Sun G. Chung

Convulsion Caused by a Lidocaine Test in Cervical Transforaminal Epidural Steroid Injection

Cervical transforaminal epidural steroid injections (CTFESI) have been used to treat cervical radicular pain with the rationale of suppressing spinal nerve root inflammation. However, potential serious procedure-related complications demand several protective measures, such as careful placement of a needle tip at the posterior wall of the neural foramen; real-time fluoroscopic surveillance of contrast flow, preferably with digital subtraction; and a local anesthetic test just before injection of the steroid [1,2]. The purpose of a local nesthetic test is to detect any temporary and reversible neurologic signs of intravascular nstillation of a short-duration local anesthetic agent so that subsequent steroid injection hat may potentially result in permanent neurologic complications can be withheld [1,3]. ince the test dose was advocated, only 2 reports [1,2] have described the value of the test y presenting cases of temporary neurologic deficits. More cases or research is needed to etermine whether and how the test should be done [1]. The present case report discusses onvulsion caused by a local anesthetic test because of inadvertent vertebral artery injection.

Relationships Between Capsular Stiffness and Clinical Features in Adhesive Capsulitis of the Shoulder

Tightening and contracture of the joint capsule are hallmarks of adhesive capsulitis of the shoulder (ACS). However, quantification of capsular stiffness and its relation to clinical features have not been investigated thoroughly.

Changes in biomechanical properties of glenohumeral joint capsules with adhesive capsulitis by repeated capsule-preserving hydraulic distensions with saline solution and corticosteroid.

To investigate whether capsule‐preserving hydraulic distension with saline solution and corticosteroid for adhesive capsulitis induces biomechanical alterations in glenohumeral joint capsules along with clinical improvements.

Crystallization of Local Anesthetics When Mixed With Corticosteroid Solutions

Objective To evaluate at which pH level various local anesthetics precipitate, and to confirm which combination of corticosteroid and local anesthetic crystallizes. Methods Each of ropivacaine-HCl, bupivacaine-HCl, and lidocaine-HCl was mixed with 4 different concentrations of NaOH solutions. Also, each of the three local anesthetics was mixed with the same volume of 3 corticosteroid solutions (triamcinolone acetonide, dexamethasone sodium phosphate, and betamethasone sodium phosphate). Precipitation of the local anesthetics (or not) was observed, by the naked eye and by microscope. The pH of each solution and the size of the precipitated crystal were measured. Results Alkalinized with NaOH to a certain value of pH, local anesthetics precipitated (ropivacaine pH 6.9, bupivacaine pH 7.7, and lidocaine pH 12.9). Precipitation was observed as a cloudy appearance by the naked eye and as the aggregation of small particles (<10 µm) by microscope. The amount of particles and aggregation increased with increased pH. Mixed with betamethasone sodium phosphate, ropivacaine was precipitated in the form of numerous large crystals (>300 µm, pH 7.5). Ropivacaine with dexamethasone sodium phosphate also precipitated, but it was only observable by microscope (a few crystals of 10–100 µm, pH 7.0). Bupivacaine with betamethasone sodium phosphate formed precipitates of non-aggregated smaller particles (<10 µm, pH 7.7). Lidocaine mixed with corticosteroids did not precipitate. Conclusion Ropivacaine and bupivacaine can precipitate by alkalinization at a physiological pH, and therefore also produce crystals at a physiological pH when they are mixed with betamethasone sodium phosphate. Thus, the potential risk should be noted for their use in interventions, such as epidural steroid injections.

Ulnar Neuropathy After Extracorporeal Shockwave Therapy: A Case Report

Currently, extracorporeal shockwave therapy (ESWT) is widely used for treatment of various musculoskeletal disorders. We report a case of ulnar neuropathy secondary to the application of ESWT. A 48‐year‐old man was diagnosed with medial epicondylitis and underwent 2 sessions of ESWT. Immediately after the second session, he experienced paresthesia and weakness in the right hand. On physical examination, atrophy of the first dorsal interosseus and weakness of the abductor digiti minimi were observed. Electrophysiologic study demonstrated ulnar neuropathy at the elbow with severe partial axonotmesis. Our case report demonstrates that ESWT might cause or contribute to peripheral nerve injury at the site of application.

Physical Medicine and Rehabilitation: Interdisciplinary, Interventional, and International

In this issue of PM&R, a new featured column is being introduced: The International Perspective. In this column, the journal will facilitate a broad look at our specialty from a global perspective. Indeed, physical medicine and rehabilitation (PMR) is not only interdisciplinary and interventional, it is also international. This new section will focus on areas of scientific and clinical relevance, and on issues of importance for the advancement of PMR in an international context. We are confident that much can be learned from each other through narrative descriptions, perspective viewpoints, and summary reviews on contemporary topics of international importance to the field of PMR. Disability is truly an international issue. In the recent World Heath Organization (WHO) “World Report on Disability,” it is stated that more than 1 billion people in the world live with some form of disability, of whom nearly 200 million experience considerable difficulties in functioning [1]. The report further states that disability will be an even greater concern in the years ahead because its prevalence is on the rise. This is due to a growing number of people over 65 years old and the higher risk of disability in older people, as well as the global increase in chronic health conditions such as diabetes, cardiovascular disease, neurologic disorders, cancer, and mental health disorders. The WHO report also presents innovative policies and programs that can improve the lives of persons with disabilities and facilitate implementation of the United Nations Convention on the Rights of Persons with Disabilities, which came into force in May 2008. The WHO report emphasizes the necessity to create or amend national plans on rehabilitation and to establish infrastructure and capacitytoimplementtheplans,soastoimproveaccesstorehabilitationservices.Weknow that there are numerous efforts being made around the world to do this. We hope that this new column will serve as a medium to present, describe, and discuss these efforts. Our specialty is young and has evolved over the past century. As an example of a highly specialized rehabilitation service, it has been less than 60 years since spinal cord injury rehabilitation was developed at Stoke Mandeville Hospital in England. In many parts of the world, the first PMR specialists were certified within the past 2 decades. The evolutionary history of PMR societies varies in different regions and countries around the world. For example, simply consider the various names of the specialty: “physical medicine and rehabilitation (PMR),” “rehabilitation medicine (RM),” or “physical and rehabilitation medicine (PRM)”[2]. These differences may reflect subtle variations in viewpoints. Understanding our varied histories, evolution, and type of worldwide training programs should help us to appreciate the role of PMR, PRM, or RM in the international medical community. Universally, PMR interacts with many other medical disciplines, usually in the spirit of cooperation but occasionally in a conflicting manner. These positive and negative interactionsusuallyoccuronissuesofdiagnosingandtreatingdiseaseandmanagingdisability.The strengthandvalueofPMRcanbedemonstratedbythedevelopmentofmedicalcareservices that have not been historically provided by other disciplines [3]. This development will be facilitated if we recognize evolutionary histories of individual PMR societies that describe how they have coped with various kinds of challenges. There is a strong need to focus on our medical education system and our training of young physicians and allied health professionals in rehabilitation [2]. Around the world, there are many examples of how core curricula in PMR and rehabilitation medicine have developed as part of our university medical systems. By describing such endeavors, we can continue to learn, agree on commonalities, and in the long term, progress toward a more unifiedknowledgeofrehabilitationinterventions.Manycountrieshavealsotakeninitiatives

Poster 5: The Effects of Community Based Group Exercise Program in Frail Older Adults: 24 Weeks Prospective Study

valvular heart disease). At baseline, 24 (40%) were classified as frail based on any of the following criteria: 6-minute walk distance (6MWD) <300m, gait speed (GS) <1m/s, timed up and go (TUG) >15s, tandem stand (TS) <10s. Interventions: Completing at least 24 sessions of CR including individualized exercise training and risk factor education. Main Outcome Measures: Change in 6MWD, GS, TUG, and TS from preto post-assessment in frail and non-frail patients. Results: Frail and non-frail CR patients improved significantly in 6MWD (274 70m vs. 331 69m, p<.001; 379 54m vs. 411 62m, p1⁄4.001, respectively). The magnitude of change was significantly greater for frail vs. non-frail (58 49m vs. 31 52m, p1⁄4.050). Improvements in GS, TUG, and TS were demonstrated in frail and non-frail patients, but statistical significance was only evident in the non-frail for GS and TUG (GS: 0.01 0.25m/s, p1⁄4.805 vs. 0.11 0.24m/s, p1⁄4.014; TUG: e0.9 2.8s, p1⁄4.136 vs. e0.8 1.6s, p1⁄4.004; TS: 4.8 5.9s, p1⁄40.152 vs. 1.4 6.4s, p1⁄4.189; frail vs. non-frail, respectively). Of the 24 patients classified as “frail” at enrollment, 13 (54%) were no longer classified as frail at completion of CR. Conclusions: Frail and non-frail patients in CR achieved multiple domains of functional enhancement. These results provide strong rationale for referring frail adults to CR. Additional modifications to CR that specifically address balance, strength, cognition, and other frailty hazards may further enhance its utility for today’s growing population of frail CVD patients. Level of Evidence: Level III

Poster 119: Relationships Between Olisthetic Conditions and Intervertebral Disc Degeneration in the Lumbar Spine

study, 65 were found to be acute cases versus 35 which were chronic cases. 60 patients were discharged home, 25 went to a nursing home, 11 went to medicine, and 4 were transferred to surgery after leaving the rehab unit. The most common modalities for pain management were steroids and opioids, specifically, Oxycodone. Out of all the vertebrae regions that were affected (cervical, lumbar, thoracic, sacral), the lumbar vertebrae were the most common location of diskitis in our patient population. Particularly, the L4-L5 vertebrae were seen to be affected the most. Of our sample population, 12 patients incurred UTI’s during their course of hospital stay, further complicating their underlying diskitis and requiring antibiotic usage. The most heavily ordered antibiotic was Rocephin. We had two cases of sepsis diskitis which was aggressively managed. Conclusions: The average FIM score upon admission was 71.82 and increased to 75 at discharge, patients with low scores at admission are likely to be discharged to a facility and those with high scores at admission are likely to be discharged to home. This correlated with our results as majority of the patient population returned home after being discharged. Level of Evidence: Level II

Poster 184 Abdominal Muscle Training with Pressure Sensor

peritendinous FCR steroid injection, but pain recurred within 6 months. Next, partial thickness Triangular Fibrocartilage tear with wrist effusion was diagnosed with MRI. Wrist arthroscopy with debridement did not result in lasting relief either. The patient was then offered FCR tenotomy versus surgical excision, which she declined. Setting: At 2 years, this patient was evaluated by Rehabilitation medicine in an outpatient setting. Results: The patient was diagnosed with focal dystonia of FCR with Writer’s cramp. 50U of intramuscular Botulinum toxin A was injected into the FCR, Flexor-Pollicis-Longus, and Flexor-Digitorum-Superficialis, followed by rehabilitation with specialized hand therapy. The patient reported gradual improvement, with resolution of symptoms in 4 weeks. Discussion: Focal dystonia should be sought out early in the course of persistent wrist pain, especially in the setting of failed conservative management for common conditions such as flexor tendinitis, and definitely before surgical intervention. Botulinum toxin can be used as an early non-invasive diagnostic tool for focal dystonia, and should improve pain intensity and frequency in case this is the diagnosis, thus avoiding expensive investigations such as MRI, as well as surgical management such as joint arthroscopy or tenotomy. Conclusions: A high index of suspicion for FCR focal dystonia should exist for persistent wrist pain that has failed conservative and surgical management for other diagnoses. Botox has merit for use as both a diagnostic and therapeutic tool for FCR dystonia. Further study can help in establishing evidence for this treatment method. Level of Evidence: Level V

Poster 150 Biomechanical Properties of the Glenohumeral Joint Capsule in Adhesive Capsulitis Patients with Diabetes Mellitus.

Disclosures: Wonkee Chang: I Have No Relevant Financial Relationships To Disclose Objective: To investigate the relationships between biomechanical properties of the glenohumeral joint capsule and clinical factors in adhesive capsulitis (AC) patients with diabetes mellitus (DM), and to compare the biomechanical properties between diabetic (DM group) and non-diabetic patients (non-DM group). Design: A retrospective study. Setting: A tertiary university hospital outpatient clinic dedicated to intra-articular hydraulic distension (IHD). Participants: A total of 154 patients (DM group 30, non-DM group 124) with AC who underwent IHD. Interventions: IHD was performed using a hydraulic distension system designed for constantevolumeespeed fluid infusion with simultaneous intraarticular pressure monitoring. Stiffness of capsule (K_cap) was defined as the slope of elastic phase in Pressure-Volume curve. Capsular capacity (V_max), defined as the total infused volume and the pressure at the maximal volume (P_max) were also recorded. Main Outcome Measures: Correlation coefficients between K_cap and demographic and clinical parameters (including glycemic profile such as HbA1c and DM duration) in DM group. Comparison of K_cap, V_max and P_max between DM group and non-DM group. Results: Duration of DM showed positive correlation with K_cap (r1⁄40.468, P1⁄4.028). HbA1c did not show significant correlation with stiffness of capsule, nor did the type of DM medication (Insulin vs OHA only) show any significant difference in K_cap. Mean age was significantly higher in DM group (n1⁄430) than non-DM group (n1⁄4123) (62.60 9.6 vs 57.33 9.7 P1⁄4.008), otherwise there were no significant differences in demographic data, shoulder ROM and biomechanical properties of glenohumeral joint capsule (K_cap, C_max and P_max). Conclusions: The stiffness of glenohumeral joint capsule had positive correlation with DM duration, suggesting that patients with longer duration of DM had stiffer joint capsule. Other clinical factors including HbA1c had no meaningful relationship with capsular stiffness in DM patients. These findings implicate that the duration of DM may be one of the key factors in the pathogenesis of adhesive capsulitis in DM patients. Level of Evidence: Level IV