Michelle Stern

Three-Dimensional (3-D) Printing: A Cost-Effective Solution for Improving Global Accessibility to Prostheses

The lack of access to prostheses is a global problem, partially caused by the high cost associated with the current manufacturing process. Three‐dimensional printing is gaining use in the medical field, and one such area is prosthetics. In addition to using cost‐effective materials, this technology allows for rapid prototyping, making it an efficient solution for the development of affordable prostheses. If the rehabilitation medicine community embraces this novel technology, we can help alleviate the global disparity of access to prostheses.

Comparative effectiveness of home blood pressure telemonitoring (HBPTM) plus nurse case management versus HBPTM alone among Black and Hispanic stroke survivors: study protocol for a randomized controlled trial

BackgroundBlack and Hispanic stroke survivors experience higher rates of recurrent stroke than whites. This disparity is partly explained by disproportionately higher rates of uncontrolled hypertension in these populations. Home blood pressure telemonitoring (HBPTM) and nurse case management (NCM) have proven efficacy in addressing the multilevel barriers to blood pressure (BP) control and reducing BP. However, the effectiveness of these interventions has not been evaluated in stroke patients. This study is designed to evaluate the comparative effectiveness, cost-effectiveness and sustainability of these two telehealth interventions in reducing BP and recurrent stroke among high-risk Black and Hispanic stroke survivors with uncontrolled hypertension.Methods/DesignA total of 450 Black and Hispanic patients with recent nondisabling stroke and uncontrolled hypertension are randomly assigned to one of two 12-month interventions: 1) HBPTM with wireless feedback to primary care providers or 2) HBPTM plus individualized, culturally-tailored, telephone-based NCM. Patients are recruited from stroke centers and primary care practices within the Health and Hospital Corporations (HHC) Network in New York City. Study visits occur at baseline, 6, 12 and 24 months. The primary outcomes are within-patient change in systolic BP at 12 months, and the rate of stroke recurrence at 24 months. The secondary outcome is the comparative cost-effectiveness of the interventions at 12 and 24 months; and exploratory outcomes include changes in stroke risk factors, health behaviors and treatment intensification. Recruitment for the stroke telemonitoring hypertension trial is currently ongoing.DiscussionThe combination of two established and effective interventions along with the utilization of health information technology supports the sustainability of the HBPTM + NCM intervention and feasibility of its widespread implementation. Results of this trial will provide strong empirical evidence to inform clinical guidelines for management of stroke in minority stroke survivors with uncontrolled hypertension. If effective among Black and Hispanic stroke survivors, these interventions have the potential to substantially mitigate racial and ethnic disparities in stroke recurrence.Trial registrationClinicalTrials.gov NCT02011685. Registered 10 December 2013.

Case study: Gluteal compartment syndrome as a cause of lumbosacral radiculoplexopathy and complex regional pain syndrome

We present the case of a 24 yr old male who was diagnosed with gluteal compartment syndrome and was subsequently found to have developed lumbosacral radiculoplexopathy and complex regional pain syndrome. The patients gluteal compartment syndrome was diagnosed within 24 h of presentation to the emergency room, and he underwent emergent compartment release. While recovering postoperatively, persistent weakness was noted in the right lower limb. Results of electrodiagnostic testing were consistent with a lumbosacral radiculoplexopathy. After admission to inpatient rehabilitation, the patient complained of pain, burning sensation, and numbness in the distal right lower limb. Based on clinical findings, he was diagnosed with complex regional pain syndrome type II, or causalgia, and was referred for a lumbar sympathetic block under fluoroscopic guidance. Sympathetic block resulted in relief of the patients symptoms. He was discharged home with good pain control on oral medications.

Poster 253: A Rare Case of Purkinje Cell Cytoplasmic Antibody and P/Q-type Voltage-Gated Calcium Channel Antibody Positive Paraneoplastic Cerebellar Degeneration

hospital 13 days post-op, then re-admitted 2 days later for uncontrollable choreiform movements in all four extremities and slurred speech. Physical examination was most notable for proximal ballistic and distal choreiform movements, along with dystonic posturing of the trunk and bilateral upper extremities. Setting: Acute rehabilitation unit within a tertiary hospital Results: MRI of the brain was performed, revealing a symmetric bilateral increase of T1 signal intensity in caudate head, globus pallidus and putamen with no evidence of acute infarction. Presentation and imaging were consistent with post-pump chorea (PPC), a rare disorder seen more often in children than adults, which develops after cardiac surgery. Discussion: PPC is an acquired movement disorder related to prolonged circulatory arrest duration, time on extracorporeal circulation, hypothermia, and/or hypoxia. Patients often have no risk factor for movement disorders. FDCG-PET scans in a prior case report of this disease showed bilateral basal ganglia deep hypometabolism, which resolved within 6 months. The patient in our report had a history of two prior major surgical procedures, however no previously reported episodes of choreiform movements. As in other reported cases, this patient had no detectable morphological brain changes, thus PPC diagnosis remains a diagnosis of exclusion. Conclusions: PPC is a very rare but potentially severe complication of cardiac surgery. The exact pathophysiological process responsible for choreoathetosis following heart surgery is still unknown. Treatment included neuroleptic medication in addition to weights placed on extremities and torso to improve motor control. Level of Evidence: Level V

Poster 182: Brachial Plexopathy in Electrical Burn, A Collaborative Team Approach for Functional Planning: A Case Report

diagnosed with rhabdomyolysis and myonecrosis, suspected secondary to nutritional supplement use. He was admitted to inpatient rehabilitation to improve ambulation and overall strength and endurance, as well as activities of daily living. Setting: Inpatient Rehabilitation of Academic Medical Center. Results: Thepatient initially had significantbackpain and spasms,which limitedhis function. Bothof these symptoms improvedwhile in rehab. His CPKs trended down toward a normal range after intensive IV and oral hydration. At discharge, he was independent with transfers and ambulation, and was able to ambulate >500 feet with no assistive device. Discussion: Rhabdomyolysis can be caused by traumatic events (crush injuries) or non-traumatic events such as supplements, drugs, infections or overtraining. Over the counter nutritional supplements are used frequently by athletes, many times in combination with other supplements as well as prescription medications. The FDA does not evaluate these supplements and great caution must be taken when considering using these products. Patients should consult with a physician to fully review all current medications as well as herbal and nutritional supplements they are taking prior to beginning any new supplements. Conclusions: Nutritional supplements can be a possible cause of rhabdomyolysis. Level of Evidence: Level V

Poster 324 Opsoclonus-Myoclonus-Ataxia Syndrome and HIV Infection. A Case Report

the intent of using this increased arousal to further stimulate progress in therapy. Unlike prior case reports, we chose to use intermittent dosing of zolpidem rather than continuous. After 3 weeks of intermittent dosing, our patient successfully emerged from a MCS and continues to make gains in cognition and communication. Setting: Veterans Affairs (VA) inpatient Polytrauma Rehabilitation Center (PRC), San Antonio, Texas. Results: Coma Recovery Scores-Modified (CRS-M) were obtained 30 minutes before and after each dose of zolpidem administered between September 24 and October 15, 2015. Zolpidem dosing of 2.5mg twice daily did not show a significant change in CRS-M scores, which remained consistent with MCS. However, emergence from MCS was seen after increasing dose to 5mg twice a day. In addition, we also noted that the patient was still able to consistently demonstrate a score on CRS-M indicative of this emergence eight days afterwards, without need for repeat administration of zolpidem. Discussion: A thorough review of the current literature summarizes the use of zolpidem as a feasible, yet controversial treatment for enhancing recovery from DOC. Increased arousal was typically correlated with increased dosing. Several case series and placebo-controlled studies have described the mixed effects of daily zolpidem use. Nonetheless, there is limited evidence regarding any lasting effects of zolpidem after the medication is discontinued, or specific dosing and frequency recommendations. There is also a paucity of information on the effects of long-term zolpidem use in TBI and anoxic brain injury populations. This case report is the first to describe the outcome of short term, intermittent dosing of zolpidem in a patient who was in a persistent minimally conscious state, resulting in sustained emergence and continued improvement in function. In addition, an effective dose and frequency of zolpidem administration were identified, along with the possibility of enduring effects on arousal even between doses. Conclusions: Given their complexity in both presentation and pathophysiology, clinical management of DOC can be challenging and nuanced. Short term, intermittent dosing of zolpidem at a dose of 5mg twice a day both increased arousal and led to emergence from MCS in our 21-year-old patient with severe TBI and concurrent anoxic brain injury. Further research is needed to elucidate the efficacy of intermittent zolpidem dosing in the TBI and anoxic brain injury patient population. This case report introduces its potential as a promising adjuvant therapy in conjunction with comprehensive rehabilitation therapy in order to effectively manage and treat patients with DOC. Level of Evidence: Level V

Poster 236 The Use of a Telepresence Communications Robot by a Patient with Spinal Cord Injury to Aid in Social Reintegration and “Virtual Mobility”: A Case Report

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

Poster 409 Tackling Pain After Above Knee Amputation: What Are Our Options? A Case Report

consisting of a physical therapist, occupational therapist, pain management therapist, neuropsychologist, nurse, resident physician and an attending physician. The pain management team saw patients that experienced pain and aided in pain control with a variety of support modalities including medications, physical and occupational therapy. There is a high correlation that can be made between the of presence pain and a cerebrovascular accident in our IRF patient population. Level of Evidence: Level II

Poster 7 Plasmodium Falciparum Malaria and Stroke: A Case Report

Disclosures: H. Wang: I Have No Relevant Financial Relationships To Disclose. Case Description: A 71-year-old man, recent immigrant from Ghana, was admitted to acute inpatient rehabilitation for left middle cerebral artery infarct developed in Ghana and was found to have deep venous thrombosis (DVT). Comprehensive rehabilitation focusing on right hemiplegia and aphasia was interrupted by spiked fever with leucopenia not responding to empiric broad spectrum antibiotics. Parasitemia with Plasmodium falciparum (0.06%) was found on blood smear. On further questioning, patient recalled a history of malaria while in Ghana. He completed a 7-day course of quinine and doxycycline. Hypoglycemia secondary to quinine-induced hyperinsulinemia was managed with intravenous glucose. Setting: Acute inpatient rehabilitation unit at a university hospital. Results or Clinical Course: Patient remained afebrile with negative blood parasites and achieved improvement in mobility and active daily activities with intensive rehabilitation. Discussion: Malaria is a parasitic disease with high prevalence in several regions of the world. Cerebral malaria is the most severe complication of Plasmodium falciparum malaria and presents with various neurological manifestations including cerebral venous thrombosis and cerebral arterial occlusion. Postulated pathogenesis favors hypercoagulable state and mechanical plugging of cerebral venules by clumped, parasitized red cells. Malaria is known to cause activation of the coagulation cascade resulting in pulmonary embolism, peripheral gangrene and intracranial venous thrombosis. In our case, with the absence of risk factors of hypertension, diabetes mellitus, smoking, dyslipidemia and previous stroke, the possibility of this stroke being a chance occurrence with Plasmodium falciparum malaria is highly likely. The concomitance DVT can also be explained as a hypercoagulation complication of malaria. Physiatrist should be aware of the possible cause of stroke by malaria for patient with high risk so that proper treatment can be initiated in a timely manner. Conclusion: Although rare, cerebral malaria should be considered as a differential diagnosis for stroke patients from hyperendemic area. Prompt diagnosis and anti-malarial therapy are critical to prevent further complications.

Poster 194 Peripheral Neuropathy in Hodgkin’s Lymphoma: Neurolymphomatosis or Guillain-Barre Syndrome. A Case Report

Disclosures: D. Berbrayer: I Have No Relevant Financial Relationships To Disclose. Objective: To explore barriers to physical activity in Adult Spina Bifida Design: This is a descriptive study in which the outcome variable is the barriers to physical activity. The Physical Activity Scale for Individuals with Physical Disabilities (PASIPD) was administered to quantify physical activity levels. The scale includes a total of 13 items which range from leisurely activities such as household cleaning to vigorous exercise. Each item is then quantified by multiplying the average hours per week of the activity by an intensity value that is specific for each item. This scale has been proven to have adequate construct validity as well as test-retest reliability. The Barriers to Physical Activity and Disability Scale (BPADS) is the second measurement scale used in this study. Through both quantitative (yes/no responses) and qualitative questions (open-ended questions), a variety of personal and environmental barriers to physical activity were elucidated. Setting: Academic teaching hospital Participants: 8 Adults with Spina Bifida Interventions: 2 questionnaires: Physical Disabilities Scale (PASIPD) and the Barriers to Physical Activity and Disability Scale (BPADS) Main Outcome Measures: Scores from the PASIPD were calculated and scores from the individual factors within the total PASIPD score. Means and standard deviations of physical activity scores will also be reported. Responses from the quantitative portion of the BPADS were tallied for frequency. Results or Clinical Course: Participants (n1⁄48) mean total PASIPD score was 25.73 15.24; mean SD. The total score was divided among 5 factors (Home Repair/Gardening e 0 0, Housework e 0.96 1.12, Vigorous Sport e 11.17 15.02, Moderate Sport e 1.6 2.03, Occupation/Transportation e 12.01 10.85). Reasons and concerns for lack of exercise participation included: cost, transportation, lack of knowledge, fear of injury, motivation and lack of energy. Conclusion: Most adult spina bifida are currently not in an exercise program or do not have a set physical activity schedule yet would like to start one. There is nothing in the physical environment that prevents exercise. Most have been told by their doctor to exercise but not been told how to exercise. Physiatrists need to be more specific in an exercise prescription for adult spina bifida.