Poster 7: Shoulder impingement syndrome: clinical indicators and short-term predictors of disability

Objective: To identify the best indicators of the current disability of patients with shoulder impingement syndrome (SIS) and the strongest predictors of 3-month SIS-related disability. Design: Prospective cohort study. Setting: Movement analysis laboratory. Participants: 41 subjects with SIS. Interventions: Evaluations at baseline and at 3 months. Main Outcome Measures: Personal, occupational, and impairment variables and the Shoulder Pain and Disability Index (SPADI). Cross-sectional explicative and 3-month predictive regression models of the level of disability (SPADI score) were developed using multivariate analyses. Results: Strength deficits in shoulder abduction-lateral rotation, pain during muscle strength testing, painful arc in abduction, scapular anterior tilting asymmetry, gender, and age explained 91% of the variance of the SPADI at baseline. The SPADI score at baseline, perceived work capacity, acromiohumeral distance at 90° of abduction, acromiohumeral distance difference between shoulders at 110° of flexion, difference between active and passive range of motion in abduction, and the presence of SIS on the dominant side predicted 86% of the variance of the SPADI at 3 months. Conclusions: Variables that best explain the current disability level and predictors of short-term level of disability should be considered in SIS treatment planning as well as for establishing prognosis.     

Poster 6: Complex regional pain syndrome and distal radius fractures: intermediate-term follow-up

Objective: To evaluate the impact of complex regional pain syndrome (CRPS) after distal radius fractures on function and health-related quality of life (HRQOL). Design: Retrospective and prospective clinical study. Setting: University orthopedic department. Participants: 28 patients with CRPS after distal radius fractures. Interventions: Fracture management (closed reduction, cast immobilization, external fixation, open reduction and internal fixation, percutaneous pinning) and CRPS management (autonomic nerve blocks, oral medications, hand therapy, median nerve decompression). Main Outcome Measures: Clinical findings; thermoregulatory testing (isolated cold stress testing, laser Doppler measurements of cutaneous perfusion and digital pulp temperature); and HRQOL instruments (McGill Pain Questionnaire, McCabe Cold Sensitivity Scale, Levine Symptom Severity and Functional Scale, Disabilities of Arm, Shoulder, and Hand [DASH] questionnaires, Wake Forest University Symptom Rating Scale). All 3 measures were compared at initial presentation and at a mean follow-up of 5 years. Results: At 5-year follow-up, patients with CRPS after distal radius fractures who received the active intervention showed diminished pain, improved strength, and decreased stiffness; however, numbness and cold intolerance was not improved. Conclusion: CRPS after distal radius fractures results in a significantly diminished function, HRQOL, and residual disability despite active and vigorous intervention.     

Poster 12: Stay well and healthy! An in-home preventive health care program for persons aging with developmental disability

Objective: To pilot an intervention to prevent functional decline and health problems among persons with intellectual and developmental disability aging in the community. Design: Pilot for a large randomized trial. Setting: Private residences and group homes. Participants: 201 adults with intellectual and developmental disability, aged 32 years and older, were randomly assigned to an advance practice nurse (APN) intervention (n=101) or health-risk appraisal and feedback only (HRA) intervention (n=100). Interventions: The APN group received in-home multidimensional assessment, targeted recommendations, and quarterly follow-up visits for up to 1 year. The HRA group received an in-home interview with written feedback. Main Outcome Measures: Health, functional status, and risks; use of acute medical services; and feasibility assessment. Results: Assessment tools and interventions were demonstrated to be feasible in a population with mild to moderate intellectual and developmental disability. Recruitment and randomization were successful (avg age, 41y; 52% men). High levels of health risks were identified (mean, 7.6; range, 1-20y); 23.4% reported “fair” or “poor” general health; 16.4% reported probable depression; 34.5% reported recent falls; 36.8% reported fair or poor oral health; and 32.7% reported pain moderate or worse. Conclusion: Interventions are feasible for trials in this population and have broad applicability to other populations aging with disability.     

Poster 5: Short-term effects of locomotor-oriented rehabilitation on postarthroplasty hip impairments and functional ability

Objective: To evaluate the effects of intensive rehabilitation offered 6 months after total hip arthroplasty (THA). Design: Intervention pilot study, before-after trial. Setting: Ambulatory care. Patients: 10 patients were evaluated 7.2±0.5 months after THA (pretest) and 2 months later (posttest). Intervention: 12 supervised sessions and unsupervised home exercises. Main Outcome Measures: Functional ability measured with Western Ontario and McMaster Universities Osteoarthritis Index (pain and disability scales), clinical locomotor tests, and laboratory gait evaluation. Hip strength and mobility impairments were also quantified. Comparisons were made with Wilcoxon signed-rank tests. Results: At posttest, patients had less pain (-56%) and less difficulty in performing daily activities (disability scale, −42%), and they performed better during the 10m walk (15%), 6-minute walk (16%), and timed stair (17%) tests, as compared with pretest. No differences were revealed in gait kinematics and kinetics or impairment measures on the operated limb. Significant changes were found in the movements of the sound limb. Conclusions: The intervention promoted better functional ability. Functional gains seem related to more efficient compensations with the sound limb and better locomotor endurance. These results stress the importance of measuring joint-specific outcomes and using bilateral measures to understand changes in global functional outcomes.     

Presentation 3: Assessing disability in older adults: the effects of asking questions with and without health attribution

Objective: To determine the effects of using questions with and without health attribution on a self-reported disability instrument developed for use with older adults. Design: Cross-sectional. Setting: Community-based. Participants: 75 community-dwelling older adults from central and eastern Massachusetts. Interventions: Not applicable. Main Outcome Measures: We administered the disability component of the Late Life Function and Disability Instrument. To test whether altering attribution influenced scores, we administered the same 16 questions with attribution to specific health conditions. Results: A higher prevalence of disability was reported in the nonattributed compared with the health attribution (t=5.76, P<.001; 95% CI, 3.8-7.8). Item analyses indicated that participants were significantly more likely to report disability on the nonattributed version of 4 of the 16 disability items that required out-of-home travel. Conclusions: In this sample of older adults, estimates of disability were underestimated by questions that included specific attribution to health conditions. Factors other than health appear to influence self-report of disability related to participation in travel outside of the home.     

Poster 21: Postacute mortality after moderate to severe traumatic brain injury

Objective: To establish very long term mortality rates and predictors of mortality for persons after moderate to severe traumatic brain injury (TBI) in adults. Design: A retrospective cohort study design. Setting: A large inpatient rehabilitation hospital in Pennsylvania. Participants: Consecutive records of persons with moderate to severe TBI who were discharged from the hospital in the years 1974-1984, 1988, and 1989 (N=642). Interventions: Not applicable. Main Outcome Measures: Eligible participants were traced and mortality was ascertained up to 24 years postinjury. Results: Poisson regression analyses revealed at least a 2-fold increased risk for mortality in relation to the general population. Preinjury characteristics and levels of disability at discharge from inpatient rehabilitation were among the strongest predictors of mortality. Conclusions: Using rigorous methodology, this study quantifies the increased risk for premature death in the postacute TBI population after a moderate to severe head injury and has clinical relevance for the prevention of premature death.     

Abstract 2: Efficacy of epidural steroid injections

Objectives: To test the efficacy of epidural steroid injections (ESIs) for the relief of radicular-, facet joint-, and lumbar stenosis-related pain 3 months postinjections and to demonstrate whether the presence of litigation and smoking influenced the response to treatment. Design: Prospective survey. Setting: Community-based hospital. Participants: 300 patients who received steroid injections for radicular-, facet joint-, and lumbar stenosis-related pain. Interventions: All participants had clinical and diagnostic evidence of lumbar radiculopathy, spinal stenosis, or facet pain. Each was then treated with a series of ESIs. Each patient filled out a preinjection survey to determine the duration and distribution of their pain. A 10-point analog pain scale determined their pre-injection pain. Factors also evaluated were the etiology of pain, the presence of a lawsuit, and if the patient was a habitual smoker. At 3 months postinjection, each participant received a survey to rate their current pain and declare other interventions such as physical therapy and surgery. Main Outcome Measures: Percentage of participants who received pain relief from their ESIs and specifically which etiology of back pain showed a better response. Results: 3 months after ESIs, approximately 80% of patients had a decrease in their symptoms by 2 or more points on the 10-point analog pain scale. Patients who experienced the most pain relief were those with radicular or stenotic symptoms, nonsmoking, or without concomitant litigation. Conclusion: Steroid injections for back pain of radicular or stenotic nature (not facet), especially for nonsmokers or those without litigation, are an effective means of treating low back pain (LBP) in the first 3 months. This study will be followed by a 6 month and 12 month survey to determine the long-term efficacy of steroid injections for LBP.     

Poster 27: Pressure ulcer history and spinal cord injury

Objective: To identify risk and protective factors associated with a history of recurrent pressure ulcers after spinal cord injury (SCI). Design: Cross-sectional. Setting: Large southeastern US specialty hospital. Participants: 826 nonambulatory adults with traumatic SCI of at least 5 years in duration. Interventions: Not applicable. Main Outcome Measures: Outcomes included current pressure ulcers, pressure ulcers within the past years, days adversely impacted by pressure ulcers, pressure ulcer surgeries, and pressure ulcer history (recurrent vs nonrecurrent). Results: 69% failed to report recurrent pressure ulcers, whereas 13% reported a clear pattern of recurring pressure ulcers of 1 or more per year (18% could not be classified). Logistic regression identified several general protective behaviors for recurrent pressure ulcers (eg, lifestyle, exercise, diet), none of which included those generally recommended during inpatient rehabilitation to prevent pressure ulcers (eg, skin checks, weight shifts). Fewer risk behaviors were associated with pressure ulcer history, although several proxy variables were related to pressure ulcer history. Conclusions: Pressure ulcer history is a more viable measure of pressure ulcer outcomes than measures taken at a single point in time (current), over a brief period of time (eg, 1y), or those relying on critical events occurring at any time since SCI onset (ie, surgeries to repair pressure ulcers). A general healthy lifestyle appears to be strongly associated with an absence of recurrent pressure ulcers, whereas the efficacy of specific prevention behaviors was not demonstrated.     

Abstract 4: Acupuncture analgesia and electromyography

Objectives: To evaluate the analgesic effect of a simple acupuncture protocol with needle electromyography and to validate independently a telescopic sham acupuncture needle. Design: Randomized, double-blinded, controlled study. Setting: University-based electrodiagnostics laboratory. Participants: 38 subjects referred for electrodiagnostic evaluation. Intervention: Before the electromyographic examination, an independent provider applied either real acupuncture needles or telescopic sham needles to the acupuncture points Large Intestine 4 and Liver 3 bilaterally. Main Outcome Measures: 100-mm visual analog scale (VAS) of the subjects’ pain before electromyography as well as pain and unpleasantness related to electromyography after 3 muscles were examined. Subjects were also asked if they thought they had received true acupuncture or sham needles. Pretest pain was subtracted from electromyography-related pain to give a measurement of pain attributable to the electromyography. Results: 21 subjects were randomized to the treatment group and 17 to the sham group. The subjects in the two treatment arms did not differ by age (P=0.9) or gender (P=0.4). The pain attributable to electromyography in the treatment group (mean, −5.38±27.6) was significantly less than the pain attributable to electromyography in the control group (mean, 11.3±17.3) (P=.037; 95% CI, −32.3 to −1.1) The percentage of subjects who thought they had received real needles in the acupuncture group (67%) did not differ from the proportion in the control group (53%) (Fisher exact test, P=.51). Conclusion: Acupuncture may represent an effective form of analgesia for electromyography. This is the first study of which we are aware that independently validates the telescopic sham acupuncture needle as an effective control.     

Poster 28: Effects of glucosamine on pain and functioning in canadians with osteoarthritis of the knee

Objective: To determine the effects of glucosamine sulphate on morbidity in osteoarthritis (OA) of the knee. Design: Randomized controlled trial. Groups were stratified on age, body mass index, gender, pain ratings, and medications. Setting: Outpatient teaching hospital in Ontario, Canada. Participants: 18 men and women, age 18 to 65 years, with moderately severe, radiologically confirmed OA. Sample size estimates indicated samples of 14 subjects would detect ’20% improvements in pain (α=.05, power=.80). Interventions: 1500mg of purified glucosamine versus color-coded drug placebo self-administered twice daily for 8 weeks. Participants were asked to refrain from all other treatments for OA, including medications. Main Outcome Measures: Baseline and 8-week measures, including visual analog pain ratings, peak torque strength on a Biodex isokinetic strength tester, quality of life using the Western Ontario and McMaster Universities Osteoarthiritis Index (WOMAC), and range of motion (ROM). Results: Both groups improved in treatment on pain (P<.05), and there were trends toward improvement on ROM in both groups, suggesting a placebo effect. There were no trends for changes in peak torque or WOMAC measures. Rate of drop out prior to completion of all study requirements was high (42%) and all patients admitted using other pain medications during the trial. The desire for more pain control was implicated in dropping out. Conclusion: The efficacy of glucosamine for treating Canadians who have OA of the knee remains unclear despite positive industry-linked trials.     

Poster 29: Barriers to community integration treatment

Objective: To examine barriers to community integration treatment (CIT) among a consecutive sample of referrals. Design: A retrospective chart review of a consecutive series of referrals to CIT. Setting: CIT program for persons with brain injury. Participants: 138 consecutive referrals (n=72 nonadmitted) to CIT from January 1 to December 31, 2002. Interventions: All persons referred were evaluated by an admissions counselor and/or treatment team to determine appropriateness. Main Outcome Measures: Data comparing persons entering treatment with those not entering treatment were retrieved from summary admissions reports. Results: Persons entering treatment did not differ in age, gender, race, distance to the program, or time postinjury from persons who did not enter treatment. Common barriers to persons not entering treatment included: reliable transportation (14%), funding for treatment (8%), poor family support (6%), and awareness for relevance of treatment (14%). Conclusions: Among a sample of consecutive referrals not admitted to CIT, approximately 42% of cases were due to barriers such as reliable transportation, funding for treatment, poor family support, and education about the relevance of CIT. These data suggest points of intervention for policymakers and clinicians to decrease disability and handicap in states serving large rural populations.     

Poster 5: Predictors of fatigue in patients with rheumatoid arthritis and major depressive disorder

Objectives: To determine the relationship between fatigue and disease activity in persons with concomitant rheumatoid arthritis (RA) and major depressive disorder (MDD) and to replicate a previous study that found fatigue was predicted by higher levels of pain, more depressive symptoms, and female gender in a cohort of persons with RA who did not have MDD. Design: Prospective 15-month study using longitudinal data. Setting: Midwestern veterans’ hospital, university medical center, and private rheumatology practice. Participants: 54 subjects (39 women, 15 men) with 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 significantly related to fatigue; subjective and objective measures of disease activity, as well as sleep, did not make additive contributions.     

Poster 36: Neuropsychiatric symptoms in patients with traumatic brain injury: 2 years postdischarge

Objective: To assess the prevalence of neuropsychiatric symptoms in traumatic brain injury (TBI) 2 years postdischarge from inpatient rehabilitation and its associated caregiver distress. Design: Follow-up study. Setting: Inpatient acute rehabilitation hospital and community. Participants: 39 consecutive patients with TBI. Interventions: Not applicable. Main Outcome Measure: The Neuropsychiatric Inventory. Results: Neuropsychiatric symptoms were present in 75% of our sample 2 years postdischarge from acute rehabilitation. Among these symptoms, the most frequently encountered were: irritability, 48.7%; depression, 43.6%; appetite and eating changes, 25.6%; night-time and sleep behavior, 23.1%; apathy, 20.5%; anxiety, 17.9%; agitation and aggression, 17.9%; and disinhibition, 10.3%. The least frequently observed behaviors included: hallucinations, 5.1%; euphoria and elation, 2.6%; and delusions, 0%. At 2-year follow-up, anxiety, agitation and aggression, apathy, and irritability caused the most emotional distress to the caregivers, while hallucination and euphoria caused the least. Conclusions: Neuropsychiatric symptoms are prevalent in patients with TBI after discharge from acute rehabilitation. These symptoms are associated with significant caregiver distress. These findings further support the continued need for adequate psychologic assessment and possible intervention postdischarge.     

Article 3: Comparing amputation patterns in veterans affairs medical centers from 1997 to 2000

Objectives: To examine patterns of amputation (all levels) among veterans who were identified as at-risk and to examine factors that predict greater risks for a major (below-knee, above-knee) amputation. Design: Database approach, secondary data analysis. Setting: Veterans Affairs medical centers (VAMCs). Participants: 451,824 were selected if they had diagnoses of diabetes mellitus or peripheral vascular disease, and were at-risk for lower-extremity amputation. These patients were followed for 4 years (1997-2000) to determine the occurrence of amputation. Interventions: Not applicable. Main Outcome Measures: Differences in frequency and level of amputation were assessed among 132 VAMCs with different Preservation of Amputation Care and Treatment (PACT) rankings. Regression techniques were used to identify factors associated with increased risk. Results: Over the 4-year period, 10,258 patients had at least 1 amputation (2.3%). Highly ranked VAMCs had greater amputation rates and performed more above-knee amputations than less well ranked VAMCs. Factors that increase risk for a major amputation include race, skin ulcers, gangrene, and prior amputation. Conclusion: High-PACT VAMCs are often located in an urban setting, affiliated with academic medical programs, and have higher volume of patients. Higher amputation rate at high-PACT facilities may reflect a movement toward centers of excellence for prevention of and treatment for lower-extremity amputations.     

Article 2: Comparability of mayo-portland adaptability inventory ratings by staff, significant others, and people with acquired brain injury

Objective: To determine the internal consistency, reliability, and comparability of the Mayo-Portland Adaptability Inventory (MPAI-4) and subscales completed independently by people with acquired brain injury, family and significant others, and rehabilitation staff. Design: Rater agreement for MPAI-4 protocols was evaluated and data were submitted to Rasch facets analysis to determine the internal consistency for each rater group and for a composite measure based on all rater groups. Setting: Outpatient rehabilitation. Participants: 134 people with acquired brain injury consecutively seen for outpatient rehabilitation evaluation, significant others, and staff. Interventions: Not applicable. Main Outcome Measure: MPAI-4 and subscales (ability, adjustment, and participation indices). Results: Rasch indicators of internal consistency were entirely within acceptable limits for 3-rater composite full scale and subscale measures, and generally within acceptable limits for measures for single rater groups. Item agreement was generally acceptable; disagreements suggested varying perspectives and sources of bias for specific rater groups. Conclusions: The MPAI-4 possesses satisfactory internal consistency regardless of rating source. For research and program evaluation, the composite measure provides a method to synthesize multiple perspectives on current status. In clinical settings, assessment of varying these perspectives during initial evaluation is helpful in developing effective rehabilitation plans.     

Abstract 13: Use of electromyography to predict functional outcome after epidural spinal injections for lumbar radiculopathy.

Objective: To determine if electromyographic diagnostic evaluation can predict functional outcome in patients undergoing lumbar spinal injections. Design: Retrospective study of functional outcome in patients undergoing lumbar interforaminal epidural spinal injections (ESIs) after electromyographic testing. Setting: Clinic. Participants: 39 subjects with low back pain with radicular symptoms into the lower extremity were evaluated for functional improvement after electromyography and ESI. Interventions: Fluoroscopic guidance of interforaminal ESI in the lumbar region was performed where positive clinical or electromyographic levels were suspected. Main Outcome Measures: Oswestry Disability Index (ODI) and Verbal Rating Scale (VRS) for current pain severity. Results: Electromyography diagnosed 18 patients with a radiculopathy; 21 had a normal or negative examination. Patients were followed postinjection on average for 10.8±3.9 weeks. Pretreatment ODI scores ± SD did not differ significantly between groups showing positive radiculopathy (72.3±12.7) or negative electromyographic findings (65.9±18.6) (P>.05). There was significantly greater improvement of ODI rating for electromyography positive radiculopathy (7.11±9.5) compared with negative electromyography (3.2±17.4) (P<.05). Positive radiculopathy subjects complained of more pain as measured on the VRS before ESI (8.1±1.0) than subjects with negative electromyographic findings (7.3±0.8) (P>.05). The VRS mean improvement did not differ significantly between the positive electromyography group (1.8±1.2) and the negative electromyography group (1.2±1.2) (P>.05). Conclusions: Subjects undergoing interforaminal ESI, who had a positive radiculopathy by electromyography prior to injection, showed significant improvement in functional outcome as measured by the ODI but not as measured by current pain intensity on the VRS. This study showed the importance and diagnostic value of electromyography for radiculopathy evaluation prior to spinal procedures and the difficulty of pain evaluation outcome by using the VRS.     

Abstract 22: Acute neuroradiograhic predictors of rehabiliation costs.

Objective: To examine acute neuroradiographic and injury predictors of rehabilitation costs in a large traumatic brain injury (TBI) population. Design: Multiple regression-based within-group design. Setting: Urban university-based neurotrauma center and rehabilitation hospital. Participants: 293 persons presenting to a level 1 trauma center with a primary diagnosis of moderate or severe TBI who required inpatient rehabilitation. Interventions: Not applicable. Main Outcome Measures: Multiple variables derived from demographics, injury characteristics, ratings of various computed tomography (CT) scan indicators of neuropathology, and charges for rehabilitation services. Results: Several key variables that are predictive of rehabilitation outcome (including age, cause of injury, admission Glasgow Coma Scale [GCS] score) and several CT-derived neuroradiographic variables were entered into a multiple regression model to predict the total dollar charges for all rehabilitation services. The variables that emerged as statistically significant were (in order of amount of variance accounted for in the predictive model: presence of subarachnoid hemorrhage (SAH) (F change=17.89; P<.0001), admission GCS total score (F change=13.59; P<.0001), presence of frontal lobe contusion (F change=8.26; P<.004), presence of left parietal contusion (F change=7.15; P<.008), presence of right epidural hemorrhage (F change=4.51; P=.035), and presence of a punctate hemorrhage (F change=4.89; P=.028). Conclusions: Charges for TBI rehabilitation are an important consideration. The ability to predict the relative cost of rehabilitation can facilitate planning and may be helpful in more accurately determining the allocation of resources. The presence of SAH was an important predictor of charges and may reflect a risk factor for secondary brain injury not captured by other measures.     

Poster 22: Loss to follow-up and potential systematic bias in survivors of traumatic brain injury 12 months postinjury

Objectives: To predict which survivors of traumatic brain injury (TBI) are more likely to be lost to follow-up and to examine the possibility of systematic bias in TBI research. Design: Characteristics of participants initially enrolled in a prospective, longitudinal follow-up study were compared with those lost and found for the 12-month follow-up using logistic regression. Setting: A prospective, longitudinal database. Participants: 1153 adult survivors of TBI. Interventions: Not applicable. Main Outcome Measures: Lost participants were those with no 12-month follow-up interview, excluding the deceased. Results: Follow-up was attempted with 1153 survivors of TBI. Initial data were collected from hospital charts. The 12-month follow-up was a telephone interview. At follow-up, 21 had died (1.8%), 574 were lost to follow-up (49.8%), and 558 (48.4%) were located and interviewed. Variables related to follow-up availability included injury severity (critical injuries vs moderate injuries) with critical injuries associated with follow-up failure (OR=.24; 95% CI .14-.38). Conclusions: Differences in information-gathering techniques led to substantial loss of participants. Differential loss to follow-up potentially biases TBI outcome research.