Robert Kent

Patient safety in the rehabilitation of the adult with an amputation.

This article reviews and summarizes the literature on patient safety issues in the rehabilitation of adults with an amputation. Safety issues in the following areas are discussed; the prosthesis, falls, wound care, pain, and treatment of complex patients. Specific recommendations for further research and implementation strategies to prevent injury and improve safety are also provided. Communication between interdisciplinary team members and patient and caregiver education are crucial to executing a safe treatment plan. The multidisciplinary rehabilitation team members should feel comfortable discussing safety issues with patients and be able to recommend preventive approaches to patients as appropriate.

A Mobile Rehabilitation Clinic to Extend Specialized Services to Community-Based Outreach Clinics

Disclosures: M. Massey, No Disclosures: I Have Nothing To Disclose. Case Description: This case report discusses the choreoathetosis of a patient due to diabetic striatal disease. The patient had no past medical history of common causes of choreoathetosis. Setting: Freestanding acute rehabilitation hospital Results or Clinical Course: CT of the head from outside hospital significant for hyperdensities in bilateral basal ganglia. Improved glycemic control during stay slowly improved symptoms of choreoathetosis. Discussion: Movement disorders are treated in the rehabilitation setting. Uncontrolled diabetes is a rare cause of choreoathetosis. Achieving blood sugar control with supplemental antipsychotic medication has been shown to improve patients’ choreoathetosis due to uncontrolled diabetes. During our patient’s admission, blood glucose control was achieved and the patient was placed on haloperidol. The patient had a baseline functional independence measure of mostly total and maximal assistance for activities of daily living and locomotion. Functional gains to minimal/setup assistance for activities of daily living were achieved. She also reached modified independence for wheelchair locomotion and standby assistance for ambulation with a rolling walker. Her initial diet of puree consistency with nectar thick liquids was upgraded to regular consistency with thin liquids. Upon discharge the patient had little, if any, residual choreoathetotic movements. Conclusions: Choreoathetosis secondary to diabetic striatal disease can be improved with glycemic control and antipsychotic medication. Physiatrists should be aware of this uncommon cause of choreoathetosis and treat accordingly.

Poster 290: Intramuscular Steroid Injections for the Treatment of Wrist Drop Due to Excessive use of Muscle Enhancement Oil Site Injections: A Case Report

Disclosures: James Meiling: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Slipped capital femoral epiphysis (SCFE) is a unique emergent hip disorder that afflicts children and teenagers. The most common presentation of SCFE is varus slip, a posterior and inferior displacement of the proximal femoral epiphysis on the femoral metaphysis; however, SCFE also presents less frequently as a valgus slip, a posterior and lateral displacement. Bilateral SCFE happens even less often than unilateral SCFE, so a case of simultaneous bilateral valgus SCFE is unique. Setting: Outpatient Primary Care, Outpatient Pediatric Specialty Clinic. Results: An 11-year-old normal weight girl presented with simultaneous bilateral valgus SCFE. She underwent bilateral in situ pinning to prevent further slippage, but post-surgery rapidly developed acute right hip pain caused by retained hardware that inadvertently entered the acetabulum and protruded into the inner wall of the pelvis. An additional operation took place where surgeons dislocated her right hip to remove the retained screw and revised pinnings of both hips. She faced numerous complications, including decreased sensation and numbness on the dorsum of her right foot and decreased peroneal distribution. Almost 2 years later she continues to experience progressive right hip pain, pinpointed to the tip of the greater trochanter on the lateral aspect of her right hip. The hardware irritation pain resolved after the removal of symptomatic hardware in the right hip. However, she still complains of severe radiating right hip pain on the anterior aspect of her hip, which displays significant acetabular dysplasia and a small cystic area on MRI. Discussion: Valgus SCFE is infrequent, but important. Limited available cases for review. Conclusions: Valgus SCFE is a rare presentation of an uncommon musculoskeletal condition. According to the literature, simultaneous bilateral valgus SCFE in a female might be anticipated, but because of the infrequency of such cases the nature of both the presentation and demographics are still being discovered and understood. Level of Evidence: Level V

Poster 388 Improvement in Pain Control in Complex Regional Pain Syndrome Treated with Buprenorphine Patch and Topical Compounding Cream Containing Ketamine and Clonidine: A Case Series

Disclosures: Elisabeth Fehrmann: I Have No Relevant Financial Relationships To Disclose Objective: To evaluate the personal factors of age and gender within the ICF, and to investigate the importance of the ICF core set for low back pain (LBP) plus additional ICF categories. Design: Cross-sectional study. Setting: The study took place in an outpatient rehabilitation center. Patients underwent an ICF interview led by ICF trained psychologists. Participants: After providing informed consent, 245 patients with chronic LBP participated in the study (52% female; Mage 1⁄4 49 17.8). Interventions: Not applicable. Main Outcome Measures: The comprehensive ICF core set for activities and participation (A&P) and environmental factors (EF) was assessed. Based on a literature review seven further ICF categories were included to the interview. Categories were considered as important, if more than 30% of the patients rated A&P as limiting, or as a facilitator/barrier. ICF categories were combined by a factor analysis, and ANOVAs were assessed to explore age and gender differences. Results: RegardingA&Polder patients reported significantly higher levels of physical disability, whereas younger men reported more problems in occupational tasks, relationships, and coping with stress compared to same-aged women. All of the environmental factors were classified as relevant, with “health professionals” and “health services” reported as the most important facilitators. In addition to the core set, “friends” and “individual attitudes of friends” were considered as relevant facilitators. Younger patients reported to be more discontent regarding public services, and societal attitudes compared to older patients. Conclusions: Assessing chronic LBP using the ICF, age and gender differences should be considered. Specific needs of older patients regarding physical functioning, and of younger men regarding coping with stress, occupational tasks, and relationships should be taken into account in rehabilitation therapy. In addition to the core set, the categories “friends,” “individual attitudes of friends” showed to be important facilitators, and should be included into the list of EF, and promoted in a resource-centred approach. Level of Evidence: Level II

Episode of Autonomic Dysreflexia Secondary to Sumatriptan in Treatment for Migraine Headache: A Case Report

visual analogue score 1-10 (VAS), self-report of the Brief Pain Inventory (BPI) and algometry measuring pressure-pain threshold (PPT). Secondary outcomes: Profile of Mood States (POMS), MOS-SF36 (SF-36), Oswestry Disability Score (OSW), cervical side bending asymmetry using difference in range of motion (ROM). Results or Clinical Course: Baseline-Visit 3 changes in aMTrPs group (means, standard deviation, p-values): BPI 3.52 1.78 -2.3 2.09 (p<.0001); OSW (p1⁄4.09); POMS (depression, tension, mood) (p<.04);POMS fatigue .9 1.02 .56 .73 (p1⁄4.08). ROM 5.38 4.7 -2.6 2.44 (p1⁄4.002). VAS average L(3.34 2.04-1.93 2) and R(3.44 2.55-2 2) (p<.005); SF36 mental health 74.4 16.379.83 11.2 (p1⁄4.02); PPT 7.08 2.43 to 8.47 2.23 (p<.001). Palpation of 29 aMTrPs changed to:10 normal,14 latent, 5 unchanged (active). Differences between baseline measures for subjects with aMTrPs compared with pain-free controls, were all statistically significant. However, differences between groups when comparing aMTrPs after treatments (Visit 3) and controls showed: No differences in POMS (all subscales) and ROM. Remaining measures remained significantly different. Conclusions: Based in on this interim analysis, subjects with aMTrPs are significantly different from pain-free controls in selfreport and algometric measures of pain. Three, weekly dry needling treatments significantly improved pain reports, PPT, MTrPs status, asymmetry of cervical side bending, symptoms of depression, tension, mood and mental health. At the end of treatment, mood and asymmetrical motion were indistinguishable from pain-free controls. Dry needing is an effective treatment for improving symptoms and mood in people with aMTrPs and chronic myofascial pain.

Hemiballismus in a Polytrauma Patient with a Severe Traumatic Brain Injury and Damage to his Basal Ganglia: A Case Report

dysarthria. He was started on broad spectrum antibiotics and once deemed medically stable was transferred to acute rehab. Setting: Acute inpatient rehabilitation. Results or Clinical Course: During the acute rehab course, therapy focused on developing speech compensatory strategies using multiple modalities for facilitating functional communication such as slower speech and use of short phrases. Training in swallow compensatory strategies included techniques to improve anterior to posterior bolus transit and tongue base contraction strength for enhanced pharyngeal propulsion. Subsequently, the patient showed improvement of dysarthria with observed tongue tip elevations. He continued to have persistent oral dysphagia for which he was able to perform compensatory strategies and was upgraded to an oral diet. Discussion: Skull base osteomyelitis usually arises from the progression of otitis externa to adjacent temporal bone and soft tissue. Atypical rare cases, such as this one, can present without otitis externa as the inciting source. Research supporting the assessment and treatment of speech and swallowing difficulties in combination with medical treatment in these cases is not widely published. For this patient, the most effective treatment approach combined compensatory speech and swallowing therapeutic techniques with targeted exercises to maximize functional muscle return in conjunction with antibiotic therapy. Conclusions: This case demonstrates a patient with severe dysarthria and dysphagia in the setting of a rare case of skull base osteomyelitis who with targeted therapy had successful return to functional communication and to a full oral diet.

A 25-Year-Old Male Polytrauma Patient Who Sustained a Traumatic Brain Injury with Recovery only to Suffer a Later Anoxic Brain Injury: A Case Report

Disclosures: J. Solberg, No Disclosures: I Have Nothing To Disclose. Case Description: A 76-year-old man presented to the hospital with acute mental status changes five days after visiting Atlantic City. He had become progressively confused and developed chills and emesis while at home. In the Emergency Room, the patient was alert but confused with a temperature of 101.2 degrees Fahrenheit. A lumbar puncture indicated meningitis. Computed tomography of the head was noncontributory. Acute treatment included intravenous dexamethasone, antibiotics, and acyclovir. Serological testing of cerebrospinal fluid with immunoglobulin M (IgM) antibody enzyme-linked immunosorbent assay confirmed West Nile Virus. Within 24 hours of admission, the patient rapidly declined and became unresponsive mandating mechanical ventilation. Elevated intracranial pressure necessitated a lumbar drain on hospital day 2; however, the comatose state persisted. On day 10, there continued to be no improvement in mentation with above treatments and the patient was started on amantadine 100 milligrams, twice daily. Setting: Inpatient Critical Care Unit. Results or Clinical Course: Within 48 hours after starting amantadine the patient had intermittent eye opening and responded to noxious stimuli. By 72 hours after administration, the patient performed simple commands such as moving left and right to verbal command and raising requested amount of fingers. Discussion: This case illustrated the potential of amantadine improving alertness and functional recovery in a patient with meningoencephalitis-related coma. The patient remained unresponsive for over 5 days while receiving treatment with antiviral medications and maintaining a normal cerebral perfusion pressure. It was not until the administration of amantadine that the patient awoke from a comatose state. Conclusions: Amantadine is documented in the literature to induce wakefulness in traumatic brain injury and even degenerative brain disorders such as Creutzfeldt-Jakob disease. There may be a similar role in the treatment of functional impairment due to encephalitis; however, further study is indicated.

Peripheral Nerve Stimulation with Inter-lead Crosstalk Leading to Complete Pain Cessation in a Patient Suffering Post-Nephrectomy Syndrome: A Case Report

C-spine. Of significance, there is a curvilinear hypointensity located in the midline and left sided dorsal epidural space at the C5-C6 levels, most compatible with gas in the epidural space. No acute abnormality within the cervical spine noted. Discussion: The loss of resistance technique is the most commonly recommended for confirming entry into the epidural space. The cervical epidural space is relatively small, measuring only 3-4mm in the lower regions, with the neck flexed.3 This leaves it susceptible to causing radicular symptoms with even the smallest amount of air or any type of space occupying lesion. Conclusions: Injection of fluid and/or air into the epidural space can potentially cause radicular compression. This should be taken into consideration when performing the procedure and limiting volume of air injectate in the loss of resistance technique is recommended.

Poster 11 Use of Hyperbaric Oxygen Treatment in Severe Traumatic Brain Injury: A Case Report

near-complete neurologic recovery. Setting: A tertiary pediatric hospital. Results: Before rehabilitation admission, the Wee Functional Independence Measure revealed deficits in self-care, sphincter control, mobility transfers, locomotion, communication, and social cognition that improved to supervision or modified independent level before discharge. Neuropsychological testing, although improved from admission, revealed deficits with executive functioning, fine motor speed, and dexterity at discharge. Discussion: Given the significant neurologic decline after mild impact and the radiologic findings of a thin subdural hematoma with a large midline shift, his injury is consistent with second impact syndrome (SIS). This case is unique in that it represents one of the longest temporal intervals (3 weeks) between head injuries and one of the best neurologic outcomes after this type of injury. Conclusions: SIS is a rare but serious condition that can result in severe neurologic deficits and potentially death. Increased time between head injuries as well as prompt medical care and rehabilitation may result in better outcomes of SIS. In addition, heightened awareness to the seriousness of a concussion and prevention of a second concussion while the brain is healing is paramount in preventing SIS.