Jane A. Emerson

Growth characteristics in cerebral palsy subtypes: a comparative assessment.

Children with quadriplegic cerebral palsy (CP) have been found to have growth rates that differ from those of children with typical development. Little research has been performed to distinguish whether growth patterns in hemiplegic, diplegic, and quadriplegic CP differ from one another. The purpose of this study was to compare growth of children with quadriplegic, hemiplegic, and diplegic CP.

Poster 160: Evaluation of Resident Research, Program Support, and Barriers

Objective: Residents use pocket references to track everything from management guidelines and site-specific protocols to contact information for consultants. Though much content has evolved into digital formats, quickly extracting information from documents during a clinical shift can be challenging. While publicly available reference apps are useful, they generally lack customization. We present an open-source approach to create a rehabilitation reference mobile web application (app) that provides content customized to a training programein this case, a spinal cord injury rotation. Topics include: American Spinal Injury Association (ASIA) exam scoring, functional expectations based on neurological level of impairment, neurogenic bowel and bladder, pressure injuries, deep vein thrombosis, autonomic dysreflexia, orthostatic hypotension, and site-specific admission orders. The app files are stored in an online software repository and use hypertext markup language (HTML) and Javascript to emulate an iOS or Android app. With some basic HTML skill, anyone can extend functionality with new content and freely share these app variations. Because the app runs on any web server, revisions to the custom app are seen instantly, avoiding complicated code deployment through app stores. Our objective was to assess the feasibility of implementation by novices using a tutorial. Design: Observational study. Setting: Academic hospital. Participants: 6 staff members with no web programming experience. Interventions: Participants followed a tutorial to start a web server, edit the app and create a new feature, simulating the process of implementation at another residency program and contribution back to the project. Main Outcome Measures: Self-reported duration to complete tutorial; ratings of difficulty and usefulness of app on 7-point scales Results: Mean duration was 26 minutes. Mean rating of difficulty was 3.5 (7 being ‘extremely difficult’); mean usefulness was 6.0 (7 being ’extremely useful’). Conclusions: Our simple approach to app creation offers a customized, collaborative, and useful reference for trainees and facilitates the democratization of technology among the healthcare workforce. Level of Evidence: Level IV

Complex Regional Pain Syndrome Associated With Microvascular Injury from Von Willebrand Disease: A Case Report

Objective: To determine if bracing frequency, region, specialty, or percentage of practice devoted to knee pain influences a provider’s usage of imaging modalities or timing of prescribing a brace for patellofemoral pain syndrome (PFPS). Design: Cross-sectional study. Setting: United States sports medicine practices. Participants: 1,307 athletic trainers (AT), physical therapists (PT) and sports medicine physicians recruited from the email listings of the American Medical Society for Sports Medicine, the American Osteopathic Academy of Sports Medicine, the American Physical Therapy Association sports PT section, the International Patellofemoral Study Group, the International Patellofemoral Retreat list, and NCAA Division 1 team registries. Interventions: Not applicable. Main Outcome Measures: Usage of imaging modalities, timing of prescribing a patellofemoral brace relative to a trial of rehabilitation. Results or Clinical Course: 1,307 of 7,999 providers replied (response rate of 16.3%). Mean bracing frequencies were 19.8% for ATs, 13.4% for PTs, and 25.1% for physicians. CT scans were used by 1.5% of respondents to aid in patellofemoral bracing decisions, while 10.0% used MRI and 0.5% used bone scans. ATs used MRI at a statistically significant higher rate (17.0% vs 5.7% for non-ATs, P<.001). Of respondents, 1.6% braced prior to a trial of rehabilitation, 55.5% braced concomitantly with rehabilitation, and 42.9% braced following a rehabilitation trial. ATs braced with rehabilitation more commonly (61.5% vs 52.4% for non-ATs, P<.001), while physicians braced more commonly after a trial of rehabilitation (50.0% vs 35.5% for non-physicians, P<.001). Statistically significant correlations existed between bracing with a trial of rehabilitation and bracing frequency (r1⁄40.93), and bracing after a trial of rehabilitation and bracing frequency (r1⁄4 -0.98). No statistically significant correlations existed regarding region, percentage of practice devoted to knee pain, or years of experience. Conclusions: Significant differences in imaging modality usage and timing for patellofemoral braces for PFPS exist among specialties and per bracing frequency.

Poster 326 Ultrasound Guidance Utilized to Refill a Challenging Intrathecal Baclofen Pump: A Case Report

returned to the emergency room within 48 hours for multiple syncopal episodes. He then had progressive complications of diffuse autonomic failure including neurogenic bladder, anhidrosis, inability to make tears or saliva, pupillary dysfunction and eventual significant orthostatic and postprandial hypotension. He remained in a tertiary care hospital for over 1 month resulting in considerable deconditioning. The patient was eventually transferred to acute inpatient rehabilitation facility with goals of regaining functional independence. Setting: Acute inpatient rehabilitation facility. Results or Clinical Course: The patient’s symptoms are consistent with a diagnosis of AAG that impacted his bowel, bladder, ability to perform transfers and activities of daily living (ADLs) safely. Discussion: AAG is considered a type of autoimmune neuromuscular disorder. Patients with AAG develop antibodies to ganglionic nicotinic acetylcholine receptors located in the sympathetic, parasympathetic and enteric ganglia resulting in symptoms of diffuse autonomic failure. There are very few documented cases of AAG, with no documented cases, to our knowledge, of rehabilitation for these patients. Conclusions: Significant autonomic dysregulation caused by AAG can pose a unique challenge to the rehabilitation process. Successful achievement of independence in mobility, ADLs and bowel/bladder management can be accomplished with an integrated team approach incorporating pharmacological, mechanophysiologic principles and a progressive rehabilitation program.

Poster 443 Prevalence of Tracheostomy and Gastrostomy Tube Utilization in Acute Traumatic Brain Injury in the Pediatric Population

responsive a short time later. Patient was transported to an outside hospital, had a tonic-clonic seizure, was intubated, and then transferred to Children’s Hospital of Wisconsin. Computed tomography (CT) of head revealed a left frontotemporal skull fracture and large heterogeneous left frontal mass with calcification and hemorrhagic transformation. Subsequent magnetic resonance imaging (MRI) of brain revealed a large (8.3x7 cm), lobulated, avidly enhancing, extra-axial heterogeneous mass that appeared consistent with a meningioma. Within 10 hours of admission, intravenous epinephrine was initiated to maintain cerebral perfusion and blood pressures. Setting: Pediatric hospital. Results or Clinical Course: Patient extubated on hospital day 3 and progressed well in physical and occupational therapy. She was discharged home on hospital day 5 without significant cognitive or functional deficits. She returned 2 months later, once fully recovered, for tumor resection, with pathology consistent with meningioma. Discussion: This is the first reported case, to our knowledge, of a meningioma bleed secondary to a traumatic brain injury. The patient’s underlying brain pathology may have predisposed her to hemorrhage and led to a more significant degree of brain injury. Conclusions: The mass effect from brain tumors like meningiomas are known to cause cognitive and functional deficits. Although meningiomas are slow growing and considered relatively benign, this case illustrates the potential acute complications of trauma in a patient with meningiomas.

Poster 398 Sydenham Chorea, an Unusual Diagnosis With Complete Functional Resolution: A Case Report

zure disorder who developed Sydenham chorea. Program Description: The patient developed chorea that was initially thought to be seizure related. Workup was unremarkable except for positive anti-streptolysin O titer and identification of erythema marginatum rash. The patient was given a dose of intramuscular penicillin, then was treated with intravenous immunoglobulin, and was transferred to acute inpatient rehabilitation to recover functional independence and strength. The chorea relapsed, however, and patient was administered a 5-day course of intravenous methylprednisolone with good results. A week after completing the methylprednisone, the chorea again worsened. In addition, the patient was experiencing frequent partial and absence type seizure activity and began having frequent periods of dysarthria and dysphagia. The following day, he had 2 generalized seizures. Upon transfer back to the acute care hospital, intravenous phosphenytoin was given, which effectively treated the seizure activity and, surprisingly, also greatly reduced the problematic chorea. Setting: Acute inpatient rehabilitation hospital. Results: Once seizure activity was effectively controlled, the patient was able to swallow and talk again. The chorea also decreased and did not relapse. Two days later, the patient was discharged home but required outpatient physical and occupational therapy. Discussion: The clinical course for Sydenham chorea in this case was vastly more drawn out and complicated than expected. It is suspected that the underlying seizure disorder in combination with the development of Sydenham chorea contributed to the clinical course. It is plausible that the patient’s seizure threshold may have been lowered due to the Sydenham chorea. Conclusions: Medical and rehabilitation management for individuals with known seizure disorder who develop Sydenham chorea is not well defined in the present literature. Based on this particular case presentation, consideration should be made for a more aggressive antiepileptic medication regimen in patients with an underlying seizure disorder who are being treated for Sydenham chorea.

Poster 396 Sydenham Chorea in a Teenage Boy With a Debilitating and Complicated Clinical Course Due to Underlying Seizure Disorder: A Case Report

patterns in children with inborn errors of metabolism, and (2) to compare the 3D joint motions of the lower extremity of these children with typically developing children grouped by specific diagnosis. Design: A retrospective comparison of gait analysis data. Setting: Gait analysis laboratory of tertiary care pediatric hospital. Participants: 24 typically developing children and 6 children with inborn errors of metabolism. Interventions: Not applicable. Main Outcome Measures: Triplanar 3D joint motion of pelvis, hip, knee, and ankle; passive joint range of motion; and muscle tone. Results: Triplanar differences of 3D joint motions were noted. In the sagittal plane, children with mitochondrial disease and glycoprotein carbohydrate syndrome exhibited increased knee flexion and ankle dorsiflexion at the initial contact and mid-stance phase. Children with glutaric acidemia type I exhibited knee hyperextension and ankle plantarflexion during the mid-stance phase. Conclusions: This study suggests that children with inborn errors of metabolism have variable gait patterns: dystonic or spastic. Gait analysis provided evidence of muscle fatigue, which manifested as variation of gait pattern between trials, which cannot be elicited with physical examination techniques. The demonstrated gait patterns differ not only from typically developing children but also within the different diagnoses of inborn errors of metabolism, which may have significant clinical value for differentiation of these diagnoses of inborn errors of metabolism.

Poster 384 Heterotopic Ossification Confused With Osteomyelitis in a Child With Cerebral Palsy: A Case Report

ankle plantar flexion was noted. Conclusions: Overall, our results are consistent with those reported by Steinbok et al, which demonstrated improvement in ambulation distances; increased stride lengths; and improved hip, knee, and ankle motions after undergoing an SDR. Also, results from this retrospective study are consistent with a previous report, by Boscarino et al, of increase hip extension during stance. Our study also reported a similar finding, by Boscarino et al, that a nonstatistical significant increase in walking speed was found to be due to a statistically significant increase in stride length. In our data, less ankle plantar flexion throughout the gait cycle and less hip and knee flexion during stance were reported. Lastly, our kinematic data are inconsistent with Nivedita et al, who reported an increase in hip and knee flexion 1 year after undergoing a SDR.

Poster 318: Functional Improvement in Swallowing and Social Cognition After Intrathecal Baclofen Pump Placement in a 4-Year-Old Boy With Quadriplegic Cerebral Palsy Secondary to Shaken Baby Syndrome: A Case Report

Disclosures: K. Rothman, None. Patients or Programs: Patient 1, a 35-month-old girl, former 30.5-week-old preemie, with spastic diplegic cerebral palsy. Patient 2, a 25-month-old girl with congenital brain malformation and left spastic hemiparesis. Program Description: Both children underwent OnabotulinumtoxinA (obtx-A) motor point blocks of gastrocnemii muscles for management of spasticity. Patient 1 had bilateral gastrocnemii injected, whereas patient 2 just the left. Both subjects received a total of 50 units of obtx-A. Patient 1 weighed 10.8 kg, and patient 2 weighed 12.2 kg. Within 24 hours, patient 1 developed new onset status epilepticus. Patient 2 had a seizure 4 days after the injection. Setting: University tertiary care pediatric hospital. Results: Both patients were placed on long-term antiepileptic drugs. Discussion: Obtx-A is commonly used to treat spasticity in children with cerebral palsy. It is generally thought to have a good side-effect profile, though the FDA has recently required a Black Box warning. There is evidence that obtx-A may have central side effects. Research suggests that Obtx-A may affect spinal cord circuitry, the brainstem, and the motor cortex. There are several proposed mechanisms by which these central circuits are affected, including blocking gamma motor endings and reducing spindle afferent input from the treated muscle, plastic changes at both the level of the motor neuron and muscle, and retrograde transport and transcytosis. Central nervous system disruptions may potentially lower seizure threshold, especially in children with underlying risk factors for epilepsy. Seizures have been reported after obtx-A injections, however, this has been poorly documented. The above 2 cases developed seizures shortly after their injections. This raises concern that obtx-A may increase risk of seizures in children receiving obtx-A injections. Conclusions: Obtx-A motor point blocks may increase risk of seizure in children at risk for seizures. Poster 318 Functional Improvement in Swallowing and Social Cognition After Intrathecal Baclofen Pump Placement in a 4-Year-Old Boy With Quadriplegic Cerebral Palsy Secondary to Shaken Baby Syndrome: A Case Report. Sathya Vadivelu, DO (University of Missouri-Columbia, Columbia, MO); Jane A. Emerson, MD.