Kevin T. White

Fatigue Analysis Before and After Shaker Exercise: Physiologic Tool for Exercise Design

Recent studies suggest that the Shaker exercise induces fatigue in the upper esophageal sphincter (UES) opening muscles and sternocleidomastoid (SCM), with the SCMs fatiguing earliest. The aim of this study was to measure fatigue induced by the isometric portion of the Shaker exercise by measuring the rate of change in the median frequency (MF rate) of the power spectral density (PSD) function, which is interpreted as proportional to the rate of fatigue, from surface electromyography (EMG) of suprahyoid (SHM), infrahyoid (IHM), and SCM. EMG data compared fatigue-related changes from 20-, 40-, and 60-s isometric hold durations of the Shaker exercise. We found that fatigue-related changes were manifested during the 20-s hold. The findings confirm that the SCM fatigues initially and as fast as or faster than the SHM and IHM. In addition, upon completion of the exercise protocol, the SCM had a decreased MF rate, implying improved fatigue resistance, while the SHM and IHM showed increased MF rates, implying that these muscles increased their fatiguing effort. We conclude that the Shaker exercise initially leads to increased fatigue resistance of the SCM, after which the exercise loads the less fatigue-resistant SHM and IHM, potentiating the therapeutic effect of the Shaker exercise regimen with continued exercise performance.

Opiates for chronic nonmalignant pain syndromes: can appropriate candidates be identified for outpatient clinic management?

White KT, Dillingham TR, González-Fernández M, Rothfield L: Opiates for chronic nonmalignant pain syndromes: Can appropriate candidates be identified for outpatient clinic management? Objective:To better define patients appropriate for opiate management for chronic pain syndromes. Design:Retrospective study of 65 patients with noncancerous pain syndromes who were on or being considered for opiates and who were transitioned into a structured outpatient clinic with close monitoring and management. Noncompliance with this outpatient pain management program was the primary outcome. Noncompliance was defined as (1) receipt of prescriptions from providers outside of this clinic, (2) increase in medication dosage without proper approval, (3) refusing toxicology screening on entrance into the program, (4) negative toxicology tests for prescribed medications, (5) positive toxicology tests for psychoactive medications not prescribed, or (6) discovery on toxicology tests of the presence of illicit substances. Results:There were 24 cases of noncompliance (37%), with age <56 yrs old demonstrating significant (P = 0.02) association with persons who were noncompliant with the outpatient program. Forty-three percent of those younger than 56 yrs were noncompliant with program, yet no patient older than 56 yrs was noncompliant. Working status approached significance (P = 0.07) with those patients out of work demonstrating a greater likelihood of noncompliance. There were no correlations found between other patient characteristics and the level of compliance with the program. Conclusions:When considering opiates as a treatment option, pain clinics should have a heightened suspicion for younger and unemployed patients. Although these findings should be examined in larger studies, they suggest that nonmedical factors play a substantial role regarding success in such a structured opiate pain program.

Individual Placement and Support in Spinal Cord Injury: A Longitudinal Observational Study of Employment Outcomes

OBJECTIVE To determine the effects of a 24-month program of Individual Placement and Support (IPS) supported employment (SE) on employment outcomes for veterans with spinal cord injury (SCI). DESIGN Longitudinal, observational multisite study of a single-arm, nonrandomized cohort. SETTING SCI centers in the Veterans Health Administration (n=7). PARTICIPANTS Veterans with SCI (N=213) enrolled during an episode of either inpatient hospital care (24.4%) or outpatient care (75.6%). More than half the sample (59.2%) had a history of traumatic brain injury (TBI). INTERVENTION IPS SE for 24 months. MAIN OUTCOME MEASURE Competitive employment. RESULTS Over the 24-month period, 92 of 213 IPS participants obtained competitive jobs for an overall employment rate of 43.2%. For the subsample of participants without TBI enrolled as outpatients (n=69), 36 obtained competitive jobs for an overall employment rate of 52.2%. Overall, employed participants averaged 38.2±29.7 weeks of employment, with an average time to first employment of 348.3±220.0 days. Nearly 25% of first jobs occurred within 4 to 6 months of beginning the program. Similar employment characteristics were observed in the subsample without TBI history enrolled as outpatients. CONCLUSIONS Almost half of the veterans with SCI participating in the 24-month IPS program as part of their ongoing SCI care achieved competitive employment, consistent with their expressed preferences at the start of the study. Among a subsample of veterans without TBI history enrolled as outpatients, employment rates were >50%. Time to first employment was highly variable, but quite long in many instances. These findings support offering continued IPS services as part of ongoing SCI care to achieve positive employment outcomes.

Poster 366: The Development of Hypertension in Chronic SCI Patients with Level of Injury T7-or-Below: A Retrospective Chart Review

tent with near-drowning (bilateral subconjunctival hemorrhage), normal upper extremity neurological function, but marked deficiencies in neurological functions of the lower extremities, including, poor proprioception in the big toes, and patchy decrease in sensation to light touch and pinprick on the lower extremities, significantly decreased lower body muscle strength and decreased rectal tone. There was also large area of bruising over the upper abdominal wall. Setting: Tertiary care pediatric hospital Results: MRI thoracic and lumbar spine demonstrated disruption of the anterior longitudinal ligament and avulsion fracture at the T11 level with hemorrhage into the vertebral body. Vague enhancement was seen within the cord, suggestive of ischemic injury to the cord. Discussion: The most common causes of spinal cord injury in a swimming pool are due to diving and impact on the bottom of the pool. In this case, a spinal cord injury resulted from the combined forces of an uncovered suction drain and the necessary effort to dislodge the boy. This caused a T11 avulsion fracture and consequent ischemic injury to the cord. Replacing defective swimming pool pumps, broken or missing drain covers is crucial to prevent similar accidents. Conclusions: This spinal cord injury was caused by a unique mechanism, namely suction entrapment in a swimming pool. There should be increased awareness of the importance of properly installed suction drain covers, and that the rescue effort may result in spinal cord injury.

Poster 312: The Use of Photobiomodulation Therapy for a Pressure Ulcer: A Case Report

for functional decline. She demonstrated short-term improvement with FIM change of 46 (when metronidazole was held temporarily) and 10 points during 2 separate admissions but quickly regressed post-discharge. At her last acute care admission, MRI head was performed showing complex areas of both nuclear and deep white matter signal abnormality with ventricular signal abnormality consistent with possible immune-provoked or toxic process. Metronidazole was discontinued and she was again sent to inpatient rehabilitation where discharge FIM improved to 92. Six weeks post metronidazole discontinuation, repeat MRI head showed interval resolution of previously noted abnormal signals. At 8-week follow-up, cognitive function had returned to baseline, she had no reported falls, and has not been re-admitted all while off metronidazole. Conclusions: MIE is a reversible encephalopathy that can mimic common impairments seen within inpatient rehabilitation facilities. Given the increasing use of metronidazole for C. difficile related disorders, physiatrists should be aware of this clinical entity for patients using this medication.