Poster 10: Evaluating cerebral disconnection in a patient with callosal syndrome: a case report
1
diagnoses of RA and MDD. Intervention: All participants received a therapeutic dosage of sertraline for their body mass. Outcome measures were collected at 4 time periods: preintervention, and at 3, 6, and 15 months postintervention. Main Outcome Measures: Measures were as follows: Multidimensional Assessment of Fatigue, Center for Epidemiological Studies–Depression scale, pain visual analog scale, Arthritis Activity Today, erythrocyte sedimentation rate, and average sleep over a 3-month period. Results: A multiple regression with fatigue as the dependent variable and pain, depression, and female gender as independent variables demonstrated a replication of the previous study at baseline (R 2 .19, P.015), 3 months (R 2 .30, P.002), 6 months (R 2 .55, P.0001), and 15 months (R 2 .52, P.0001). However, the addition of disease activity and sleep variables in hierarchical fashion found that disease activity and sleep did not make significant contributions above and beyond the replicated model. Conclusions: In this cohort of patients with RA and MDD, higher levels of pain, more depressive symptoms, and female gender were signifi- cantly related to fatigue; subjective and objective measures of disease activity, as well as sleep, did not make additive contributions. Key Words: Depression; Fatigue; Rehabilitation; Rheumatoid arthritis. Brain Injury Poster 6 Traumatic Brain Injury as a Relevant Cause of Growth Hormone Deficiency in Adults. Experience from KIMS (Pharmacia International Metabolic Database). Maria Koltowska- Haggstrom (Pharmacia AB, Stockholm, Sweden); Alfonso Leal Cerro; Peter Jonsson; Miklos Goth; Felipe Casanueva, e-mail: [email protected]. Disclosure: Koltowska-Haggstrom, Pharmacia employee; Jonsson, Pharmacia employee; Other authors: None. Objective: To compare baseline clinical characteristics and 1-year growth hormone (GH) replacement results in patients with adult onset growth hormone deficiency (GHD) caused by traumatic brain injury (TBI) versus nonfunctioning pituitary adenoma (NFPA). Design: Pharmaco- epidemiologic survey of hypopituitary adults with GHD. Setting: Records were selected from the KIMS database, which contains information on 8500 patients with GHD, for 168 of whom TBI was identified as a cause. Participants: Both groups (NFPA group, n207; TBI group, n29) were age- (at pituitary disorder onset and entry into the KIMS database) and sex-matched (60% men, 40% women), previously not irradiated, and had not received GH. Interventions: Not applicable. Main Outcome Measures: Values given as mean SE. Results: The age at GHD diagnosis was 38.82.0 years for the TBI group and 41.50.5 years for the NFPA group. In both groups, the most frequent additional hypopituitary deficiency was luteinzing hormone/follicle-stimulating hormone, followed by adrenocorticotropic hormone and thyroid-stimulating hormone. The mean GH peak at diagnosis was 1.250.42ng/mL in the TBI group, which was significantly lower than that of the NFPA group (2.380.7ng/mL). There were no significant statistical differences in medical history, glucose level, lipids, waist circumference, or body composition measurements. Interestingly, pa- tients with TBI were significantly shorter (168.21.5cm) than the NFPA patients (172.50.6cm). After 1 year of GH treatment, differences were shown in waist, lean mass, heart rate, glucose levels, quality of life as measured by the Quality of Life Assessment in Growth Hormone Deficient Adults and insulin-like growth factor I. Conclusions: Although hypopituitarism secondary to TBI was described more than 50 years ago, it is only now evident that a considerable number of patients experience severe GHD after TBI. It is suspected that a large number of patients after TBI have undiagnosed GHD. The present results confirm that clinical characteristics and GH treatment effects in GHD caused by TBI are indistinguishable from those in GHD caused by NFPA. Key Words: Brain injuries; Hypopituitarism; Rehabilitation. Poster 7 Impact of Balance Deficits After Traumatic Brain Injury on Inpatient Rehabilitation Func- tional Outcome: A Multicenter Study. Brian D. Greenwald, MD (UMDNJ/ New Jersey Medical School, Newark, NJ); Jennifer H. Marwitz, MA; David X. Cifu, MD; Jeffrey S. Englander, MD; Ross D. Zafonte, DO; Allen W. Brown, MD, e-mail: [email protected]. Disclosure: None. Objective: To evaluate how sitting and standing balance ratings of patients with traumatic brain injury (TBI) on admission to rehabilitation impacts functional outcome, rehabilitation charges, and rehabilitation length of stay (LOS). Design: Multicenter analysis of consecutive admissions to designated Traumatic Brain Injury Model Systems (TBIMS). Setting: TBIMS centers. Partici- pants: 908 adults with TBI were included in the study. Interventions: Not applicable. Main Outcome Measure: FIM™ instrument admission and discharge scores, FIM change and efficiency; rehabilitation LOS and charges; and discharge disposition. Results: Persons with grossly impaired sitting balance on admission to rehabilitation had lower discharge FIM scores and greater rehabil- itation charges than those with normal or mildly impaired sitting balance. Persons with mildly impaired sitting balance had lower discharge FIM scores and greater rehabilitation charges than those with normal sitting balance. Subjects with grossly impaired standing balance compared with normal or mildly impaired standing balance had greater rehabilitation charges and LOS and lower discharge FIM scores and FIM efficiency. Subjects with grossly impaired balance on admission to rehabilitation had significantly lower motor FIM items compared with those who had normal or mildly impaired balance. Subjects with grossly impaired sitting balance were discharged from rehabilitation to someplace other than their home more than twice as often as those with normal sitting balance (11.7% vs 23.3%). Subjects with grossly impaired standing balance were discharged from rehabilitation to someplace other than their home more than 3 times as often as subjects with normal standing balance (6.7% vs 21.5%). Conclusion: In patients with TBI, sitting and standing balance ratings on admission to rehabilitation are useful indicators of functional impairment and not returning home at discharge from rehabilitation. Key Words: Balance; Brain injuries; Multicenter studies; Rehabilitation; Treatment outcome. Poster 8 Acupuncture for Persistent Symptoms in a Patient With Mild Traumatic Brain Injury: A Case Report. Sridevi Mukkamala, MD (Metro Health Medical Center, Cleveland, OH); Nishin Tambay, MD, e-mail: [email protected]. Disclosure: None. Setting: Physical medicine and rehabilitation outpatient clinic in a tertiary care hospital. Patient: 26-year-old woman with postconcussive symptoms. Case Description: The patient had complained of headaches, impaired concentration, memory deficits, fatigue, and neck and upper back pain after a motor vehicle collision. She struck her head against the head support but remained conscious. Computed tomography and magnetic resonance imaging scans of the brain were negative. She failed a trial of multiple medications and could not work. She was seen in our clinic 6 weeks postinjury. She was started on amantidine and referred to physical therapy (PT), rehabil- itation psychology, and speech therapy. Patient experienced only partial relief of symptoms. She was treated with acupuncture once a week for 3 weeks. Standard acupoints on the scalp, face, back, and upper extremities were used. She had near-complete relief of symptoms and returned to work on a part-time basis. Within 2 days after returning to work, she experienced a recurrence of all her symptoms, however, with much less intensity. She underwent 3 more acupuncture treatments. All her symptoms resolved except the mild residual neck and upper back pain. She was referred to PT to enable her to return to her previous activities of yoga and rock climbing. Amantadine was stopped. Assessment/Results: 5 months after her initial injury, the patient returned to work full-time without recurrence of symptoms. Discussion: Mild traumatic brain injury (TBI) presents a unique challenge to physiatrists. The symptoms can last for a significant period of time and may not respond to standard interventions. Conclusion: Our case report highlights the potential use of acupuncture to treat persistent symptoms in mild TBI. Key Words: Acupuncture; Physical therapy; Post concussion syndrome; Rehabilitation. Poster 9 The Enigma of Urinary Retention in Posttraumatic Minimally Responsive State: A Case Report. Karen S. Chua, MD (Tan Tock Seng Hospital, Singapore, Singapore), e-mail: [email protected]. Disclosure: None. Setting: Tertiary inpatient rehabilitation hospital. Patient: 43-year-old Asian woman with posttraumatic minimally responsive state and tetraparesis. Case Description: 4 months into her inpatient rehabilitation program after severe traumatic brain injury (TBI), the patient developed acute urinary retention (UR) with high postvoid urine volumes and urodynamic evidence of detrusor acontractility. Subsequent management involved 4 hourly intermittent catheterizations. Spinal cord injury, fecal impaction, diabetes mellitus, and bladder paralytic drugs were absent. Possible etiologies for her bladder paralysis included treatments instituted for severe spasticity of all 4 limbs: 300mg/d of oral dantrolene sodium, 500U of intramuscular botulinum toxin type A (Dysport) to both upper limbs, and partial alcohol neurolysis of the right sciatic nerve for severe knee flexor spasticity. Baclofen was not used. Assessment/Results: Spontaneous voiding returned with reduc- tion of dantrolene sodium to 150mg/d, with eventual attainment of catheter-free status within 1 week. Urodynamic studies documented return of detrusor activity. Discussion: This is the first reported case to my knowledge of urinary retention after spasticity treatment involving therapeutic doses of dantrolene sodium. Patients in a minimally responsive state after TBI may already be at increased risk of UR due to severe immobility, motor weakness, profound cognitive-linguistic impairment which may confound the diagnosis of UR, and pontine and/or brainstem injury. Conclusion: Patients in a minimally responsive state receiving high doses of dantrolene sodium to treat spasticity may benefit from routine monitoring of voiding status and postvoid residual urine volumes. Key Words: Brain injuries; Dantrolene; Minimally conscious state; Rehabilitation; Urinary retention. Poster 10 Evaluating Cerebral Disconnection in a Patient With Callosal Syndrome: A Case Report. Jonah Green, MD (NYU, New York, NY); Jill Posa, OTS; Jung H. Ahn, MD, e-mail: [email protected]. Disclosure: None. Setting: Urban inpatient rehabilitation hospital. Patient: A 40-year-old man on an inpatient rehabilitation unit with a recent diagnosis of a glioblastoma multiforme located in the area of the corpus callosum. Case Description: The patient presented in 1995 with new onset seizures and was found to have a right frontal lobe tumor for which he underwent resection. Postopertively, the patient had no neurologic deficits and was “tumor free.” In November 2002, his wife noticed that he was neglecting the left side of his body. A brain magnetic resonance imaging showed a recurrence of the tumor predominantly in the genu of the corpus callosum. The patient was treated with chemotherapy and admitted for inpatient rehabilitation diagnosed with gait disorder (the patient’s wife stated that he kept “falling to his left side”). Assessment/Results: While on the rehabilitation unit, the patient underwent a battery of tests that illustrated the symptoms of callosal syndrome, including left apraxia to verbal commands, left tactile anomia, and left agraphia. He was also asked to complete a draw-a-clock test, which showed left inattention when drawn with the right hand but not with the left. Figures drawn by the patient were compiled and his progress monitored throughout his rehabilitation. Discussion: This study of a patient with callosal syndrome offered us the opportunity to observe each hemisphere of the brain in isolation. Knowing the capabilities of a single hemisphere can help direct the rehabilitation of a patient with single hemispheric lesions. Conclusion: Reha- bilitation in this case focused mainly on retraining the intact hemispheres to compensate for the loss of interhemispheric communication. On review of medical literature, this is the first reported case in the last 15 years of callosal syndrome with its implications, teaching capabilities, and rehabili- tation objectives. Key Words: Corpus callosum, Rehabilitation. A7 ACADEMY ANNUAL ASSEMBLY ABSTRACTS Arch Phys Med Rehabil Vol 84, September 2003
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Transcript of Poster 10: Evaluating cerebral disconnection in a patient with callosal syndrome: a case report
diagnoses of RA and MDD. Intervention: All participants received a therapeutic dosage of
sertraline for their body mass. Outcome measures were collected at 4 time periods: preintervention,
and at 3, 6, and 15 months postintervention. Main Outcome Measures: Measures were as follows:
Multidimensional Assessment of Fatigue, Center for Epidemiological Studies–Depression scale,
pain visual analog scale, Arthritis Activity Today, erythrocyte sedimentation rate, and average sleep
over a 3-month period. Results: A multiple regression with fatigue as the dependent variable and
pain, depression, and female gender as independent variables demonstrated a replication of the
previous study at baseline (R2�.19, P�.015), 3 months (R2�.30, P�.002), 6 months (R2�.55,
P�.0001), and 15 months (R2�.52, P�.0001). However, the addition of disease activity and sleep
variables in hierarchical fashion found that disease activity and sleep did not make significant
contributions above and beyond the replicated model. Conclusions: In this cohort of patients with
RA and MDD, higher levels of pain, more depressive symptoms, and female gender were signifi-
cantly related to fatigue; subjective and objective measures of disease activity, as well as sleep, did
not make additive contributions. Key Words: Depression; Fatigue; Rehabilitation; Rheumatoid
arthritis.
Brain Injury
Poster 6Traumatic Brain Injury as a Relevant Cause of Growth Hormone Deficiency in Adults.Experience from KIMS (Pharmacia International Metabolic Database). Maria Koltowska-Haggstrom (Pharmacia AB, Stockholm, Sweden); Alfonso Leal Cerro; Peter Jonsson; MiklosGoth; Felipe Casanueva, e-mail: [email protected]: Koltowska-Haggstrom, Pharmacia employee; Jonsson, Pharmacia employee; Otherauthors: None.
Objective: To compare baseline clinical characteristics and 1-year growth hormone (GH)replacement results in patients with adult onset growth hormone deficiency (GHD) caused bytraumatic brain injury (TBI) versus nonfunctioning pituitary adenoma (NFPA). Design: Pharmaco-epidemiologic survey of hypopituitary adults with GHD. Setting: Records were selected from theKIMS database, which contains information on �8500 patients with GHD, for 168 of whom TBIwas identified as a cause. Participants: Both groups (NFPA group, n�207; TBI group, n�29) wereage- (at pituitary disorder onset and entry into the KIMS database) and sex-matched (60% men, 40%women), previously not irradiated, and had not received GH. Interventions: Not applicable. MainOutcome Measures: Values given as mean � SE. Results: The age at GHD diagnosis was38.8�2.0 years for the TBI group and 41.5�0.5 years for the NFPA group. In both groups, the mostfrequent additional hypopituitary deficiency was luteinzing hormone/follicle-stimulating hormone,followed by adrenocorticotropic hormone and thyroid-stimulating hormone. The mean GH peak atdiagnosis was 1.25�0.42ng/mL in the TBI group, which was significantly lower than that of theNFPA group (2.38�0.7ng/mL). There were no significant statistical differences in medical history,glucose level, lipids, waist circumference, or body composition measurements. Interestingly, pa-tients with TBI were significantly shorter (168.2�1.5cm) than the NFPA patients (172.5�0.6cm).After 1 year of GH treatment, differences were shown in waist, lean mass, heart rate, glucose levels,quality of life as measured by the Quality of Life Assessment in Growth Hormone Deficient Adultsand insulin-like growth factor I. Conclusions: Although hypopituitarism secondary to TBI wasdescribed more than 50 years ago, it is only now evident that a considerable number of patientsexperience severe GHD after TBI. It is suspected that a large number of patients after TBI haveundiagnosed GHD. The present results confirm that clinical characteristics and GH treatment effectsin GHD caused by TBI are indistinguishable from those in GHD caused by NFPA. Key Words:Brain injuries; Hypopituitarism; Rehabilitation.
Poster 7Impact of Balance Deficits After Traumatic Brain Injury on Inpatient Rehabilitation Func-tional Outcome: A Multicenter Study. Brian D. Greenwald, MD (UMDNJ/ New JerseyMedical School, Newark, NJ); Jennifer H. Marwitz, MA; David X. Cifu, MD; Jeffrey S.Englander, MD; Ross D. Zafonte, DO; Allen W. Brown, MD, e-mail: [email protected]: None.
Objective: To evaluate how sitting and standing balance ratings of patients with traumatic braininjury (TBI) on admission to rehabilitation impacts functional outcome, rehabilitation charges, andrehabilitation length of stay (LOS). Design: Multicenter analysis of consecutive admissions todesignated Traumatic Brain Injury Model Systems (TBIMS). Setting: TBIMS centers. Partici-pants: 908 adults with TBI were included in the study. Interventions: Not applicable. MainOutcome Measure: FIM™ instrument admission and discharge scores, FIM change and efficiency;rehabilitation LOS and charges; and discharge disposition. Results: Persons with grossly impairedsitting balance on admission to rehabilitation had lower discharge FIM scores and greater rehabil-itation charges than those with normal or mildly impaired sitting balance. Persons with mildlyimpaired sitting balance had lower discharge FIM scores and greater rehabilitation charges thanthose with normal sitting balance. Subjects with grossly impaired standing balance compared withnormal or mildly impaired standing balance had greater rehabilitation charges and LOS and lowerdischarge FIM scores and FIM efficiency. Subjects with grossly impaired balance on admission torehabilitation had significantly lower motor FIM items compared with those who had normal ormildly impaired balance. Subjects with grossly impaired sitting balance were discharged fromrehabilitation to someplace other than their home more than twice as often as those with normalsitting balance (11.7% vs 23.3%). Subjects with grossly impaired standing balance were dischargedfrom rehabilitation to someplace other than their home more than 3 times as often as subjects withnormal standing balance (6.7% vs 21.5%). Conclusion: In patients with TBI, sitting and standingbalance ratings on admission to rehabilitation are useful indicators of functional impairment and notreturning home at discharge from rehabilitation. Key Words: Balance; Brain injuries; Multicenterstudies; Rehabilitation; Treatment outcome.
Poster 8Acupuncture for Persistent Symptoms in a Patient With Mild Traumatic Brain Injury: A CaseReport. Sridevi Mukkamala, MD (Metro Health Medical Center, Cleveland, OH); NishinTambay, MD, e-mail: [email protected].
Disclosure: None.
Setting: Physical medicine and rehabilitation outpatient clinic in a tertiary care hospital.
Patient: 26-year-old woman with postconcussive symptoms. Case Description: The patient had
complained of headaches, impaired concentration, memory deficits, fatigue, and neck and upper
back pain after a motor vehicle collision. She struck her head against the head support but remained
conscious. Computed tomography and magnetic resonance imaging scans of the brain were
negative. She failed a trial of multiple medications and could not work. She was seen in our clinic
6 weeks postinjury. She was started on amantidine and referred to physical therapy (PT), rehabil-
itation psychology, and speech therapy. Patient experienced only partial relief of symptoms. She was
treated with acupuncture once a week for 3 weeks. Standard acupoints on the scalp, face, back, and
upper extremities were used. She had near-complete relief of symptoms and returned to work on a
part-time basis. Within 2 days after returning to work, she experienced a recurrence of all her
symptoms, however, with much less intensity. She underwent 3 more acupuncture treatments. All
her symptoms resolved except the mild residual neck and upper back pain. She was referred to PT
to enable her to return to her previous activities of yoga and rock climbing. Amantadine was
stopped. Assessment/Results: 5 months after her initial injury, the patient returned to work full-time
without recurrence of symptoms. Discussion: Mild traumatic brain injury (TBI) presents a unique
challenge to physiatrists. The symptoms can last for a significant period of time and may not respond
to standard interventions. Conclusion: Our case report highlights the potential use of acupuncture
to treat persistent symptoms in mild TBI. Key Words: Acupuncture; Physical therapy; Post
concussion syndrome; Rehabilitation.
Poster 9The Enigma of Urinary Retention in Posttraumatic Minimally Responsive State: A CaseReport. Karen S. Chua, MD (Tan Tock Seng Hospital, Singapore, Singapore), e-mail:[email protected].
Disclosure: None.
Setting: Tertiary inpatient rehabilitation hospital. Patient: 43-year-old Asian woman with
posttraumatic minimally responsive state and tetraparesis. Case Description: 4 months into her
inpatient rehabilitation program after severe traumatic brain injury (TBI), the patient developed
acute urinary retention (UR) with high postvoid urine volumes and urodynamic evidence of detrusor
acontractility. Subsequent management involved 4 hourly intermittent catheterizations. Spinal cord
injury, fecal impaction, diabetes mellitus, and bladder paralytic drugs were absent. Possible
etiologies for her bladder paralysis included treatments instituted for severe spasticity of all 4 limbs:
300mg/d of oral dantrolene sodium, 500U of intramuscular botulinum toxin type A (Dysport) to
both upper limbs, and partial alcohol neurolysis of the right sciatic nerve for severe knee flexor
spasticity. Baclofen was not used. Assessment/Results: Spontaneous voiding returned with reduc-
tion of dantrolene sodium to 150mg/d, with eventual attainment of catheter-free status within 1
week. Urodynamic studies documented return of detrusor activity. Discussion: This is the first
reported case to my knowledge of urinary retention after spasticity treatment involving therapeutic
doses of dantrolene sodium. Patients in a minimally responsive state after TBI may already be at
increased risk of UR due to severe immobility, motor weakness, profound cognitive-linguistic
impairment which may confound the diagnosis of UR, and pontine and/or brainstem injury.
Conclusion: Patients in a minimally responsive state receiving high doses of dantrolene sodium to
treat spasticity may benefit from routine monitoring of voiding status and postvoid residual urine
volumes. Key Words: Brain injuries; Dantrolene; Minimally conscious state; Rehabilitation;
Urinary retention.
Poster 10Evaluating Cerebral Disconnection in a Patient With Callosal Syndrome: A Case Report.Jonah Green, MD (NYU, New York, NY); Jill Posa, OTS; Jung H. Ahn, MD, e-mail:[email protected].
Disclosure: None.
Setting: Urban inpatient rehabilitation hospital. Patient: A 40-year-old man on an inpatientrehabilitation unit with a recent diagnosis of a glioblastoma multiforme located in the area of thecorpus callosum. Case Description: The patient presented in 1995 with new onset seizures and wasfound to have a right frontal lobe tumor for which he underwent resection. Postopertively, the patienthad no neurologic deficits and was “ tumor free.” In November 2002, his wife noticed that he wasneglecting the left side of his body. A brain magnetic resonance imaging showed a recurrence of thetumor predominantly in the genu of the corpus callosum. The patient was treated with chemotherapyand admitted for inpatient rehabilitation diagnosed with gait disorder (the patient’s wife stated thathe kept “ falling to his left side” ). Assessment/Results: While on the rehabilitation unit, the patientunderwent a battery of tests that illustrated the symptoms of callosal syndrome, including leftapraxia to verbal commands, left tactile anomia, and left agraphia. He was also asked to completea draw-a-clock test, which showed left inattention when drawn with the right hand but not with theleft. Figures drawn by the patient were compiled and his progress monitored throughout hisrehabilitation. Discussion: This study of a patient with callosal syndrome offered us the opportunityto observe each hemisphere of the brain in isolation. Knowing the capabilities of a single hemispherecan help direct the rehabilitation of a patient with single hemispheric lesions. Conclusion: Reha-bilitation in this case focused mainly on retraining the intact hemispheres to compensate for the lossof interhemispheric communication. On review of medical literature, this is the first reported casein the last 15 years of callosal syndrome with its implications, teaching capabilities, and rehabili-tation objectives. Key Words: Corpus callosum, Rehabilitation.
A7ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Arch Phys Med Rehabil Vol 84, September 2003
