left-sided hemiplegia. Patient was admitted to inpatient rehabilitation. He required assistance in all functional areas. Patient made significant developments during the admission. Electrical stimulation to his left lower extremity helped to facilitate function. He wore a hinged left ankle foot orthosis to counteract foot drop and to improve ambulation. At discharge, the patient was able to ambulate without an assistive device. Further developments will be discussed. Setting: Urban tertiary rehabilitation center. Results: Patient developed left vertebral artery dissection after diving, leading to left medullary stroke with left hemiplegia. The extensive dissection resulted in lateral medullary syndrome, causing immediate onset of symptoms and resulting in a long recovery period with residual weakness. Discussion: This is the first reported case, to our knowledge, of VAD immediately following a dive into shallow waters. Possible causes are discussed with review of literature. Radiological workup is presented. Conclusions: The differential diagnosis for neurological symptoms consistent with stroke in young individuals should include VAD after diving. Though not considered direct trauma, cervical hyperextension from the impact of the head with the water could cause extensive vertebral artery dissection.

Cardiopulmonary rehabilitation and cancer rehabilitation. 1. Cardiac rehabilitation.

UNLABELLED This self-directed learning module highlights cardiac rehabilitation issues facing able-bodied populations. It is part of the chapter on cardiovascular, pulmonary, and cancer rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article focuses on various aspects of the management of cardiac disease and rehabilitation, including medication, exercise, risk-factor modification, secondary prevention, and surgery. Topics discussed include myocardial infarction, coronary artery disease, cardiomyopathy, and angina. New advances covered in this article include the various phases of cardiac rehabilitation, data on lifestyle adaptations for cardiac disease, and recent surgical advances for the treatment of severe heart failure. OVERALL ARTICLE OBJECTIVE To review aspects of the management of cardiac disease and rehabilitation, including medication, exercise, risk-factor modification, secondary prevention, and surgery.