Seema R. Khurana

Spasticity and the use of intrathecal baclofen in patients with spinal cord injury

Muscle spasms and spasticity constitute a significant problem in patients with spinal cord injury, interfering with rehabilitation and leading to impairments in quality of life in addition to medical complications. Administration of intrathecal baclofen (ITB) is indicated when spasticity continues to produce a clinical disability despite trials of oral treatments and other alternatives in patients who have functional goals and/or pain without contractures. Severe spasticity of spinal origin has been shown to respond dramatically to long-term ITB when used in appropriate patients with spasticity.

Effect of cognitive demand on functional mobility in ambulatory individuals with multiple sclerosis

BACKGROUND As disease progresses, cognitive demands may affect functional mobility in individuals with multiple sclerosis (MS). The Timed Up and Go (TUG) test assesses functional mobilityin populationssuch as MS. A cognitive-demanding task can be added to the TUG test to assess its effect on functional mobility. METHODS People with MS (n = 52) and controls (n = 57) performed three versions of the TUG test: TUG alone (TUG-alone), TUG plus reciting the alphabet (TUG-alpha), and TUG plus subtracting numbers by 3s (TUG-3s). Times to complete the TUG tests were compared among controls and three groups of participants with MS created using Expanded Disability Status Scale (EDSS) scores 0 to 3.5, 4.0 to 5.5, and 6. Differences among groups were analyzed using split-plot analysis of variance. RESULTS Group and TUG type were significant (P < .001 for both), with no interaction effect of group × TUG type (P = .21). Mean times were 8.7, 9.4, and 11.1 seconds to perform the TUG-alone, TUG-alpha, and TUG-3s, respectively. Mean times for groups were 8.0, 8.2, 11.1, and 11.6 seconds for controls and individuals with MS and EDSS 0 to 3.5, 4.0 to 5.5, and 6, respectively. CONCLUSIONS People with MS with an EDSS score greater than 3.5 had a statistically significant reduction in performance of the TUG test even with the addition of a simple cognitive task, which might have implications for a persons more complex everyday activities.

Undiagnosed Catheter Connection Malfunction in a Two-Piece Catheter as the Cause of Failed Intrathecal Baclofen (ITB) Pump Therapy. A Case Report

functional outcome. Our patient had excellent prognosis with a combination of medical treatment and rehabilitation. Conclusions: This case demonstrates a favorable outcome in a condition where rehabilitation outcomes are not well documented. Of note, pre-existing HIV did not affect the neurological and functional outcomes of GBS. This patient had devastating symptoms but ultimately returned to baseline functional status after aggressive medical and rehabilitation treatments, demonstrating that despite the severity of GBS along with HIV seroconversion, a favorable outcome is possible.

Poster 248 A Novel Infusion Method of Intrathecal Baclofen Using Personal Therapy Manager: A Case Series

a 23-year-old woman with chronic right lower quadrant abdominal pain starting months following a motor vehicle crash. She reported no abdominal pain or other injury immediately post accident. Point of maximal tenderness localized in the region of right rectus abdominis with EMG findings similar to Patient 1. She received 100 units ONA in this region with symptom relief for up to 4 month periods. Setting: Spasticity clinic in a tertiary care center. Results: These 2 cases illustrate focal post-traumatic abdominal wall pain, clinically diagnosed as post-traumatic focal dystonia, that was responsive to treatment with ONA. Patients noted greater degree and longer duration of improved symptoms than with prior treatments, and each decreased oral medication utilization. Discussion: ONA has been shown to effectively manage the most common focal dystonias. Focal abdominal dystonia has rarely been reported in the literature. These cases illustrate effective treatment of post-traumatic, focal abdominal dystonia with ONA. Conclusions: Effective management of refractory, post-traumatic abdominal pain secondary to focal dystonia is possible through treatment with ONA. Level of Evidence: Level V

Poster 379 Paraneoplastic Myelitis Secondary to Hodgkin's Lymphoma: A Case Report

Disclosures: Michelle Chi: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 61-year-old woman was referred to the rehabilitation clinic for management of a 7-year history of refractory left foot pain and swelling, starting in 2009. She has a history of stage 4-endometrial cancer status post debulking with total abdominal hysterectomy, bilateral salpingo-oophorectomy, and retroperitoneal lymph node dissection in 2008 with recurrence in 2009. Recently, she was diagnosed with Lynch Syndrome, with a medullary carcinoma of the left transverse colon, and underwent total colectomy in 2015. Her left foot pain had been refractory to various prior treatments, including oral analgesics and physical therapy. Upon re-evaluation, the patient reported extreme left foot pain associated with increased edema since her recent surgery. Examination was notable for a mottled, erythematous appearing left foot associated with pitting edema from her ankles to toes. The diagnosis of CRPS in the context of lymphedema secondary to lymph node dissection was made. Treatment included lymphedema therapy, consisting of manual therapy and compression, with a 1-year history of pain relief. Due to recurrence, she was ultimately referred to pain management for further evaluation and subsequently underwent a lumbar sympathetic block. Setting: Outpatient cancer rehabilitation clinic. Results: Following sympathetic block, the patient reported no relief of pain. Treatment options for refractory CRPS were reassessed and she ultimately opted for a spinal cord stimulator (SCS) trial. After good pain relief from the trial, the patient is currently in the process of arranging implantation of a SCS. Discussion: This is a unique case, to our knowledge, of a patient with refractory lower extremity CRPS in the setting of lymphedema, originally stemming from multiple oncologic comorbidities. Additionally, this case highlights the unique position of the physiatrist in diagnosing and treating CRPS. Conclusions: CRPS is a serious and functionally limiting condition that may be especially difficult to treat in cancer patients who have undergone multiple extensive surgeries, resulting in lower extremity lymphedema. Level of Evidence: Level V

Poster 500 A Five Year Longitudinal Intervention for Improving Medical Student Exposure to Physical Medicine & Rehabilitation (PM&R).

Design: Cross-sectional survey. Setting: A major academic-medical and trauma center in West Africa. Participants: Residents and medical students completing training in 7 medical and surgical specialties (N1⁄4253). Interventions: Not applicable. Main Outcome Measures: Responses to a 25-item survey organized into four domains: 1. General attitudes towards persons with disability (PWDs); 2. Perceived adequacy of disability education; 3. Importance of disability training and education to current and future practice; and 4. General perceived value of caring for PWDs. Results: Of all respondents, 51% were female, 94 were residents, 159 were medical students and the mean age was 24.0 3.85 years old. Majority of respondents were in a surgical (41%) or medical specialty (21%). Residents had limited experience with PWDs (12% had some experience and 13% had little experience) whereas medical students had very limited experience (a total of 50% had little to no experience with PWDs) and more negative responses towards PWDs. Overall, residents demonstrated significantly higher mean composite scores than medical students for general perceived value of care for PWD (P 1⁄4 .0001), importance of disability education (P 1⁄4 .0001), and perceived adequacy of disability education score (P 1⁄4 .006). There was no statistically significant difference between the 2 groups for general attitudes composite score (P 1⁄4 .08). The mean composite scores of West-African trainees in each of the survey domains were comparable to the scores of physiatry residents in the United states, with the highest positive attitudes demonstrated for importance of disability education and perceived adequacy of disability education. Conclusions: The study highlights attitudinal health challenges towards disabled persons in a milieu devoid of rehabilitation-trained physicians and identifies areas of opportunity for strategic interventions. Level of Evidence: Level III

Poster 316 How a Flexible Differential Yielded an Elusive Diagnosis: A Case Report

Setting: Academic Medical Center and Physical Medicine & Rehabilitation Clinic. Results: After discharge, she struggled to progress and eventually declined in function several months later. She returned to clinic for her 6-month follow-up, and MRI of the cervical spine was ordered. No abnormality on imaging explained her decline, and she was instructed to go to the emergency department for further neurologic work-up. On examination, she exhibited new dysarthria, much weaker strength, diffuse muscular atrophy, and fasciculations. An electrodiagnostic study demonstrated findings of definite amyotrophic lateral sclerosis (ALS) according to the El Escorial criteria with upper and lower motor neuron findings in 4 of 4 areas (bulbar, cervical, thoracic, and lumbosacral). Discussion: The patient’s deficits were initially attributed to lumbar radiculopathy and cervical spinal stenosis. Her decline in function several months later along with speech dysfunction prompted additional testing with an electrodiagnostic study revealing a diagnosis of definite ALS. Conclusions: Early ALS may be confused with other diagnoses such as cervical myelopathy. Careful correlation of electrodiagnostic data with clinical findings is necessary to prevent mis-diagnosis of ALS, prevent potentially harmful procedures, and initiate timely interventions. Level of Evidence: Level V

Non-Traumatic Acute-Onset Quadriplegia in an 11-year-old Boy Secondary to Anterior Cord Infarct

Oxygen consumption in walking test pre and post hamstring lengthening. Results or Clinical Course: 11.5 percent of our population presented with knee hyperextension after hamstring lengthening. Regression analysis showed that the main predictor of hyperextension after hamstring lengthening is knee flexion at midstance (mean of 23.9 degrees). Analysis of oxygen consumption data did not reveal any significant changes in children with hyperextended knees vs. nonhyperextended knees. Conclusions: Incidence of knee hyperextension after hamstring lengthening in our population is 11.5 percent. Pre operative knee flexion at midstance was correlated with the presence of knee hyperextension post surgery. Interestingly, there was no significant change in gait efficiency as measured by oxygen consumption in hyperextended knees vs non-hyper extended knees.

Acute Inflammatory Demeylinating Polyneuropathy in a Pediatric Patient with History of Multiple Sclerosis

Disclosures: E. Katz, No Disclosures: I Have Nothing To Disclose. Objective: To assess ambulatory activity in children with cerebral palsy (CP) during school days and weekend days and compare to age-matched controls. Design: Cross-sectional comparison cohort Setting: Outpatient, Regional Tertiary Care Children’s Hospital Participants: 81 children with CP, aged 10-13 years, classified as Gross Motor Function Classification System (GMFCS) levels I to III and 30 age/gender-matched typically developing controls. Interventions: not applicable Main Outcome Measures: Average daily total step counts, percentage of time active, peak activity index (average steps/minute of the most intensive 30 individual minutes in the day), percent time and number of steps at medium (15-42 steps/minute) and high (>42 steps/minute) activity. Results or Clinical Course: Children with CP demonstrated significantly lower levels of all outcomes than typically developing youth (TDY) (p .001). Both cohorts have a significantly higher peak activity index during the school days as compared to weekend days (p<.001 for CP, p1⁄4.028 for TDY). Youth at GMFCS level III walked on average significantly less each day (school days: 2103 steps/day, p<.001; weekend days: 1538 steps/day, p<.001) with a lower peak activity index (school days: 28.45, p<.001; weekend days: 23.18, p<.001) as compared to TDY and GMFCS Levels I and II. Conclusions: Children with CP walk less than TDY and walking levels decrease as functional motor impairment increases. All groups are less active on the weekends compared with school days. Interventions should focus on increasing walking and physical activity on the weekends for all children. More research is needed to understand barriers to physical activity that children with higher GMFCS level encounter.

Poster 4 An Interactive Format for Improving Medical Student Exposure to Physical Medicine & Rehabilitation

Vishal Rekhala, DO; Laurentiu Dinescu, MD; Fred Aziz, MD; Ethan Egan, MD; Travis VonTobel, MD. Interventions: A multidisciplinary approach was used to identify and define: a) the steps involved in the completion of consults on a consult service, b) barriers in the process, c) interventions that remove or minimize the barriers. The major barriers identified included: a) lack of prioritization of consults, b) Lack of coordinated communication between resident physicians, rehab office administrators and attending physicians, c) reduced opportunities for teaching of residents on consult service, and d) inaccurate workload data collected for follow-up visits on the consult service. A time study on 109 consults was carried out to determine the number of minutes needed to complete a consult by a resident. Data was also collected on the number of consults requests received by day of the week. Once identified, the interventions were implemented in a pilot program. Data collected revealed the following: a) majority of the consults occurred early in the week and b) time to complete consults ranged from 35-52 minutes. The interventions identified for the pilot program were: a) addition of another resident, b) an “on-call” consult attending physician schedule, c) developing a mechanism to collect data that was more reflective of all workload completed by residents on consult service, d) developing and implementing a mechanism to prioritize consults, e) establishing a “cap” on the total number of consults to be completed per day by residents, and f) strategies to improve communication between all involved parties. Main Outcome Measures: Resident satisfaction survey. Results: Residents have expressed improvement in the overall quality of the consult service rotation in terms of improved supervision, teaching and workload. Conclusions: Resident experience on a PMR consultation service can be improved through a multidisciplinary approach and using QI methodology.