James Crew

The Effect of Vitamin D Supplementation on Pain, Mood, Depression, and Strength in Patients with Spinal Cord Injury

Setting: Tertiary care pediatric hospital. Participants: A total of 134 children (61% male and 39% female) received botulin toxin type A injections for treatment of refractory CMT between 2004 and 2013. Interventions: Each infant was injected with 15 to 30 units of botulinum toxin type A following standard clinical procedure into each of the following muscles: the sternocleidomastoid, upper trapezius, and scalene muscles. Main Outcome Measures: Key outcome measures analyzed for each subject included age at time of diagnosis, age at time of initiation of physical therapy, age at time of injection, total number of injection series utilized, muscles injected, and degrees of active and passive cervical rotation and lateral flexion preand post-injection. A successful outcome was documented if a child could achieve 45 of active lateral flexion and 80 of active cervical rotation postinjection. Results: Eighty-two children (61%) had successful outcomes. When breaking it down by each motion, 83 (62%) achieved success when only accounting for lateral flexion, while 112 (84%) achieved success when only accounting for cervical rotation. When reviewing the characteristics of the children there was no significant determinant when predicting a successful outcome. Conclusions: Botulinum toxin is a safe and effective method for treatment in refractory cases of congenital muscular torticollis. Level of Evidence: Level III

Low Vitamin D Levels in Persons with Spinal Cord Injury and Increased Incidence of Venous Thromboembolic Events During Acute Inpatient and Rehabilitation Stay

Disclosures: M. A. Timmerman, No Disclosures: I Have Nothing To Disclose. Objective: To determine if low serum 25-hydroxyvitamin D level is associated with an increased incidence of venous thrombotic events (VTE) in spinal cord injury (SCI) patients during their acute hospital or rehab stay. Design: Retrospective cohort study. Setting: Academic Medical Center. Participants: Two hundred and five persons admitted consecutively to acute rehabilitation at Santa Clara Valley Medical Center (SCVMC) with a diagnosis of SCI from December 2009 to June 2012. Interventions: The following demographic data was collected: age, gender, race, and admission date. Additional information regarding injury was obtained including: level of injury (paraplegia versus tetraplegia), motor completeness of injury (motor complete versus motor incomplete), and etiology of injury (traumatic versus non-traumatic). Serum 25-hydroxyvitamin D (VitD25OH) levels and presence of VTE (deep vein thrombosis or pulmonary embolism) during acute hospital or rehab stay was also recorded. Main Outcome Measures: We looked at incidence of vitamin D deficiency in our patient population. Chi-square analysis was used to determine significant associations with regard to demographic variables, injury characteristics, and vitamin D deficiency. Specific to our hypothesis, we looked at whether low vitamin D levels had a significant association with VTE. P values of <.05 were regarded significant. Results or Clinical Course: We found 83% of persons with SCI admitted to acute inpatient rehabilitation have low levels of vitamin D. Patients who had low vitamin D levels had three and a half times the incidence of developing VTE (p1⁄4.036). Discussion: Vitamin D is biosynthesized in the skin from 7dehydrocholesterol or obtained through nutrition. It is modified in the liver and kidneys to form the active metabolite 1,25dihydroxyvitamin D3 (calcitriol). Recent in vivo and in vitro evidence suggests that calcitriol exerts an effect on coagulation by binding to nuclear vitamin D receptors (VDR) present in blood and subendothelial tissues and exerting anticoagulant effects by upregulating the expression of the anticoagulant glycoprotein, thrombomodulin (TM), and downregulating the expression of a critical coagulation factor, tissue factor (TF) in monocytic cells. Conclusions: This study is the first to demonstrate an association between low vitamin D levels in persons with SCI in acute inpatient rehabilitation and VTE.

Volitional Voiding of the Bladder after Spinal Cord Injury: Validation of Bilateral Lower Extremity Motor Function as a Key Predictor

Purpose: In many individuals with spinal cord injury a return of volitional bladder voiding is considered more important than regaining motor function. Recently a predictive model using only composite bilateral lower extremity motor scores for levels L2‐S1 (range 0 to 50) was proposed by the EMSCI (European Multicenter Study about Spinal Cord Injury) group. The model showed exceptional predictive power with an AUC of 0.912. We sought to further validate the EMSCI model in a national spinal cord injury cohort. Materials and Methods: We created models of volitional voiding using the United States NSCID (National Spinal Cord Injury Database) for 2007 to 2016. In addition to testing lower extremity motor scores, we evaluated other patient variables that we hypothesized might affect volitional voiding. Results: Volitional voiding was present in 1,333 of the cohort of 4,327 individuals (30.8%) at 1‐year followup. While younger age, female gender, increased sacral sparing, improved AIS (American Spinal Injury Association Impairment Scale) classification and a more caudal sensory level predicted volitional voiding, lower extremity motor scores were most predictive (AUC 0.919). Adding the other patient characteristics did little to improve model performance (full model AUC 0.932). Further analysis of the predictive power of lower extremity motor scores suggested that while the AUC appeared to decrease in persons who were most likely to void volitionally, the performance of the predictive model remained outstanding with a combined AIS C and D AUC of 0.792. Conclusions: Our study verifies the validity of the EMSCI predictive model of volitional voiding after spinal cord injury. The differing performance of lower extremity motor scores in various AIS classifications should be noted.

Use of nonsteroidal anti-inflammatory drugs to prevent heterotopic ossification after spinal cord injury: a retrospective chart review

Study DesignRetrospective chart review.ObjectivesThe objective of this study is to evaluate the efficacy of nonsteroidal anti-inflammatory drug (NSAID) prophylaxis for heterotopic ossification (HO) in the acute phase after spinal cord injury (SCI).SettingAcute rehabilitation hospital in California, USA.MethodsThis retrospective chart review (October 2013–March 2017) included individuals with motor complete SCI followed by the SCI service within 60 days of injury. Group demographics and HO diagnosis were compared in those who received and those who did not receive NSAID prophylaxis. A backward stepwise multiple regression was employed to assess the predictive association between injury characteristics and HO prophylaxis on HO diagnosis.ResultsA total of 108 AIS A and B cases were included, and 27 received ≥ 15 days of therapy (overall range 6–44 days). Logistic regression analysis revealed those who received ≥ 15 days of NSAID prophylaxis had an odds ratio of 0.1 of being diagnosed with HO compared with those who did not (95% CI, 0.02 to 0.52). Significant predictors of HO diagnosis were tracheostomy (OR 2.8, 95% CI, 1.05 to 7.5), urinary tract infection (OR 4.3, 95% CI, 1.5 to 12.2), and pressure injury (OR 3.3, 95% CI, 1.1 to 9.5). Adverse effects of NSAID use were minimal.ConclusionsNSAID prophylaxis appears to help prevent HO development during the acute phase after SCI. Prospective study with prolonged follow up is necessary to confirm the long-term efficacy of HO prevention and to further evaluate safety following spinal fusion.SponsorshipNone.

Venous Thromboembolism is Associated with Lack of Vitamin D Supplementation in Patients with Spinal Cord Injury and Low Vitamin D Levels

The role of vitamin D in the pathogenesis of venous thromboembolism (VTE) and prevalence of low vitamin D (LVitD) in spinal cord injury (SCI) has motivated vitamin D testing and supplementation. This is an exploratory study of data collected at a time before the routine clinical practice of vitamin D supplementation, allowing for evaluation of the natural history of vitamin D levels in patients with SCI.

Poster 22: Lack of Vitamin D Replacement in Low Vitamin D Individuals with Spinal Cord Injury is Associated with an Increased Risk of Venous Thrombotic Events During Acute Inpatient and Rehabilitation Hospitalization

Disclosures: Reza Ehsanian: I Have No Relevant Financial Relationships To Disclose Objective: To determine if lack of vitamin D replacement in persons with acute spinal cord injury (SCI) and low vitamin D levels is associated with an increased risk of venous thrombotic events (VTE). Design: Retrospective cohort study. Setting: Academic Medical Center. Participants: Two hundred eighty two persons admitted consecutively to acute inpatient rehabilitation at Santa Clara Valley Medical Center (SCVMC) with a diagnosis of SCI from December 2009 to January 2013. Interventions: Not applicable. Main Outcome Measures: We investigated the incidence of low vitamin D in our patient population and determined significant associations with regard to demographic variables, injury characteristics, low vitamin D and replacement status. Specific to our hypothesis, we looked at whether low vitamin D levels and status of vitamin D replacement correlated with VTE incidence. Results: The risk of VTE is clinically relevant but not statistically significant among SCI patients who have low vitamin D levels (43/228 1⁄4 18.8%) vs. normal vitamin D levels (6/54 1⁄4 11.1%) (Fisher’s exact test, p 1⁄4 .23). Individuals with low vitamin D who did not have vitamin D replaced had a VTE rate of 24 % (42/178) vs. 2% (1/50) amongst those with low vitamin D who did not receive replacement (p 1⁄4 .0002); Odds ratio 15.13; 95% CI 2.03-113. In contrast, there was no statistically significant difference of VTE rates (p1⁄4 1.0) in persons with normal vitamin D levels who were not taking vitamin D supplementation vs. those who were taking vitamin D supplementation (10.8% (5/46) vs. 12.5% (1/8). Conclusions: This study is the first to demonstrate an association between lack of vitamin D replacement and VTE occurrence in person with acute SCI and low vitamin D. Level of Evidence: Level III

Poster 235 Patterns of Intracranial Hemorrhage Based on Traumatic Brain Injury Etiology

extremity weakness persisted and he was discharged with a power wheelchair. Discussion: Cocaine-induced spinal cord infarctions are rare, with few documented cases. The pathogenesis of spinal cord infarct remains poorly understood, but may include hypertension, vasoconstriction, thrombosis, and vasospasm. Similarly, prognosis is difficult to assess. In our case, the patient’s underlying copper and zinc deficiencies may have limited his recovery. Copper and zinc are essential cofactors for the functioning of superoxide dismutase, an antioxidant with neuroprotective and neurorestorative properties. Decreased levels of superoxide dismutase are associated with worse outcomes following stroke. Conclusions: Copper and zinc deficiencies may predispose to spinal cord infarct and can worsen outcomes following spinal cord injury. Screening and adequate repletion may facilitate recovery. Malnourished individuals, such as drug users, are at increased risk for these deficiencies. Further studies are required before definitive recommendations for repletion can be made. Level of Evidence: Level V

The Impact of Axial Injury, Extra-Axial Injury, and Combined Injury on Functional Status in Traumatic Brain Injury (TBI)

Disclosures: Nathan Cook: I Have No Relevant Financial Relationships To Disclose Objective: Symptom reporting in student athletes with attentiondeficit hyperactivity disorder (ADHD) who are slow-to-recover from a sport-related concussion can be difficult to interpret; it can be challenging to differentiate pre-existing symptoms from concussionrelated symptoms. This study documents preseason symptom reporting in athletes with and without ADHD. Design: Cross-sectional, case-control, cohort survey study. Setting: High schools from the state of Maine, USA. Participants: Participants were 37,510 high school athletes who completed a baseline preseason health survey and symptom questionnaire between 2009 and 2014. None reported suffering a concussion within the past 6 months. A total of 2,409 (6.4%) self-reported having ADHD, and 786 (32.6%) reported taking medication to treat ADHD. Three groups included: (1) controls, (2) ADHD with medication use (Medication), and (3) ADHD but no medication use (No Medication). Interventions: None. Main Outcome Measures: The Post-Concussion Scale includes 22 symptoms such as headache, dizziness, concentration problems, and forgetfulness. Students rate the severity of each symptom from 0 to 6. Results: Groups differed significantly on the Post-Concussion Scale [girls: X(2)1⁄422.6.29, P <.001; boys: X(2)1⁄4267.15, P <.001]. Pairwise comparisons revealed similar results for both sexes; namely, the Medication group (boys: Md1⁄44; girls: Md1⁄49) and No Medication group (boys: Md1⁄43.5; girls: Md1⁄47) did not differ from one another. Both the No Medication group (girls: Mann-Whitney U1⁄42,881,457, P <.001; boys: U1⁄48,170,938, P <.001) and the Medication group differed significantly from Controls (girls: Md1⁄42; U1⁄41,187,040.5, P <.001; boys: Md1⁄41; U1⁄43,836,183.5, P <.001). Girls with ADHD, regardless of medication status, had greater total symptom scores compared to boys with ADHD. Frequencies of endorsing specific symptoms (ie, item score > 1), stratified by group and gender, are presented. Conclusions: Better understanding of symptom reporting in uninjured student athletes with ADHD can facilitate the clinical interpretation of symptoms in those who are slow to recover following a concussion. Level of Evidence: Level III

The Value of Maintaining Primary Board Certification in Physical Medicine and Rehabilitation

D. B. is a 49-year-old physiatrist. He is board certified in physical medicine and rehabilitation (PMR however, because his practice is entirely focused on SCI medicine, he is wondering if he should continue to maintain his primary board certification in PM&R in addition to his SCI certification. James Crew, MD, will argue that maintaining subspecialty certification in SCI is sufficient, and Michelle Gittler, MD, will argue that maintaining primary board certification is essential for D. B. Please note: These views do not represent the views of the American Academy of Physical Medicine and Rehabilitation or the ABPMR, and this discussion is intended for educational purposes.

Re: A Descriptive Study of Vitamin D Levels in Persons With Acute Spinal Cord Injury

5 e: A Descriptive Study of itamin D Levels in Persons With cute Spinal Cord Injury We read with interest the article titled “A Descriptive tudy on Vitamin D Levels in Individuals With Spinal Cord njury in an Acute Inpatient Rehabilitation Setting” by Nemuaitis et al in the March 2010 issue of PM&R [1]. The study ighlights the frequency (93%) of vitamin D inadequacy in he acute spinal cord injury (SCI) population, including evere ( 10 ng/mL of VitD-25(OH)) deficiency in 21% of the opulation. During the past several months, we also have een checking the vitamin D levels of all persons with acute CI who are admitted to our rehabilitation center, and e found very similar rates of inadequacy and severe defiiency as those established by Nemunaitis et al. However, here seemed to be little discussion in the article on the otential impact of vitamin D replacement in such patients eyond the possible delay in progression to osteopenia or steoporosis. Data exist to support other clinical effects of low vitamin D hat may be critical when considering acute SCI rehabilitaion. For instance, a strong correlation has been shown etween hypovitaminosis D and musculoskeletal pain in a on-SCI population [2]. In addition, vitamin D replacement ay play a role in optimizing muscle strength in patients who re participating in acute SCI rehabilitation. Mice that lack itamin D receptor in muscle have been found to have maller and more immature muscle fibers, despite optimizaion of systemic calcium [3]. Improved muscle function has een demonstrated after vitamin D supplementation in older dults [4]. Here, it is noteworthy that the median age at time f SCI continues to increase, and there has been a trend oward a greater frequency of injuries in persons older than 0 years of age. Furthermore, vitamin D deficiency has been ssociated with depressed mood in adults even after adjustng for race, age, gender, and season [5]. Given the impact of ain, muscle function, and mood on the success of a rehabiltation program, it seems important to consider these among ther potential benefits of vitamin D replacement. The medical community appears to be coming to consenus on the appropriate treatment of vitamin D deficiency.