Naomi Lynn H. Gerber

Poster: Teaching letter writing using a programmable haptic device interface for children with handwriting difficulties

We designed a virtual hand-writing teaching system for children with handwriting difficulties due to attention or motor deficits, using a haptic interface that could provide a neutral, repetitive engaging approach to letter writing. The approach we took to accomplish this included: (a) Using letter primitives, (b) User friendly interface for teachers, therapists, subjects and parents, (c) Adjustable force and assessment mode, and (d) Quantitative reports. We evaluated 4 subjects. We obtained pre-training letter formation, then followed with a prescribed training session in which a fixed number of haptic driven repetitions was performed. Subjects were post-tested with free-form letter writing. Anecdotally, 2 children had obvious improvement in accuracy of letter formation, one slowed down speed with which he formed letters, which resulted in more legible handwriting. Children were engaged in the process and reported they had fun and would do it again.

Markerless identification of key events in gait cycle using image flow

Gait analysis has been an interesting area of research for several decades. In this paper, we propose image-flow-based methods to compute the motion and velocities of different body segments automatically, using a single inexpensive video camera. We then identify and extract different events of the gait cycle (double-support, mid-swing, toe-off and heel-strike) from video images. Experiments were conducted in which four walking subjects were captured from the sagittal plane. Automatic segmentation was performed to isolate the moving body from the background. The head excursion and the shank motion were then computed to identify the key frames corresponding to different events in the gait cycle. Our approach does not require calibrated cameras or special markers to capture movement. We have also compared our method with the Optotrak 3D motion capture system and found our results in good agreement with the Optotrak results. The development of our method has potential use in the markerless and unencumbered video capture of human locomotion. Monitoring gait in homes and communities provides a useful application for the aged and the disabled. Our method could potentially be used as an assessment tool to determine gait symmetry or to establish the normal gait pattern of an individual.

Motion based markerless gait analysis using standard events of gait and ensemble Kalman filtering.

We present a novel approach to gait analysis using ensemble Kalman filtering which permits markerless determination of segmental movement. We use image flow analysis to reliably compute temporal and kinematic measures including the translational velocity of the torso and rotational velocities of the lower leg segments. Detecting the instances where velocity changes direction also determines the standard events of a gait cycle (double-support, toe-off, mid-swing and heel-strike). In order to determine the kinematics of lower limbs, we model the synergies between the lower limb motions (thigh-shank, shank-foot) by building a nonlinear dynamical system using CMUs 3D motion capture database [1]. This information is fed into the ensemble Kalman Filter framework to estimate the unobserved limb (upper leg and foot) motion from the measured lower leg rotational velocity. Our approach does not require calibrated cameras or special markers to capture movement. We have tested our method on different gait sequences collected from the sagttal plane and presented the estimated kinematics overlaid on the original image frames. We have also validated our approach by manually labeling the videos and comparing our results against them.

Ultrasound Imaging and Elastography for Characterizing Muscle Tissue in Myofascial Pain Syndrome

home from the EC the same day or kept overnight in the EC observation unit. A difference in length of stay between the two groups was identified in the upper quartile of patients, which included the patients admitted to the hospital for more than one day. There were 338 patients in the Control group who were admitted longer than one day for a total of 2033 hospital days. There were 51 patients in the PM&R Consult group admitted for more than one day for a total of 243 hospital days. The mean LOS for patients admitted more than one day was 6.01 days for the Control group and 4.76 days for the PM&R Consult group. When the mean LOS for the PM&R Consult group was applied to the Control group it equated to a savings of 424 hospital days. A Wilcoxon two-sample test was performed to compare the similarity of the length of stay data in the two groups. The Wilcoxon twosample test results indicated that for patients admitted longer than one day the LOS was significantly lower in the PM&R Consult group (p< .0001). Conclusions: The length of stay for patients admitted to the hospital for more than one day with back pain was significantly less for patients who received a PM&R consultation in the EC.

Chapter 21 – Measures of Function and Health-Related Quality of Life

Abstract National and international health agencies define health as physical, mental, and social well-being of an individual. Measurement of these domains poses a challenge to clinicians and researchers because administering tests is time consuming, and the information obtained include self-reports. Nonetheless, these measures of function, quality, and health-related quality of life (HRQL) are important to patients and are critical for quality care. Function is the usual or customary activities of a person. Functional status is the degree to which an individual can perform chosen roles without limitation in three key domains: physical, social, and psychocognitive. HRQL measurements assess a patients perception of his/her ability to perform function as influenced by illness. General quality of life (QoL) is a reflection of overall satisfaction with life. This chapter discusses an approach to the selection and application of measures, using patient-reported outcomes that are designed to evaluate function, HRQL and QoL; and identifies valid, reliable, and sensitive instruments that have been used in clinical research. It presents the new techniques, item response theory, and computer adaptive testing, used in creating efficient and appropriate self-reports.

Poster 199 Vibration Elastography to Assess the Effect of Dry Needling on Myofascial Trigger Points in Patients Affected by Myofascial Pain Syndrome

Disclosures: S. Gingrich, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 72-year-old woman presented to an outpatient clinic for severe left medial knee and proximal left leg pain which she begannoticingwhile shoppingwithout any preceding trauma. Two daysprior toher symptoms’onset, shehadbeenanticoagulated for atrial fibrillation with rivaroxaban. Physical examination of the left leg revealed antalgic gait with significant edema, extensive ecchymosis, medial knee joint line tenderness and a large knee effusion. The dorsalis pedis pulses and neuromuscular examination were normal. Setting: Outpatient clinic. Results or Clinical Course: Emergent lower limb venous duplex studies were negative for thrombosis. A left knee musculoskeletal ultrasound showed a large complex effusion interspersed with hypoechoic and isoechoic signal. Arthrocentesis yielded only approximately 2 cc of sanguinous fluid. Subsequent left knee MRI showed a complex joint effusion with low T1 and variable T2 signal intensities consistent with coagulated blood product. After discussion with the patient’s primary care physician, rivaroxaban was discontinued in favor of warfarin. The patient has not had a repeat hemarthrosis after changing her anticoagulant. Discussion: Spontaneous atraumatic hemarthroses are known to occur during warfarin anticoagulation. Such incidents are often, though not always, attributed to supratherapeutic dosing. This case, to our knowledge, is the first reported incident of spontaneous atraumatic hemarthrosis occurring during appropriately dosed rivaroxaban anticoagulation. Conclusions: Oral direct thrombin and factor Xa inhibitors such as rivaroxaban and dabigatran differ from vitamin K antagonists such as warfarin in that their anticoagulative activity is typically unmonitored. This raises the possibility of inducing a spontaneous bleeding event such as hemarthrosis in individuals who could be more sensitive to such medications. Thus, as our case demonstrates, hemarthrosis should be considered in the differential diagnosis of any orally anticoagulated patient presenting with a knee effusion regardless of the anticoagulant used.

Fear of Flying: Flying Practices of Breast Cancer Survivors with and without Lymphedema

Poster 74 Fear of Flying: Flying Practices of Breast Cancer Survivors with and without Lymphedema. Kayla Williams, BS (National Institues of Health, Bethesda, MD, United States); Lucinda Pfalzer, PT, PhD, FACSM, FAPTA; Ellen W. Levy, PT, OCS; Ching-yi A. Shieh, PhD; Naomi Lynn H. Gerber, MD; Charles L. McGarvey, PT, DPT, MS, FAPTA; Barbara Springer, PT, PhD, OCS, SCS; Peter Soballe, MD; Nicole Stout, MPT, CLT-LANA.

Dry-Needling is Effective in Treating Active Myofascial Trigger Points in Subjects with Chronic Myofascial Pain: A Prospective Trial

Disclosures: A. Reddy, No Disclosures: I Have Nothing To Disclose. Objective: Development of functional assessment tool for chronic pain patients that provides practitioners with a common outcome evaluation to quantify patients’ progress during a pain management program. It was hypothesized that the functional assessment tool developed will show objective evidence of decreased physical capabilities by patients with chronic pain relative to healthy participants’ outcomes. Design: Case-control study. Setting: Outpatient pain treatment center. Participants: 31 healthy control participants and 104 chronic pain patients. Interventions: Literature review performed initially to assimilate various individual functional tests into a single comprehensive assessment tool which was named, Marianjoy Pain Functional Assessment Tool (MPFAT). Collection of data was obtained utilizing MPFAT on healthy control subjects and initial assessments of chronic pain patients enrolled in a comprehensive pain management program. Main Outcome Measures: The MPFAT outcomes were based upon subject’s assessment of initial self physical ability, visual analog pain score, 6 minute walk test, fast walking 10 meters, handgrip strength, sit to stand repetitions, lifting adjustable weighted object, step-ups, subject’s estimate of perceived exertion, and assessment of pain behavior using Modified University of Alabama-Birmingham Pain Behavior Scale. T-tests and Chi-Square were used for comparison between healthy control subjects and chronic pain patients’ initial assessments. Results or Clinical Course: All performance outcomes measured by the MPFAT showed significant (p<.05) decrease in baseline physical function of chronic pain patients compared to healthy control subjects, with exception of hand grip strength. Most significant mean differences were noted by chronic pain patients’ lower 6 minute walk test, fast walking 10 meters, sit to stand repetitions, and lifting adjustable weighted object compared to healthy controls. Conclusions: Framework provided by MPFAT showed objective evidence of physical decline in the chronic pain patient study group as hypothesized. Thus, it may be plausible for the MPFAT to be further used in other pain management program settings to objectively track patient progress.

Poster 42 Feasibility of Haptic Use for Patients with Chronic Traumatic Brain Injury

Disclosures: N. H. Gerber, No Disclosures. Objective: Determine the utility of a force feedback robot and virtual reality interface in assessed upper extremity activities in subjects with chronic traumatic brain injury (TBI). Design: Prospective cohort study. Setting: Biomedical research facility. Participants: 19 adults with TBI (7 mild, 3 moderate, 9 severe), 11 male / 8 female, mean age 50.4 years (SD 7.1), mean years from injury 10 year (SD 6.4). 3 were employed, 1 full time student; 9 received inpatient neurorehabilitation. Seven injuries resulted from MVA, 9 from falls, 2 from IED and 1 sports. Interventions: Stylus-driven haptic device navigating virtual scenes in 3D space. Subjects performed three repetitions of virtual tasks: 1. remove tools from a workbench (TOOL), 2. compose three-letter words (SPELL), 3. manipulate utensils to prepare a sandwich (SAND). Main Outcome Measures: Self-report of engagement in the activities (boredom), time to completion or number of words completed, neuropsychological symptom inventory (NSI), Purdue Peg Motor Test (PPT). Results: All 19 reported high engagement; 6 reported high level of frustration, but completed tasks with short breaks. Mean boredom score: 108 (SD 17.7) (normal range 81-117); mean PPT 54 (SD 15), (normal range for assembly line workers 67); mean NSI: 33 (SD 26). Change in three trials: best improvement in TOOL time decreased by (mean) 48 secs (SD 56.9); best improvement in SPELL was (mean) 2.8 words (SD 2.6), and best improvement in SANDprep time decreased by (mean) 19.7 sec(SD 32). PPT correlated with baseline SAND (r-.61, P .008) and SAND improvement time (r.60, P .02). NSI correlated with improvement in TOOL time (r-.45, P .09). Conclusions: All subjects were highly engaged, despite some subjects having difficulty with the task. Almost all subjects improved their performance suggesting significant practice effects that will require further study before this tool can be deployed as an assessment measure. The significant correlations between the PPT, NSI and haptic outcomes suggest a promising level of external validity.

Poster 397 Comparison of Clinical Characteristics in Research Subjects With Chronic Neck Pain and Active Myofascial Trigger Points and Normal Controls

Disclosures: M. Delille, No Disclosures. Case Description: This case series reports on 15 patients who presented with radicular pain symptoms. Initial rehabilitation treatment consisting of medications and physical therapy failed to alleviate their symptoms. In all cases, magnetic resonance imaging (MRI) revealed severe neuroforaminal stenosis causing ipsilateral radicular symptoms consistent with the affected level. All patients then underwent a single ipsilateral retrodiscal transforaminal epidural steroid injection. Setting: University hospital-based spine center. Results or Clinical Course: The retrodiscal approach for injection with ropivacaine and betamethasone for radicular symptoms in a disc herniation resulted in complete or nearly complete pain relief after 1-2 injections. Utilizing fluoroscopy, no difficulty was encountered to enter the retrodiscal space. Pain relief in the patients started 24 hours to 1 week postinjection and persisted for at least 6 months in most of the patients. Functionally, the patients improved or returned to their previous level of activity. Discussion: The retrodiscal approach (RDA) was used in this series of 25 patients as an alternative to the classical approach of performing a transforaminal epidural steroid injection (TFESI) or selective nerve root block (SNRB). The RDA technique consists of approaching the site of pathology as one would for a discogram in the inferior aspect of the neural foramen. The anterior advancement of the needle is monitored by fluoroscopy in multiple planes so as to not puncture the annulus. This approach has been reported only sporadically in the literature, but has been found safe in all cases. An advantage of this approach is fewer intravascular injections and delivery of medication even closer to the site of the herniation. Its use in cases of severe neuroforaminal stenosis, which prevents an adequate entry of the needle into the affected neuroforamen, is advocated. We have consistently seen that with the use of contrast, it spreads and exits the neuroforamen of the same target level. Conclusions: Cases with severe neuroforaminal stenosis prevent a safe needle entry subpedicularly; however, they may still benefit from a retrodiscal trasforaminal epidural injection. Future studies comparing the traditional subpedicular transforaminal injection technique with the RDA technique should be considered.