Posters


Poster 498 – Third Place (TIED) Resident Research

Factors Associated with Community Versus Personal Care Home Discharges After Inpatient Stroke Rehabilitation: The Need for a Pre-Admission Predictive Model.

Alexander Wasserman1, Michelle Thiessen2, Sepideh Pooyania1

1Section of Physical Medicine and Rehabilitation, Faculty of Medicine, University of Manitoba, Winnipeg, Canada

2University of Manitoba, Winnipeg, Canada

Introduction: With improved risk factor management and interventional techniques, more patients are surviving strokes than ever before. While a success for acute care, this has placed greater strain on inpatient stroke rehabilitation (ISR) resources.

Objective: The purpose of this study is to identify the pre-ISR admission factors that accurately prognosticate rehabilitation outcomes and best predict eventual personal care home (PCH) discharge.

Participants: The research team reviewed the charts of all 60 patients discharged to PCH from ISR from 2008-2017, along with 180 randomly selected controls discharged to the community. The control group was selected to evenly represent these ten years.

Methods: The data for this retrospective cohort study was collected through both manual and electronic chart review using local and national databases. For data analysis, univariate logistic regression was performed for each measured variable. Stepwise forward selection using multivariate logistic regression was then used to identify variables independently associated with eventual discharge to PCH versus community.

Results: A total of 242 charts were reviewed, of which 60 were discharged to PCH. It was found that patients were significantly more likely to be discharged to PCH if they were older (OR 1.09; CI[1.05-1.15] of PCH discharge for every additional year), had a lower functional independence measure (FIM) score at admission (OR 0.95; CI [0.92-0.97] of PCH discharge with every additional point), had cognitive deficits (OR 6.19; CI [2.37-18.06]), lived alone before their stroke (OR 7.77; CI [2.75-24.55] when compared to living with spouse/partner), and if a BERG balance scale could not be measured at admission to ISR due to excessive truncal instability (OR 0.17; CI [0.06-0.45] of PCH discharge if able to measure). Taken together, the predictive value of PCH discharge using these five variables was 91.6%.

Conclusions: A combination of age, admission FIM, cognitive impairment, pre-stroke living situation, and measurability of the BERG balance scale on admission to ISR was highly predictive of eventual PCH discharge after ISR. This study suggests that it is possible to accurately predict which patients are at high risk of PCH discharge upon their admission to ISR.


Poster 499 – Resident Research Contest

Factors That Mitigate A Useful Reflection In Identifying CANMED Competencies Among PM&R Residents: Qualitative Study 

1Zainab Al Lawati, MD, FRCPC, 2Gregory MacKinnon
1Department of Medicine, Division of Physical Medicine and Rehabilitation, Dalhousie University, Capital District Health Authority; Halifax, NS
2Professor of Science & Technology Education Acadia University School of Education Halifax NS Canada

Introduction: Throughout my residency as a medical learner I was advised to reflect on my medical experiences on a regular basis. The important aspect that most of the reflection assessments would dismiss is the evaluation of CanMed medical competencies. Given that Canadian medical training system is raiding towards competency based training; addressing CanMed roles through reflections is an important evaluation method.
Objective: The objective of this study is to determine the factors that mitigate useful reflection in identifying CanMed competencies among PM&R residents.
Methodology: A survey was given to PM&R residents to be completed prior to the reflection session as a part of the academic schedule. It included Physical Medicine and Rehabilitation residents. The survey had two parts. In part 1: they were asked to provide an example of a clinical encounter they have acquired and address CanMed competencies to that situation. In part 2: they were provided a questionnaire around addressing preceptor and peers feedback in their reflections and addressing CanMed competencies and what would be the common barriers to use reflection as an educational method. A semi-structured interview guide was followed and conducted with 3 participants. Results: the survey showed that more then 80% agreed that reflections can be used as a learning tool in identifying CanMed competencies. The main themes identified in the analysis are: emotional sensitivity, reflection as a learning style, reflection environment and the role of reflections in addressing CanMed competencies.
Conclusion: Reflection is an important tool in promotive the metacognitive skills during residency. It is also important to address all the CanMed competencies required to effectively meet the health care needs of the people they serve. Implementing longitudinal reflections portfolio in Competency Based Medical Education would aid in addressing CanMed competencies more effectively. 


Poster 500

Virtual Reality, the New Standard of Care for Burn Patient Pain Management

Lauren M. Cormier1

1 University of Alberta, Edmonton, AB, Canada

Context: Burns are common but not usually fatal injuries in developed nations. Severe burns require extensive, painful wound care and rehabilitation for months to years. Burns not only carry the risk of becoming infected but also long-term consequences such as scarring, contractions and heterotrophic ossification which can limit Range of Motion (ROM) and overall function of affected limbs. Rehabilitation, is vital to preventing these long-term consequences but the associated pain is a significant impediment to successful completion.

Results: The current standard of care using only pharmaceuticals is suboptimal for managing pain in burn patients. Opioids, which are commonly used, have serious side effects that can’t always be avoided, especially at higher doses. Virtual Reality (VR) has proven to be a safe and effective tool that diverts attention away from painful stimuli and reduces anxiety associated with treatment and therapy. VR is a simple, cost effective technique for managing pain with little risk and great benefit.

Conclusion: In addition to the current standard of care VR should be seriously considered for both short-term and long-term pain management during wound care and rehabilitation. Furthermore, VR can potentially be utilized for pain management in other medical fields and with other populations.

Keywords: Burn, Pain Management, Virtual Reality

Poster 502Platelet rich plasma in common knee disorders – a review of applications and outcomes.

Alexander Wasserman1, Graeme Matthewson1, Peter MacDonald1

Submitter: Alexander Wasserman

1 – University of Manitoba, Winnipeg, Manitoba, Canada

Objective: To consolidate and synthesize the most recent evidence on the effects of platelet-rich plasma (PRP) in the knee with respect to osteoarthritis, meniscal injuries, ACL reconstruction, total knee arthroplasty (TKA), and high tibial osteotomy.

Design/Methods: This review included the most recent literature (over the past three years) on PRP injection into the knee, and its efficacy in various contexts. It also included the classic PRP literature that forms the basis of current studies and contributes to the scientific community’s understanding of PRP’s composition, preparation techniques and function.

Results/Findings: PRP has been shown to be more beneficial in the context of knee osteoarthritis compared to both placebo and hyaluronic acid. Direct comparison with corticosteroid injections has been sparsely studied. It has also been shown to improve the clinical postoperative course in meniscal injuries and to a lesser extent TKA. Radiographic improvements without clinically significant benefits have been observed with ACL reconstructions treated with PRP.

Summary: PRP injections may be more beneficial than other current non-surgical management options for specific knee pathologies. Further research should broaden the knowledge of PRP effects on the knee, and identify the type of PRP, growth factor distribution, and route of administration associated with the most benefit.

#504

Exposure to Physical Medicine and Rehabilitation: the impact of a two-week pre-clerkship residency exploration program on specialty interest and understanding

Emily AL Sheppard BSc, MScPT1, Michael Smyth BSc, MSc1, Todd Dow BSc1, T. Sebastian Haupt BA1 and Sonja McVeigh, MD, FRCPC Dip. Sport Med1,2

1Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada

2Division of Physical Medicine and Rehabilitation, Dalhousie University, Halifax, Nova Scotia, Canada

Objective: Physical Medicine and Rehabilitation (PMR) is one of many medical specialties competing for more time in the standard undergraduate medical school curriculum. The aim of this study was to assess the impact the Pre-clerkship Residency Exploration Program (PREP) had on student career interest, understanding of PMR, and to assist in making informed career choices.

Design/Methods: During the two-week program, students were exposed to a PMR elective, skills workshop, career presentation, and panel discussion with PMR residents. Interest and understanding were assessed using pre- and post-program questionnaires.

Participants: Forty second-year medical student participants were randomly selected from 74 applicants at Dalhousie University.

Results: Interest in PMR did not significantly change between time point collections, though understanding of the roles and responsibilities of physiatrists increased significantly, with larger trends in those with greater exposure time. Higher exposure time was correlated with an increased top 3-career selection. Comfort level in common PMR procedures also significantly increased.

Conclusion: PREP effectively refined student interest in PMR, while also significantly improving participant understanding of the specialty. A brief exposure as part of a two-week summer elective is beneficial for career decision planning and may be feasible to implement in medical curricula.

Keywords: Career choice, Education, Medical, Physical and Rehabilitation Medicine, Undergraduate


Poster 505

Functional outcomes of patients with Posterior Fossa Syndrome following acute inpatient rehabilitation

Derek J Boyd1, Erika Erlandson2, Scott Millis1

1 Rehabilitation Institute of Michigan, Detroit Medical Center, Wayne State University, Detroit, MI, USA

2 Children’s Hospital of Michigan, Detroit Medical Center, Detroit, MI, USA

Context: Posterior Fossa Syndrome (PFS), observed in 8-24% children after posterior fossa surgery, has an unknown pathophysiology, characterized by clinical symptoms of mutism, ataxia, emotional lability, and behavioral symptoms. Treatment consists exclusively of supportive care, including multidisciplinary teams in acute inpatient rehabilitation. However there are limited studies assessing clinical and functional outcomes in this population, after a course of intense acute inpatient rehabilitation. Our design is a case series, where we retrospectively analyze admission and discharge Functional Independence Measures for Children (WeeFIMs) in a pediatric population with a diagnosis of PFS while enrolled in an intense acute inpatient rehabilitation program. Also assess which PFS clinical symptoms are present and which improve or resolve while in inpatient rehabilitation.

Findings: With regards to WeeFIM scores, overall there was an increase from admission to discharge in every measure, with the largest increase in upper extremity dressing and lower extremity dressing, and the lowest increase in bladder.

With regards to PFS symptoms, in all patients there was improvement or resolution of patient’s symptoms that involved mutism, ataxia and emotions. Although the majority of patients saw improvement or resolution of behavioral symptoms, some patients saw no change to the PFS behavioral symptoms from admission.

Conclusion/Clinical Relevance: Our data supports trends of improvement across all studied clinical and functional measures after acute inpatient rehabilitation. From our data, it appears that only behavioral symptoms did not improve or resolve in all patients. It is possible that these clinical symptoms may take longer to improve than the others, or may have a lower likelihood of resolving. Our findings support the continued use of supportive care through multidisciplinary teams in an intensive and structured acute inpatient rehabilitation unit for the treatment of patients with PFS.

Keywords: Child, Neoplasms, Inpatients


Poster 506

Low back pain home-based exercise and wellness web-application: a prospective cohort study (in progress)

Darsan Sadacharam

Queen’s University Kingston ON, Canada

Context: Low back pain (LBP) is an increasingly prevalent medical complaint resulting in significant functional deficit, reductions in quality of life, as well as financial, and societal burden. Various national guidelines emphasize managing LBP using physical, psychological, and self-management strategies. Unfortunately, many patients are unable to receive the necessary physical therapy or psychological care due to financial or accessibility factors. To mitigate this health inequity, many physicians provide patients with a list of exercises to help self-manage their LBP at home. Despite these strategies, it is likely significant improvements can still be made to address the gaps in patient education, psychosocial factors, and follow-up.

Objective: To develop a web-based application that will serve as a tool for physicians to prescribe home-based exercise, mindfulness therapy and educational resources to patients with non-specific low back pain.

Participants: Patients presenting with an initial episode of LBP and no additional symptoms that may indicate a more concerning pathology will be recruited.

Design: To assess the efficacy of this application, we will be conducting a prospective cohort study at the Queen’s Family Health Team Clinic in Kingston, ON. Participants will create an online account and complete a questionnaire, that will individualize their home-based exercise therapy based on the patient’s LBP localization and flexion/extension response.

Intervention: The program will guide participants through 15-minute exercise sessions, three times per week, and two 15-minute mindfulness sessions per week. Participants will also have access to educational material on various topics regarding LBP, such as their specific back pain pattern and conservative management strategies. Throughout the 4-week trial, their pain, mood, and satisfaction will be collected weekly. These data points will be amalgamated with their initial medical questionnaire and presented on the patient’s report page, enabling patients and their physicians to monitor their rehabilitation progress.

Outcome Measures: After the 4-week trial is complete, a custom-designed questionnaire equivalent to the one administered at the start of the program will be used to assess for any change in symptom severity, functional capacity and quality of life.

Results/Conclusion: The goal is to create a more effective and resource-efficient solution for managing LBP. This tool may provide greater access for patients to self-manage their LBP and help identify those in need of greater levels of care.

Key words: mindfulness, self-management, rehabilitation


Poster 507 – Resident Research Contest
Rehabilitation Post Lance Adams Syndrome: Case Report 
1Zainab Al Lawati, MD, FRCPC, 1Amra Saric FRCPC Dalhosuie University
1Department of Medicine, Division of Physical Medicine and Rehabilitation, Dalhousie University, Capital District Health Authority; Halifax, NS
Introduction: Management of movement disorders requires multidisciplinary approach. With the advances in rehabilitation medicine and its multimodal approach
Physiatrists are able to troubleshoot complex movements disorders and be an essential part in the multidisciplinary approach to provide better care.
Case description: We report a 40-year-old man sustained anoxic – ischemic brain injury as a result of his suicide attempt via hanging. His major visible residual neurologic issue was action myoclonus which is consistent with Lance Adams syndrome. In addition to the medical and psychological management, he was admitted to the rehabilitation facility to address his myoclonus and optimize his functional rehabilitation. He showed significant progress in his therapies that included falls prevention strategies, resistance exercises, and proper education on using gait aids. Cognitive and vocational rehabilitation strategies were implemented prior to his discharge. Upon follow up, he was able to participate in the gym using free weights and weight machines (to do bench presses, shoulder presses, biceps work, triceps work, etc.), without any difficulty whatsoever.
Significance: this report illustrates the art behind the rehabilitation medicine in managing complex movement disorders changing their patients’ quality of life.


Poster 511

A Literature Review on the relationship between Biomechanics and Low Back Pain

Ans Osman Sabzwari

University of Manitoba, Max Rady College of Medicine Student Level: PGY2, Physical Medicine and Rehabilitation , Winnipeg, Manitoba, Canada

Objective: Presenting literature on key biomechanical concepts that are lacking in patient resources for non-specific low back pain (LBP). These include movement patterns, proprioception, abdominal bracing, supper stiffness, and mind muscle connection. Secondly, reviewing the effectiveness and feasibility of Internet based interventions to disperse information.

Design and Setting: A literature review analyzing the relationship between LBP with numerous variables including movement patterns, proprioception, posture, lifting technique, gluteus maximus (GM), and cross sectional area (CSA).

Outcomes: Healthy movement patterns are important for low back health. There is weak evidence linking proprioception with LBP. Poor posture and lifting technique may contribute to LBP. Decreased GM CSA was associated with LBP.

Literature findings: Decreased ratio of lumbar extensor to flexor muscular endurance and an increase in type 1 fast twitch fibres in patients with LBP. Poor evidence connects decreased proprioception in sitting with LBP. Prolonged postures lead to vulnerability of soft tissues to injury. Abdominal bracing, super stiffness, and mind muscle connection are tools to improve movement patterns. Internet based interventions have been shown to be feasible in a primary care setting, and have been shown to be effective in multiple healthcare initiatives.

Goal: To review the importance of biomechanics in LBP generation.


Poster 512

Determinants of REHABILITATION potential and improvement in severely DECONDITIONED PATIENTS: A Prospective Cohort Study

Daniel Chan Chun Kong1, Odette Laneuville1,2, PhD & Guy Trudel1,3,4,5, MD, FRCPC

1Bone and Joint Research Laboratory;

2Department of Biology, University of Ottawa;

3Department of Medicine, Division of Physical Medicine and Rehabilitation,

4The Ottawa Hospital Research Institute, 5Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON, Canada.

Background: Long stays in hospital acute care cause deconditioning that is amenable to rehabilitation. Few if any evidence-based objective criteria measure a patient’s level of deconditioning in order to determine who will most.

Objectives: 1) Measure biological variables of deconditioned patients and describe how they change throughout an inpatient rehabilitation intervention 2) Determine whether demographic, administrative and biological variables at rehabilitation admission correlate with functional improvement.

Design/Methods: This was a pilot prospective cohort design. Rehabilitation improvement was measured using the Functional Independence Measure (FIM) score, expressed as FIM Gain (FIM discharge-FIM admission) and FIM Efficiency (FIM Gain/days in rehabilitation). Demographic (eg. age), administrative and biological variables (e.g.; weight, BMI, complete blood counts) were serially recorded throughout the inpatient rehabilitation stay. Changes in FIM and biological variables were assessed over 4 weeks of rehabilitation treatment using Friedman’s ANOVA with post-hoc Wilcoxon test. Spearman’s correlation was used to determine which variables at admission were associated with FIM Gain.

Participants: Deconditioned patients (N=10) who spent >3 weeks combining hospital acute care and met the criteria for admission to a rehabilitation center. All patients received ≥4 weeks of interdisciplinary inpatient rehabilitation.

Results: All patients showed functional improvements with a mean FIM Gain of 26.4±11.0 and FIM Efficiency of 0.88points/day. Results from the Freidman’s ANOVA showed significant changes with FIM scores (p=0.001), white blood cells (WBC) (p=0.01), neutrophil concentrations (p=0.03) and red cell distribution width (RDW) (p=0.01) over rehabilitation. Wilcoxon test showed that as FIM significantly increased with rehabilitation (p=0.01), WBC (p=0.01) and neutrophil concentration (p=0.02) increased from Week 2 to Week 4 and RDW decreased from Admission to Week 2 (p=0.02) and to Week 4 (p=0.04). Spearman’s correlational revealed that older age at admission was significantly associated with a higher FIM Gain (r=0.63; p=0.05).

Conclusion: Inpatient rehabilitation was effective for deconditioned patients. Longitudinal assessment indicates WBC, RDW and neutrophil concentrations as potential indicators of rehabilitation improvement. Older age was not a detrimental factor to functional improvement. The results support the feasibility of larger scale study to identify objective criteria to predict inpatient rehabilitation success in these patients.

Keywords: Hospitals, Rehabilitation; Muscle Weakness; Pilot Projects; Biomarkers; Hospitalization; Health Status

Granting Agency/Funding Source: The Academic Health Sciences Centre Alternate Funding Plan Innovation Fund, The Ottawa Hospital Academic Medical Organization


Poster 513
Functional Improvement Related to Enrolment in Parkinson’s Disease Rehabilitation Program

Beverley M Chow1, MD, Florin Feloiu2 MD, Assunta Berardocco3 MSc (PT), David Ceglie 4(MBA), Shanker Nesathurai5 (MD)
1McMaster University, Hamilton, ON, Canada

2McMaster University, Hamilton, ON, Canada

3Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharine’s, ON, Canada

4Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharine’s, ON, Canada 5 – McMaster University, Hamilton, ON, Canada

Objectives: Parkinson’s Disease (PD) is a progressive neurodegenerative disorder with manifestations of tremor, rigidity, bradykinesia and more. The objective of this study was to evaluate the efficacy of outpatient multidisciplinary rehabilitation.

Design: 179 patients participated in the six-week program. The following outcomes were measured: “Timed Up and Go” (TUG), “Sit to Stand” five times (STSx5) and in 30 seconds (STS30), “6 Minute Walk” distance (6MWD) and gait velocity (6MWV), MOCA, bilateral grip strength, 360-degree turn (360 R, 360 L) and bilateral 9-hole peg test. Pre- and post- data was analyzed via paired t-tests. Multiple regression was used to determine whether age or gender affected outcomes.

Results: Patients showed a statistically significant improvement (p<0.05) in all outcomes. Mean TUG improved by 1.63 seconds (s), STSx5 by 4.19s, STS30 by 2.37 repetitions, 6MWD by 66.8 metres, 6MWV by 0.15m/s, MOCA by 1.50 points, 360 R by 1.17s, 360 L by 1.60s, Grip R by 0.78kg, Grip L by 0.95kg, 9HP R by 1.71s and 9HP L by 1.58s. Gender had no influence. Age was a statistically significant predictor in STSx5 and 6MW.

Conclusions: An outpatient multidisciplinary program was successful at decreasing motor impairment and increasing overall functional independence in PD.
The report no financial disclosures.

#515

Let’s not forget about post-traumatic amnesia — strategies to improve patient lives after brain injury

Cathy Meng Fei Li1, Lawrence Russell Robinson1,2, Alan Ka Ho Tam1,2

1 Department of Medicine, University of Toronto, Ontario, M5S1A8

2 Division of Physical Medicine and Rehabilitation, Sunnybrook Health Sciences Centre, Ontario, M4N3M5

Introduction: Patients with moderate-to-severe traumatic brain injuries (TBIs) frequently suffer from post-traumatic amnesia (PTA). PTA duration is an important prognosticator of patient outcomes that is amenable to pharmacological and non-pharmacological interventions. Despite its importance, there is a limited understanding of PTA and its management remains inconsistent in practice.

Objective: To clarify the symptomatology of PTA in facilitating early diagnosis, the use of pharmacological agents in minimizing PTA duration, and the role of early rehabilitation.

Results: PTA consists of a constellation of fluctuating cognitive symptoms and neurobehavioural sequelae that require prudent medical attention. There is evidence for phenytoin as seizure prophylaxis in severe TBI patients, and neuroprotective agents that minimize neurochemical disruptions and length of PTA. Neuroprotective agents include methylphenidate for managing cognitive impairments, melatonin for restoring sleep-wake cycles, and beta-blockers for acute agitation. Early rehabilitation and physiatrist interventions in trauma centres are associated with shorter hospital stays and improved functional outcomes.

Conclusion: We recommend serial administration of Galveston Orientation and Amnesia Test (GOAT) in trauma centres, and integrating the Confusion Assessment Protocol (CAP) into initial admission assessments for inpatient rehabilitation. Personalized early rehabilitation coupled with neuroprotective interventions can minimize PTA duration and facilitate TBI recovery with improved long-term outcomes.


Poster 516

Virtual reality in rehabilitation: A promising tool

Dave K. Saraswat1
1Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada

Virtual reality (VR) has the potential to improve the accessibility and outcomes of rehabilitation. This paper aims to discuss the evidence surrounding the use of VR in both assessment of patient status and treatment of patients with stroke or spinal cord injury. VR is a promising tool for assessment which may quickly assess patients’ cognitive status and precisely compare patients’ upper and lower limb coordination. Similarly, VR is a promising addition to conventional rehabilitation in stroke patients, with the strongest evidence supporting the use of immersive VR in upper limb rehabilitation and weaker evidence supporting its use in cognitive and lower limb rehabilitation. For spinal cord injury, VR may persistently improve neuropathic pain and gait; however, its clinical utility in upper limb rehabilitation is limited. Ultimately, while the evidence surrounding VR is encouraging, there is little agreement on which tools to use, and most studies have small sample sizes, making it difficult to draw a definitive conclusion on its efficacy. Thus, while VR may improve outcomes in certain settings, future research should focus on establishing standardized normative scores to facilitate its use in patient assessment and demonstrating its efficacy in larger-scale randomized controlled trials.


Poster 517 – Third Place (TIED) Resident Research

Do we have agreement? Examining the use of the six-minute walk test to monitor cardio-respiratory fitness response to cardiac rehabilitation in patients with heart failure

Travis Davidson, MD, PhD1,2; Daniele Chirico, PhD1; Tasuku Terada, PhD1; Kyle Scott, MSc1; Marja-Leena Keast, DipPT1; Robert D. Reid, PhD, MBA1,2; Andrew L. Pipe, CM, MD1,2 ; Jennifer L. Reed, R.Kin, PhD 1,2,3

1 Division of Cardiac Prevention and Rehabilitation, Exercise Physiology and Cardiovascular Health Lab, University of Ottawa Heart Institute, Ottawa, Ontario, Canada ;

2 University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada;

3 University of Ottawa, Faculty of Health Sciences, School of Human Kinetics, Ottawa, Ontario, Canada

Objectives: The examined the agreement between existing prediction equations from 6MWT distance and cardiopulmonary exercise test (CPET) to estimate change in peak oxygen uptake (V̇O2peak) in patients with heart failure (HF) enrolled in cardiac rehabilitation (CR). The secondary purpose was to compare differences on the 6MWT between responders and non-responders to evaluate CRF responsiveness to CR.

Background: Assessing fitness using cost-effective and time-efficient methods, such as the 6MWT, is clinically important to monitor responses to lifestyle interventions, such as CR.

Methods: This was a retrospective study of 54 (n=9 women) patients with HF that completed a clinical CR program. Functional capacity was examined using distance ambulated on the 6MWT. Four previously published equations using 6MWT distance were used to estimate V̇O2peak and were compared to a CPET using the Bland-Altman method. Participants were grouped as responders and non-responder, based on whether they met an increase of 0.5 metabolic equivalent (MET) increase in fitness as determined by CPET.

Results: The mean age of participants was 64 ± 10 years. Bland-Altman plots revealed proportional bias between the prediction equations and actual measured V̇O2peak, whereby the difference between methods depended on the average fitness, with overestimation of prediction equations at greater levels of fitness. Distance ambulated on the 6MWT improved in responders and non-responders, despite the fact that V̇O2peak did not change in non-responders.

Conclusion: Estimated V̇O2peak using distance ambulated on the 6MWT demonstrated poor agreement with measured V̇O2peak in patients with HF. Caution must be taken when using the 6MWT to monitor fitness, or prescribe exercise in clinical CR programs.


Poster 519

Chronic pain: a practical physician-led approach to psychological treatment

Alexander Joseph Whelan1

1Dalhousie University, Halifax, NS, Canada

Introduction: Chronic pain is a major health issue within the Canadian healthcare system. There is limited medical training in psychological treatment strategies.

Objectives: To explore how physicians outside the field of psychiatry can incorporate psychological treatment strategies into chronic pain management.

Discussion: There is evidence to support the use of pain neurophysiology education (PNE), cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT). PNE should be structured around five topics: the origin of pain from nociception to brain processing, the protective purpose of acute pain, the difference between acute versus chronic pain, the development of chronic pain and the perpetuating factors that sustain chronic pain. CBT techniques can be applied by having patients complete the Pain Catastrophizing Scale (PCS). By identifying the questions of the PCS with the highest score, patients can be challenged to reframe their negative thoughts. Physiotherapy referrals should be approached with a CBT mindset, with clear instructions to patients and physiotherapists to move through graded exposure techniques to address kinesiophobia. Mindfulness and cognitive defusion exercises should be incorporated from ACT models to address the cognitive-emotional appraisal of pain.

Conclusion: There are several techniques that can be applied to improve chronic pain care delivery.

Funding: No funding sources to disclose


Poster 521

Prednisone for acute complex regional pain syndrome: A retrospective case series

Andrew Jamroz BSc1, Michael J. Berger MD, PhD, FRCPC1 2, Paul Winston MD, FRCPC 1 2

1University of British Columbia, Island Medical Program.

2Division of Physical Medicine & Rehabilitation, Department of Medicine, University of British Columbia, Victoria, Canada

Running Prednisone for acute complex regional pain syndrome

Objective: Corticosteroids have been proposed to treat complex regional pain syndrome (CRPS) but there are few studies to support their use. The purposes of this retrospective case series were to: 1) evaluate prednisone effectiveness on clinical features of CRPS and 2) determine whether patient factors could predict clinical outcome following prednisone.

Methods: A single-centre, retrospective cohort design was used. Inclusion criteria were: 1) CRPS diagnosed by Budapest criteria 2) multi-joint involvement 3) treatment with prednisone and 4) disease duration less than one year (n=39). Typical prednisone treatment was a 28-day taper regimen from an initial 60mg dose. Patient variables collected were age, sex, inciting event, location, and duration of CRPS. Patient symptoms and signs (pain and sensory, vasomotor, sudomotor/edema, and motor/trophic) were compared before and after prednisone using McNemar’s test. Kendall’s tau b correlations were used to identify associations between patient variables and clinical outcome. Logistic regression was used to determine if any variables predicted treatment outcomes.

Results: CRPS disease duration before prednisone treatment was 80.8 ± 67.7 days. At final assessment after prednisone treatment, 19 (48.7%) patients reported complete pain resolution, 19 (48.7%) patients reported meaningfully decreased pain permitting functional use, and 1 (2.6%) patient saw no improvement in pain. All symptoms and signs decreased significantly following oral prednisone treatment (p<0.001). At the final assessment, the sensory, vasomotor, and sudomotor/edema symptoms were present in 5%, 8%, and 8% of patients, respectively. The sensory, vasomotor, and sudomotor/edema signs were present in a similar proportion. At the final assessment, the motor/trophic symptoms and signs, specifically range of motion (ROM) deficits, persisted in 19 (49%) patients. However, 17 of these 19 patients reported functional ROM recovery. The time-to-treatment and ROM recovery demonstrated a positive correlation (r=0.354, p<0.05). Logistic regression did not demonstrate associations among any patient factors and clinical outcomes. The majority of patients (71.8%) reported no side effects.

Conclusions: Prednisone treatment for acute CRPS resulted in significant decreases in pain, symptoms, and signs. The association between time-to-treatment and ROM recovery suggests earlier treatment may result in improved outcomes. The data supports the use of short-course prednisone for acute CRPS patients and provides justification for future prospective studies.


Poster 522

Effect of pelvic floor muscle training on people with nonspecific low back pain: A systematic review

BERNARD, Stéphanie1,2, GENTILCORE-SAULNIER, Evelyne1,2,3, MASSÉ-ALARIE, Hugo1,2, MOFFET, Hélène1,2

1 Center for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), 525 Wildrid-Hamel, Québec (Québec), G1M 2S8, Canada

2 Université Laval, 1050 chemin de la Médecine, Pavillon Ferdinand-Vandry, Québec (Québec), G1V 0A6, Canada

3 Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale-Nationale, 2915, avenue du Bourg-Royal, Québec (Québec) G1C 3S2, Canada

Background: Pelvic floor muscles (PFM) are contributors to the optimal control of the lumbopelvic spine. Recent research shows that PFM function appears altered in some people with nonspecific low back pain (LBP). To evaluate whether adding PFM training (PFMT) to another exercise intervention can be more effective at improving pain and function in people with nonspecific LBP than without PFMT, we performed a systematic review and meta-analysis.

Methods: Literature search was performed on Medline, Embase, CINAHL, Cochrane Central and Web of Sciences up to October 2018. Selection criteria were 1) participants with nonspecific LBP; 2) additional PFMT to an exercise intervention; 3) comparison to the same intervention without PFMT; 4) included minimally one planned outcome; and 5) a randomized controlled trial. Two reviewers performed screening, data extraction (primary outcome; pain severity, secondary outcome; physical function) and risk of bias assessment. Meta-analysis was performed using mean difference and 95% confidence intervals.

Results: A total of six studies were included (n=200). Participants with PFMT had lower pain severity in comparison with the group without PFMT (mean difference: -0.61, 95%CI[-0.91,-0.31],p<0.0001 and low heterogeneity:I2=0%). Subgroup analysis show significant effect for interventions lasting longer than 8-weeks. No difference was found for function. Overall risk of bias was unclear across all studies.
Conclusion: There is very low-quality evidence that there is a small benefit of adding PFMT to another exercise intervention on pain severity in nonspecific LBP. A lumbopelvic exercise program lasting 8 weeks or longer would likely improve pain in this population.


Poster 523 – Third Place

The Impact of Introducing a Physical Medicine and Rehabilitation Consultation Service to an Academic Burn Center

Lawrence R. Robinson1 MD;

Division of Physical Medicine and Rehabilitation, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

St. John’s Rehab Program, Sunnybrook Health Sciences Centre and University of Toronto

Matthew Godleski MD; Division of Physical Medicine & Rehabilitation, Department of Medicine, University of Toronto

Sarah Rehou MS; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre,

Sunnybrook Research Institute, Toronto, Ontario, Canada

Marc Jeschke MD, PhD; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre,

Sunnybrook Research Institute, Toronto, Ontario, Canada

Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

Division of Plastic and Reconstructive Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

Department of Immunology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

This study was supported by the Innovation Fund of the Alternative Funding Plan from the Academic Health Sciences Centres of Ontario. There was no support from industry or pharmaceutical companies for this research.

Objective: Prior retrospective studies suggest that physical medicine and rehabilitation (PM&R) acute care consultation improves outcome and reduces acute care length of stay (LOS) in trauma patients. There have not been prospective studies to evaluate this impact in burn patients.

Design: This cohort study compared outcomes before and after the introduction of a PM&R consultation service to the acute burn program, and the inpatient rehabilitation program, at a large academic hospital. The primary outcome measures were LOS in acute care and during subsequent inpatient rehabilitation.

Results: For the acute care phase, there were 194 patients in the pre-consultation group and 114 who received a consultation. There was no difference in age, Baux Score, or LOS in these patients. For the rehabilitation phase, there were 109 patients in the pre-physiatrist group and 104 who received PM&R care. The LOS was significantly shorter in the latter group (24 days vs. 30 days, p=0.002). FIM change, unexpected readmission, and discharge destination were not significantly different.

Conclusions: The addition of a burn physiatrist did not influence acute care LOS. However, there was a significant reduction in inpatient rehabilitation LOS.

Key Words: Burn, Rehabilitation, Consultation, Physical Medicine & Rehabilitation


Poster 524 – First Place Resident Research Contest

Category: Original Research

Mesenchymal stem cells injection as a therapy for collagenase-induced murine Achilles tendinopathy

Beatrice Deschenes St-Pierre MD MSc1, Mathieu Boudier-Reveret MD2, Shant Der Sarkissian PhD3, Louis Gaboury MD PhD4, Henry Aceros PhD3, Carl-Elie Majdalani BSc2, Melanie Borie MSc3, Nicolas Noiseux MD MSc3, Martin Lamontagne MD2

1 Department of Physical Medicine and Rehabilitation, Centre Hospitalier Universitaire de Quebec (CHUQ), Laval University, Quebec City, Qc, Canada

2 Department of Physical Medicine and Rehabilitation, Centre Hospitalier Universitaire de Montreal (CHUM), University of Montreal, Montreal, Qc, Canada

3 CHUM Research Centre, Montreal, Qc, Canada

4 Department of Pathology, CHUM, University of Montreal, Montreal, Qc, Canada

Context: Tendinopathy represents 30 to 50% of sports-related injuries. A significant proportion of patients do not respond to the first-line conservative management with progressive loading and strengthening exercises program. Recently, Mesenchymal Stem Cells (MSC) have emerged as a potential regenerative treatment in tendinopathy. Celastrol, an HSP90 inhibitor and antioxidant, is proposed to increased stem cells viability and therapeutic efficiency.

Objective: To determine whether the injection of Mesenchymal Stem Cells (MSC) promotes histopathological healing in murine Achilles tendinopathy compared to injection of Phosphate-Buffered Saline (PBS).

Design: Prospective, randomized controlled trial.

Settings: This trial was conducted at the CHUM Research Centre. Rats were hosted in cages under controlled conditions (temperature, lighting, food, water).

Participants: Eighteen Sprague-Dawley rats, 36 Achilles tendons, divided into three groups.

Interventions: All 18 rats (36 tendons) were injected with collagenase type 1A (25 international units) under ultrasound guidance. After one week, rats were randomly and equally assigned to receive, also under ultrasound guidance, an injection of 60 μL of either: 1) PBS; 2) 2.3M MSC derived from rat bone marrow aspirate or; 3) 2.3M CCMSC.

Outcome Measures: The histopathological changes were assessed using Modified Bonar Score (tenocytes morphology, cellularity, vascularity, abundance of mucin and collagen organization) graded by a blinded experienced pathologist at 4 weeks (8 tendons/group) and 12 weeks (4 tendons/group).

Statistics: Since available literature did not provide standard deviations necessary for sample size calculation, power was calculated post hoc with the study results. Multiple comparison ANOVAs (Bonferroni) were conducted based on Kruskal Wallis.

Results: At four weeks, with eight specimens per group, the power of the sample was ≥ 85%, but at 12 weeks, with four tendons per group, the power was only 8%. There were no statistically significant differences between groups at four weeks and 12 weeks (α > 0.05).

Conclusion: No difference was found in Modified Bonar Scores in tendon specimens injected with PBS compared to MSC and CCMSC at four weeks. However, the number of rats that were observed until 12 weeks was insufficient to conclude. Nonetheless, these results underline that we need to host rats for a longer period before pathologic analysis. We are currently expanding this experiment with a larger number of rats to be assessed at 12 weeks.

Acknowledgments: Association Quebecoise des Medecins du Sport et de l’Exercice for financial support.

Keywords: Tendinopathy, Mesenchymal Stem cells, Pathology


Poster 525

CURRENT TREATMENT OPTIONS AND THE DEVELOPMENT OF ANTI-NGF AGENTS FOR NON-SURGICAL MANAGEMENT OF KNEE OSTEOARTHRITIC PAIN

Medical Student Essay Contest Submission

Tej-Jaskirat (Jessie) Grewal*

Queen’s University, Faculty of Medicine

Keywords: Osteoarthritis, Pain, Clinical trials, Nerve growth factor

Osteoarthritis (OA) is the most prevalent chronic disease and a leading cause of disability in the world. Although several treatment options are available for non-surgical management of OA, it continues to impose a significant burden on quality of life of patients, and costs to the health care system. Major efforts on the part of pharmaceutical companies have led to the development of a new class of analgesics that inhibits nerve growth factor (NGF) to control osteoarthritic pain. Among the anti-NGF agents for OA, the best studied is tanezumab by Pfizer and Eli Lilly. Early studies of these agents showed promising results, but the United States Food and Drug Administration halted these trials in 2010 due to safety concerns related to osteonecrosis. After reviewing safety data presented by Pfizer, development of anti-NGF agents for osteoarthritic pain was allowed to continue with restrictions and stringent monitoring. Several trials are currently underway. The purpose of this paper is to outline the current treatment options and to discuss progress towards development of anti-NGF agents as a potential new class of analgesics for non-surgical management of knee osteoarthritic pain.


Poster #526

Surgical Management of Persistent Suprascapular Neuropathy from

Neuralgic Amyotrophy

  1. Ali Bateman MD1,2, Jordan VanderEnde MD1,2, Douglas C. Ross MD1,3, Robert Hammond MD1,4, Thomas A. Miller MD1,2

1Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada

2Department of Physical Medicine & Rehabilitation

3Division of Plastic & Reconstructive Surgery, Department of Surgery

4Department of Pathology & Laboratory Medicine

Context: Neuralgic amyotrophy (NA), or brachial neuritis, is a clinical syndrome characterized as a monophasic inflammatory illness causing severe pain and flaccid paralysis in one or multiple peripheral nerves of the brachial plexus. Although previously thought to have excellent recovery, evidence from large, observational studies suggests more than 50% of patients affected by NA experience long-term sequelae. Emerging evidence demonstrates focal, hourglass-like nerve constrictions in affected peripheral nerves, and that surgical options to decompress, transfer, or graft refractory neuropathies due to NA may improve outcomes in well-selected cases.

We present a case of NA with persistent suprascapular neuropathy managed surgically to improve function. We discuss the clinical, electrodiagnostic (EDX), neuroimaging, and nerve pathology characteristics.

Findings: A 55-year-old man presented with sudden onset of severe, atraumatic, neuropathic shoulder pain followed by weakness of right shoulder abduction (MRC 0/5) and external rotation (MRC 0/5); a diagnosis of NA was made. Clinical and EDX evaluation 4 months post-onset demonstrated isolated axillary and suprascapular nerve (SSN) weakness with marked denervation (MRC 0/5, no motor units seen on EMG). At 9 months post-onset, the axillary nerve showed signs of recovery to deltoid (MRC 3/5 strength, nascent and reinnervated motor units on EMG); in contrast, there was no electrophysiological or clinical recovery of the SSN (supra- and infraspinatus MRC 0/5, no motor units on EMG). Magnetic resonance imaging demonstrated focal constriction of the SSN 3.2 cm superomedial to the suprascapular notch. Surgical exploration of the brachial plexus and SSN revealed focal corkscrew compression of the SSN and no contraction of supra- or infraspinatus with stimulation across this segment. The segment was excised and the SSN was grafted with a tension-free repair. Neuropathology of the excised SSN segment demonstrates near complete loss of large myelinated fibres, increased endoneurial collagen, and abundant regenerative clusters. Post-operatively, the patient regained active shoulder function.

Conclusions: The pathophysiology of NA is complex, and requires careful clinical, EDX, imaging, and surgical consultation to minimize disability. Given the pathological changes in the nerve, refractory neuropathy due to NA can cause significant disability and may be amenable to nerve surgery, as in the outlined case.

Keywords: Neuralgic Amyotrophy, Brachial Neuritis, Electrodiagnosis, Nerve Surgery, Neuropathology


Poster 527

AUTOMATED SOFTWARE TO FILL CLINIC APPOINTMENT CANCELLATION SPOTS: A CASE STUDY

Jocelynn L Gray, MD1

1 University of Alberta, Edmonton, Alberta, Canada

Health care appointments that go unfilled due to late cancellation represent an inefficient use of health care resources and lost income for the clinic. Traditional methods of re-filling these appointments require clinic staff to sequentially contact wait-listed patients until a suitable person to fill the appointment is found. The use of automated software that contacts wait-listed patients as dictated by a pre-determined algorithm may improve success in filling cancelled appointments, as well as decrease burden on office administrative staff. This report evaluated the effectiveness of one such commercially available software (CancellationSpot) in filling cancelled appointments at a Physical Medicine & Rehabilitation clinic. The software allows clinicians to assign voluntarily subscribed patients to a specific calling pool depending on the type of appointment required. The patient supplies relevant information (such as preferred contact method, availability, and the amount of notice they require), which is then factored into the software’s algorithm. When a cancelled appointment arises, the clinic staff simply input the time, date, and type of appointment into the system, and an online broadcast system contacts patients in the appropriate pool. Unlike the traditional office system, no other staff involvement is needed until a patient calls to accept the appointment slot.

METHODS: Data were gathered from the electronic medical record and the software program records to determine how many appointments were filled using automated software and the length of time it took for these appointments to be filled. Further analysis of one physician’s data was undertaken to determine the wait time of patients who used the cancellation system versus those who were seen on the same day in a typically scheduled appointment slot.

RESULTS: The automated system was successful in re-filling over 80% of cancelled appointments. Wait times were shorter by about 40 days for the individuals who were successful in matching to a cancellation spot using the software as compared to patients who were seen in a regularly scheduled appointment on the same day.

CONCLUSIONS: Use of an automated software for filling cancelled appointments shows promise as an efficient method for successfully filling cancelled appointments while at the same time not increasing staff workload. Other benefits may include better resource utilization by optimizing clinic time.

KEY WORDS: Appointment, clinic, software


Poster 530

ASSESSING THE TOLERABILITY OF SUPRASCAPULAR AND MEDIAN NERVE BLOCKS FOR THE TREATMENT OF SHOULDER-HAND SYNDROME IN STROKE

Marc Monsour1, Mark Campbell1, Rosendo Rodriguez2, Adnan Sheikh3

1Division of Physical Medicine and Rehabilitation, The Ottawa Hospital Rehabilitation Centre1,

2The Ottawa Methods Centre, The Ottawa Hospital, General Campus

3Division of Radiology, The Ottawa Hospital

Background and Objectives: Complex regional pain syndrome (CRPS) is a debilitating condition characterized by severe pain and allodynia of the shoulder and hand in stroke patients. In the stroke population, CRPS is common and is referred to as shoulder hand syndrome (SHS). Current management of pain is limited and often, ineffective. Peripheral Nerve blocking has been reported effective for alleviating pain in other clinical conditions. We assessed tolerability of suprascapular and median nerves block for acute control of pain in post-stroke SHS.

Methods: We enrolled patients with confirmed diagnosis of SHS according to the Budapest criteria. Tolerability was assessed by the composite of a change in VAS score for the pain at the shoulder and wrist, the rate of associated adverse events and level of patient satisfaction. VAS score measurements were performed before (baseline) and after the procedure (immediately and 2 weeks).

Results: Five patients (mean age: 68.5 ± 9.5 years old) completed the interventional protocol. Both blocking procedures were well tolerated. The acute effect of SSN blocking on pain reduction was greater than median nerve. Shoulder pain decreased by -62.6mm ± 25.6 (p=0.043) and hand pain decreased by -33mm ± 40.2 (p=0.08) Their effect decreased at 2 weeks though remained below the baseline pain score. There were no adverse events and all patients reported being fully satisfied after the procedure.

Conclusions: SSN and median nerve blocks were shown to be safe and well-tolerated by all participants. Peripheral nerve blocks may represent a new avenue of treatment for SHS.


Poster 531 – First Place

Accuracy of Ultrasound-Guided Pudendal Nerve Block at the Ischial Spine and Alcock Canal Levels: A Cadaveric Case Study.

Béatrice Soucy, M.D 1, Dien Hung Luong, M.D. 1, Johan Michaud, M.D. 1, Mathieu Boudier-Revéret, M.D. 1, Stéphane Sobczak, PT, PhD 2,3

1Physical Medicine and Rehabilitation Department, Centre hospitalier de l’Université de Montréal, Montreal, Quebec, Canada,

2Département d’Anatomie, Université du Québec à Trois-Rivières, Quebec, Canada,

3Research Unit of clinical and Functional Anatomy, Université du Québec à Trois-Rivières, Quebec, Canada.

No conflicts of interests were declared by any of the .

Background: Pudendal neuralgia may cause disabling, neuropathic pain in the innervation territory of the pudendal nerve (PN). Its diagnosis remains essentially clinical. Blockade of the PN using ultrasound (US) guidance has been described at the levels of the ischial spine and the Alcock canal. However, no study has been conducted to compare anatomical accuracy between different approaches in targeting the PN.

Objective: To investigate the accuracy and reliability of US-guided injection of the PN at the ischial spine and Alcock canal levels. Since these are US-guided infiltration techniques with a high level of difficulty, this study also compared the accuracy of the infiltrations of three sonographers with different levels of experience.

Methods: An experimental cadaveric case series

Setting: Anatomy laboratory

Specimens: Eight Thiel-embalmed cadavers, for a total of sixteen hemipelvises

Interventions: Three physiatrists trained in musculoskeletal US imaging with 12, 5 and 1 years of experience carried the injections. Each injected a 0.1 mL bolus of colored dye in both hemipelvises of each cadaver at the ischial spine and Alcock canal levels under US guidance. Each cadaver received a total of 6 injections (three injections per hemipelvis). The accuracy of the injection was determined following hemipelvis dissection by an anatomist.

Main outcome measure: The accuracy of the US-guided injection of the PN

Results: The injections were accurate 32 times out of the total 42 attempts, resulting in a 76% accuracy. Sixteen out of 21 injections at the ischial spine level were on target (76% accuracy), while the approach at Alcock canal level yielded 17 successful injections (81% accuracy); however, the difference was not statistically significant. There was also no significant difference in accuracy between all operators.

Conclusions: US-guided injection of the PN can be performed accurately at both ischial spine and Alcock canal levels. Injections at the Alcock canal are likely to be more accurate.

Keywords: Pudendal nerve, ultrasound-guided injection, cadaveric study.

Abbreviations used in the manuscript: Pudendal nerve (PN), pudendal nerve entrapment (PNE), ultrasound (US)


Poster 532

A scoping review on the effects of exoskeleton in management of pain in spinal cord injury patients

Melissa Weidman1

1University of Toronto, Toronto, Ontario, Canada

Background and Purpose: Pain, especially neuropathic, is a common (48-92%)1,2,3 and debilitating secondary complication of spinal cord injury (SCI) with effects on mobility, activity, even quality of life. Most research into exoskeleton use examine their effectiveness in improving ambulation, however little is known about benefits for chronic pain.

Research Question/Objective: Does the use of exoskeleton devices in rehabilitation improve control of pain secondary to SCI?

Methods: Medline, Embase, and Cochrane Central databases were searched (1974 to present) using the search terms “spinal cord injury”, “paraplegia”, “hemiplegia”, “quadriplegia”, “exoskeleton”, “pain”, “neuropathy”, “quality of life”, and their variations. Studies were included if pain was used as an outcome measure. A secondary search of initial articles was performed. Selected articles were assessed for quality and risk of bias.

Results: The database search yielded a total of 89 articles with seven studies fulfilling inclusion criteria. Of these, two were case series, two observational, two cross sectional, and one nonrandomized clinical trial. All studies had small sample sizes, ranging from two to 52 SCI patients. Populations included acute, subacute, and chronic SCI, traumatic, non-traumatic, complete, incomplete, and cervical to lumbar SCI level. Overall, four studies documented reductions in pain following training. Three studies reported no significant change, and no studies reported worsening of pain.

Conclusions: The results suggest that the use of exoskeleton may improve pain after SCI. Additional research with larger sample sizes and proper control for potential major confounders are needed to determine whether exoskeleton devices improve control of pain after SCI.


Poster 533

Visuomotor behavior of upper limb prosthesis users: a quantitative approach to measuring sensory-motor function

Jacqueline S. Hebert, Craig C. Chapman, Albert H. Vette, Patrick M. Pilarski

University of Alberta, Edmonton, Alberta, Canada

Objective: The use of an upper limb prosthesis for functional tasks requires movement compensation and visual attention to the prosthesis. The goal of this study was to quantify the visuomotor behaviors of typical prosthesis users compared to non-disabled gaze and movement behavior during goal-directed object interaction tasks.

Participants: Nine upper limb prostheses users with acquired amputation (5 transradial, 4 transhumeral) were recruited for this study. Twenty non-disabled participants were recruited as a normative reference.

Methods: Participants performed two standardized goal-oriented tasks (Cup Task and Pasta Task) with simultaneous motion and eye tracking data recording. Kinematic and eye gaze data were segmented into Reach, Grasp, Transport, and Release phases and time-normalized. Metrics included performance time, phase duration, angular joint kinematics for the upper limb and trunk, and eye fixation metrics (percentage of time fixated on the current (upcoming) target of action compared to the relative time fixated to the hand/terminal device).

Results: The prosthesis users had significantly longer total task and phase durations across both tasks compared to normative, however, the grasp and release phases were relatively more prolonged for the Cups Task (p<0.01). Prosthesis users showed less fixation to the current target and more fixations to the hand in transport compared to non-disabled; but significantly more fixation to hand for cups, likely due having to monitor the compliance of the cups during transport. For kinematic strategies, all prosthesis users showed similar compensations with increased trunk motion and generally less shoulder and elbow motion. Trends indicated that skill level may be associated with less visual attention to the prosthesis, although the task demands impacted the compensations seen across prosthesis users.
Conclusion: Prosthesis users spend a disproportionate amount of time in grasp and release during goal-directed tasks, indicating the importance of working on grasp strategies for tasks with object interaction. Visual attention to the prosthetic device is most prominent when transporting objects requiring grasp dexterity. All prosthesis users showed less shoulder motion with mostly trunk compensation. This study demonstrates that precise quantification of visuomotor behaviour in prosthesis users can illustrate differences in compensatory strategies compared to non-disabled performance. This assessment approach could apply to a variety of upper limb sensory-motor impairments.

Granting Agency/Funding Source: Defense Advanced Research Projects Agency (DARPA) Biology Technology Office (BTO) under the auspices of Dr. Doug Weber and Dr. Al Emondi.

Grant Number: N66001-15-C-4015.


Poster 534

Glycemia within the first week after injury as a determinant of survival and neurological recovery within the first year after traumatic spinal cord injury

Julio C. Furlan 1,2

1Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada;

2Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada;

Context/Objective: The impact of hyperglicemia in secondary mechanisms of neuronal damage after acute spinal cord injury (SCI) has been under-investigated. This study examined the potential association of glycemia in the hyperacute stage after SCI and outcomes within the first year after acute traumatic SCI.

Design: This retrospective cohort study analyzed data from the National Spinal Cord Injury Study (NASCIS) 3 trial with regards to the potential effects of glycemia within 24 hours, at 48 hours and at day 7 on clinical and neurological outcomes after acute traumatic SCI.

Setting: Acute spine trauma.

Participants: This retrospective cohort study includes all patients who were enrolled into the NASCIS-3 trial.

Interventions: None

Outcome Measures: Survival within the first year, and neurological recovery (as assessed using the NASCIS motor, sensory and pain scores) at 6 weeks, at 6 months and at 1 year following acute traumatic SCI.

Results: There were 76 women and 423 men with mean age of 35.7 years who mostly sustained cervical SCI due to motor vehicle accident or falls. On admission, 96.6% of the individuals had hyperglycemia (range: 125 to 533 mg/L). There was a significant decline in the initial glycemia within 24 hours (188.20 ± 2.29 mg/L) when compared to glycemia at 48 hours (164.44 ± 2.08 mg/L) and at day 7 after SCI (125.02 ± 2.25 mg/L; p<0.01).

Using regression analyses, higher glycemia at 24 hours was associated with lower motor, sensory and pain scores up to 6 months, but not at 1 year post- SCI. Glycemia at 48 hours and at day 7 post-injury was not associated with motor, sensory and pain scores up to 1 year post-SCI, except for a poorer motor recovery and a greater pain score at 1 year post-SCI related to higher glycemia at 48 hours.

Survival analysis revealed that hyperglycemia within 24 hours and at 48 hours was not associated mortality within the first year after SCI (p=0.33 and p=0.07, respectively). However, hyperglycemia at day 7 was associated with greater mortality after SCI.

Conclusion: Our results suggest that hyperglycemia at day 7 may be associated with greater mortality within the first year post-SCI. Among the survivors, glycemia at 24 hours was associated with poorer motor and sensory recovery, and greater pain scores within the first 6 months after SCI. However, glycemia at 24 and 48 hours, and at day 7 post-injury did not adversely affect the individuals’ neurological recovery at 1 year after SCI.

Granting Agency/Funding Source: Wings for Life Spinal Cord Research Foundation

Grant Number: WFL-CA-09/16


Poster 535

A scoping review of the clinical studies on concussion and mild traumatic brain injury: Multiplicity of research initiatives and variability in injury definitions

Julio C. Furlan 1,2; Michael M. Radan 2

1Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada;

2Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada;

Abstract:

Context/Objective: While many patients with concussion and mild traumatic brain injury (mTBI) recover completely, prolonged post-concussive remains a challenge and opportunity for clinical practice and research. This led numerous research initiatives over the last two decades. We reviewed all clinical studies on diagnosis and management of concussion/mTBI that were registered at ClinicalTrials.gov.

Methods: This systematic review with scoping synthesis included all clinical studies on diagnosis and management of patients with concussion/mTBI that were registered in the website at www.clinicaltrials.gov since 2000. The terms “concussion, brain” were used for the primary search on the condition or disease on June 25th 2018. Definitions of concussion and mTBI were obtained from the study protocols as documented in the website. When a definition was missing in the website, the study’s principal investigator was contacted via email for clarification.

Results: There were 273 studies registered either as interventional studies (n=188) or observational studies (n=85). Most of the studies were single-center initiatives (72.5%). The majority of the studies are from institutions in the United States (n=191) followed by Canada (n=33), Denmark (n=6), France (n=5) and other countries. Most of the studies are either completed (37.4%) or still recruiting (29.7%). Most of the studies are focused on diagnosis of concussion/mTBI (n=109) using clinical assessments, imaging, biomarkers, and novel technological tools. Also, there are studies on non-pharmacological therapies (including exercise-based therapy [n=15], vision therapy [n=12], balance therapy [n=10], hyperbaric oxygen therapy [n=8]), pharmacological therapies (n=27) and prevention measures (n=7). There was a single study using cell-based therapy. The definitions of concussion and mTBI were widely different among the studies. Only 70 study protocols in the website included a definition of concussion or mTBI. Of the 203 studies missing a definition, a clarification was provided by the investigators of 26 studies.

Conclusion: The results of this scoping review suggest that most of the clinical studies are focused on diagnosis and non-pharmacological therapies for patients with concussion/mTBI. Most of the studies are single-center initiatives and are led by American and Canadian institutions. The broad variety of definitions of concussion/mTBI among the clinical studies suggests significant limitations when comparing studies. Disease/injury definition should be required when registering clinical studies in the website.

Granting Agency/Funding Source: Wings for Life Spinal Cord Research Foundation

Grant Number: WFL-CA-09/16


Poster 536

Does older age adversely affect the costs of the initial spine care of individuals with acute spine trauma?

Julio C. Furlan, MD, LLB, MBA, MSc, PhD, FRCPC1,2

Michael G. Fehlings, MD, PhD, FRCSC, FACS3,4

  1. Catharine Craven, BA, MD, MSc, FRCPC1,2

1Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada;

2Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada;

3Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, ON, Canada;

4Spinal Program, Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada.

Context/Objective: Aging of the population has prompted an escalation of service utilization and costs in many jurisdictions. Yet, the economic impact of the caring for the elderly with spine trauma remains incompletely understood. This study examined the potential effects of age on the service utilization and costs of the management of patients with acute spine trauma (AST).

Design: This retrospective cohort study compared elderly (≥65 years) and younger individuals regarding their costs for the initial spine care.

Setting: Quaternary university hospital.

Participants: Consecutive patients with AST admitted from February/2002 to September/2007.

Interventions: None

Outcome measures: Hospital costs for the initial spine care that were converted and updated to US dollars.

Results: There were 55 women and 91 men with AST (age range: 16 to 92 years, mean age: 49.9 years) of whom 37 were elderly. Elderly individuals had a significantly longer stay in the acute spine trauma center (p<0.01) and greater total hospital costs than younger individuals with AST (p=0.04). However, elderly people with AST had significantly lower per diem total costs, lower per diem fixed costs, lower per diem direct costs, and lower per diem indirect costs than younger individuals with AST. While elderly people with AST had significantly lower per diem fixed costs than younger individuals with AST (p<0.01), there were no significant differences between the groups regarding their per diem variable costs (p=0.28).

Using multivariate regression analysis, higher total hospital costs were significantly correlated to longer stay in the acute spine trauma center, complete traumatic SCI, and need for mechanical ventilation (p<0.05). There was a significant interaction between longer hospital stay and need for mechanical ventilation (p<0.01).

Also, higher per diem total costs were significantly associated with shorter stay in the acute spine trauma center and lumbosacral AST (p<0.05). There was no significant interaction between length of stay and level of AST.

Elderly people with AST were comparable to their younger counterparts regarding their proportions of the hospital services utilized during admission for management of AST (p=1.00).

Conclusion: Given the escalating demand for surgical and nonsurgical spine treatment in the age of aging population, the results of this study timely underline key aspects the economic impact of the spine care of the elderly. Further investigations are needed to fulfill significant knowledge gaps on the economics of caring for elderly with AST.

Granting Agency/Funding Source: Wings for Life Spinal Cord Research Foundation

Grant Number: WFL-CA-09/16

Fig. 1. Comparisons between elderly and younger individuals with acute spine trauma with regards to their per diem total, fixed, variable, direct, and indirect costs.


Poster 537

Usability of IoT-inspired technology in rehabilitation therapy: A thematic analysis of physical therapists’ perspectives.

Courtney Larsen1, Colleen O’Connell2, Shane McCullum2, Satinder Gill3, Erik Scheme3

1Dalhousie University School of Medicine (NB), Saint John, NB, Canada

2 Stan Cassidy Centre for Rehabilitation, Fredericton, NB, Canada

3Institute of Biomedical Engineering, University of New Brunswick, Fredericton, NB, Canada

CONTEXT/OBJECTIVE: This study explores the practical applications of a newly developed “SmartCane” equipped with electronic sensors that allow for unobtrusive monitoring of the user’s weight-bearing, gait, balance, and activity level. The data obtained by the cane’s sensors can be wirelessly transmitted and stored on a mobile device. The goal of this study was to explore the ways in which this cane could be used to assist therapists in rehabilitation applications.

DESIGN: Using a qualitative research design, physical therapists participated in semi-structured interviews. The interviews were transcribed verbatim and thematic analysis was performed.

SETTING: The SmartCane system, developed by the Institute of Biomedical Engineering at the University of New Brunswick, was presented to groups of physical therapists working at three different urban health centres in New Brunswick, Canada: the Stan Cassidy Centre for Rehabilitation (SCCR) in Fredericton; the Dr. Everett Chalmers Regional Hospital (DECRH) in Fredericton; and the Saint John Regional Hospital (SJRH) in Saint John.

PARTICIPANTS: Physical therapists were recruited from within the publicly-funded provincial healthcare system of New Brunswick, Canada. Ten physical therapists agreed to be interviewed; three were from the SCCR, four were from the DECRH, and three were from the SJRH.

INTERVENTIONS: Physical therapists were asked to attend a demonstration session on the use and functions of the SmartCane. Therapists participated in semi-structured interviews in which they were asked to provide feedback on ways in which the SmartCane could be helpful in their work, and to make suggestions on how the design could be improved.

RESULTS: Therapists indicated that measurement of weight-bearing status and the ability to provide biofeedback to their patients would be particularly helpful features, among other possible enhancements. Common themes also included the importance of ease of use, safety, durability, and additional applications for the technology.

CONCLUSION: The results of this study have the potential to help researchers and engineers develop more effective mobility aids that use IoT (Internet of Things) based technology. The volume and breadth of recommendations from physical therapists strongly suggest that technology developers should work in partnership with clinicians in the development of assistive devices to ensure clinical relevance and eventual translation to practice and commercialization.

Funding Acknowledgement: Dalhousie University Medical School, Research in Medicine program

Keywords: Assistive technology, mobility limitation, physical therapist, rehabilitation

Submitting Courtney Larsen (cr417615@dal.ca)


Poster 538

REASONS FOR ACCESSING MULTIDISCIPLINARY AMYOTROPHIC LATERAL SCLEROSIS (ALS) CARE: A QUALITATIVE STUDY.

Brendan Kushneriuk1, Darren Nickel1, Gary Linassi1, Kerri Schellenberg1

1University of Saskatchewan, Saskatoon, SK, Canada

Context: Access to a multidisciplinary clinic (MDC) has been suggested as standard of care for persons with ALS. Persons with ALS may travel long distances, even out of province, in order to access ALS MDC care. Our research aimed to identify reasons for seeking ALS MDC care out of province in an era when multidisciplinary ALS care was not locally available. Additional queries included perceived value of alternative technologies (such as Telehealth) in ALS care, and identifying challenges in obtaining ALS MDC care. The used thematic analysis to assess three semi-structured telephone interviews involving three patients and two family members. Findings: Two themes were identified including ”Accessibility in Obtaining Care” with subthemes of comprehensiveness of services, preference for personal solutions for telehealth, and motivation for leaving province; and ”Requirements of Travel” with subthemes of time, cost, and fear.

Conclusion/Clinical Relevance: Persons with ALS and their family members find MDC care helpful to receive reliable answers from multiple care providers and feel supported knowing they can contact the clinic whenever necessary. Some patients with ALS have pursued care out of province despite the requirements and challenges of travel. Reasons for out of province travel vary but include the desire to obtain answers and access to interdisciplinary care, which at the time of their ALS diagnosis was not available within Saskatchewan. Travel to ALS MDC involves high financial cost, time, fear of travel, and the impacts of travel on spouses and family members. Patients with ALS see value in personal solutions that focus on the convenience of obtaining care through home-based videoconferencing; however, they are also aware of the limits of technology and some prefer in-person contact.


Poster 539

DYSVASCULAR AMPUTATIONS IN THE YOUNG – UNIQUE CHALLENGES, SAME CO-MORBIDITIES

Mayo, Amanda.L.1,2 *, Cimino S.R.3, Hitzig S.L.3,4,5

1 St. John’s Rehab, Sunnybrook Health Sciences Centre, Toronto, Canada.

2 Faculty of Medicine, University of Toronto, Toronto, Canada.

3 St. John’s Rehab Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Canada.

4 Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Canada.

5 Department of Occupational Science & Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada.

BACKGROUND: The majority of lower limb amputations (LLA) in Canada are dysvascular due to complications of diabetes and/or vascular disease. Traditionally dysvascularamputations have occurred in the elderly. With younger onset of adult diabetes, amputations are now occurring in non-geriatric populations. An understanding of younger patients with dysvascular LLA is needed to determine their risk factors, and unique health and psychosocial challenges.

OBJECTIVES: To obtain a depiction of the key demographic and impairment characteristics of adults 65 years and younger with dysvascular LLA undergoing inpatient rehabilitation.

METHODOLOGY: A retrospective chart review was completed on inpatient adult amputation rehabilitation patients over a five year period. Data extracted included socio-demographics, Functional Independence Measure (FIM) scores, co-morbidities, and discharge outcomes.

FINDINGS: One hundred and forty-threepatients who were 65 years and younger were included, which represented almost a quarter of all admissions. Most patients were male (79%) with an average age of 55 years old (SD=8). The majority (72%) were unemployed. The mean number of co-morbidities was5.2(SD=8.2). Individuals discharged home (n=122) had higher (p < .05) FIM scores than those readmitted to acute care or discharged to long-term care (n=20).

CONCLUSIONS: Similar to the literature on older dysvascular LLA patients, our study found high rates of disability and co-morbidities in younger patients with dysvascular LLA, which might impact their ability to work. Given these challenges, better amputation prevention strategies and targeted rehabilitation programming for this population are needed. ​


Poster 540

Surgical microfascicular neurectomy of the medial pectoral nerve to the pectoralis major muscle after predictive diagnostic nerve block.

Emily M. Krauss MD MSc FRCSC, 1,2 Dr. Paul Winston MD FRCPC 1 3

1 Island Health. Victoria BC, University of British Columbia.

2 Division of Plastic Surgery. 3 Division of PMR

Objective: We have encountered patients with life-altering spastic muscle overactivity of the upper extremity in whom our traditional approaches to spasticity are not meeting patient goals. Patients complain of pain, poor limb position and hygiene concerns. For these patients with insufficient results from traditional toxin treatment and therapy to the spastic shoulder, surgical microfascicular neurectomy is an option to permanently improve the complications spastic muscle overactivity. We describe a case of 51-year-old woman with left hemiplegia and spastic muscle overactivity in the pectoral muscles.

Methods The patient was assessed for surgery by a multidisciplinary team including a physiatrist, interventional anesthesiologist and a hand surgeon. Ultrasound-guided e-stimulation diagnostic nerve block (DNB) of the pectoral nerves was performed. Significant improvement in passive shoulder abduction and external rotation and reduced pain was observed after DNB. Surgical neurectomy was offered.

The surgery involved the release of the overlying muscle fascia and the nerve branch identified. Using a Medtronic nerve stimulator to isolate the pectoralis major. Microfascicular dissection was performed to avoid affecting other nerve branches. Detailed understanding of the microfascicular anatomy and intraoperative nerve stimulation is used to identify motor nerve branches for neurectomy. The pectoralis muscle relaxed substantially after dissection.

Results At five weeks follow-up. Passive abduction increased from 90 degrees to 134 degrees. External rotation improved to similar degrees, hence the combined flexed abducted externally rotated position was far greater. Some capsular restrictions remained. Though, weak, her abduction actively increased minimally. The carrying angle of the flexed elbow position similarly improved. At 3.5 months the abduction remained the same, but external rotation continued to improve.

There were no perioperative complications. The patient reported improved comfort and positioning and ease of dressing, positioning and reduced pain.

Conclusions Surgical neurectomy of selective motor branches to spastic muscles in the upper extremity can reduce symptoms of pain and improve range of motion and positioning. Surgery should only be considered in well-selected patients after DNB demonstrated increased passive or active ROM in whom a trial of traditional methods has been insufficient. Long term follow-up is required.

  1. 1 Zlotolow DA. Surgical Management of Spasticity of the Shoulder. Hand Clin. 2018;34(4):511-516. doi:10.1016/J.HCL.2018.06.008.

Poster 541

Felix Guyon and Ulnar Neuropathy at the Wrist: The challenge with Gait Aids.

Jordan VanderEnde1 MD, E. Ali Bateman1 MD, Douglas C. Ross2 MD MEd FRCSC, Greg J. Garvin3 MD FRCP, Thomas A. Miller1,2 MD FRCPC

1Department of Physical Medicine & Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada

2Roth-Macfarlane Hand and Upper Limb Centre, St. Joseph’s Health Care, London, Ontario, Canada

3Department of Radiology, St. Joseph’s Health Care, London, Ontario, Canada

Introduction: Félix Guyon (1831-1920) was a professor of genitourinary surgery in Paris. In 1861, he described the passage of the ulnar nerve and artery through a fibro-osseous tunnel in the wrist that was later named Guyon’s canal. The canal is not a static structure: it changes shape and volume with wrist movement. Cadaveric studies show narrowing of the pisohamate hiatus within Guyon’s canal with wrist flexion resulting in compression of the deep branch of the ulnar nerve from the pisohamate arcade. Conversely, the ulnar nerve is put under tension with wrist extension, which predisposes the nerve to injury. By requiring weightbearing through the wrist in extension, the use of a gait aid can affect the biomechanics of Guyon’s canal and predispose patients to compression of the ulnar nerve at the wrist.

Results: We present a series of four patients with ulnar nerve compression at the wrist, highlighting the role of clinical and electrodiagnostic evaluation in diagnosis and management. Mean age at presentation was 57.3 years (±4.6). All patients presented with clumsy hand function and weakness of the hand intrinsics (FDI MRC grade 1-3, ADM MRC grade 2-4). All patients had electrodiagnostically confirmed ulnar neuropathy at the wrist. Three of 4 neuropathies were related to the use of a gait aid (2 canes, 1 axillary crutch), and 1 from a bicycle handle. Three of 4 underwent surgical release of Guyon’s canal. Post-operatively, all 3 had an improvement of one or more MRC grade in both FDI and ADM. On post-operative electrodiagnostic testing, one patient had no improvement in CMAP to FDI, one improved from 2.1mV to 6.0mV, one improved from NR to 14mV. The patient managed conservatively stopped biking and improved from ADM MRC grade 2 and FDI MRC grade 1 to full strength (5/5).

Clinical Relevance: The use of a gait aid can impact the biomechanics of Guyon’s canal and lead to ulnar nerve compression at the wrist. The importance of this anatomy and preventative rehabilitation strategies are crucial in minimizing the disability associated with axonal loss in ulnar neuropathy at the wrist.

Keywords: Ulnar neuropathies, ulnar nerve compression, Guyons Canal, canes, crutches, electrodiagnosis


Poster 544

REDUCING WASTE: A GUIDELINES-BASED APPROACH TO REDUCING INAPPROPRIATE VITAMIN D AND TSH TESTING IN THE INPATIENT REHABILITATION SETTING

Short Reducing Vitamin D and TSH Testing in Inpatient Rehabilitation

Emma A. Bateman,1,2 Alan Gob,2,3 Ian Chin-Yee,2,3,4 Heather M. MacKenzie1,2

1Department of Physical Medicine & Rehabilitation, St. Joseph’s Health Care London

2Schulich School of Medicine & Dentistry, Western University

3Division of Hematology, Department of Medicine, London Health Sciences Centre

4Department of Pathology and Laboratory Medicine, London Health Sciences Centre

Background: Laboratory overutilization increases healthcare costs, and can lead to overdiagnosis, overtreatment, and negative health outcomes. Discipline-specific guidelines do not support routine testing for Vitamin D and TSH in the inpatient rehabilitation setting yet 94% of patients had Vitamin D and TSH tests on admission to inpatient rehabilitation at our institution. Our objective was to reduce Vitamin D and TSH testing by 25% on admission to inpatient Stroke, Spinal Cord Injury, Acquired Brain Injury, and Amputee rehabilitation units.

Methods: A fishbone framework for root cause analysis revealed potential causes underlying overutilization of Vitamin D and TSH testing. A series of PDSA cycles were introduced to target remediable factors, starting with an academic detailing intervention with key stakeholders that reviewed applicable clinical guidelines for each patient care discipline and the rationale for reducing admission testing. Simultaneously, computerized clinical decision support (CCDS) limited Vitamin D testing to specific criteria. Audit and feedback were used in a subsequent PDSA cycle. Frequency of Vitamin D and TSH testing on admission was the primary outcome measure. The number of electronic admission order caresets containing automatic Vitamin D and/or TSH orders before and after the interventions was the process measure. Rate of Vitamin D supplementation and changes in thyroid-related medication were the balancing measures.

Results: After implementation, 3.4% of patients had admission Vitamin D testing (96% relative reduction) and 56% of patients had admission TSH testing (40% relative reduction). Admission order caresets with pre-populated Vitamin D and TSH orders decreased from 100% (n=6) to 0%. The interventions were successful; similar to previous literature, CCDS was more effective than education and audit and feedback interventions alone. The interventions represent >$9000 annualized savings.

Keywords: Quality Improvement; Laboratory Utilization; Rehabilitation; Physical Medicine & Rehabilitation; Vitamin D; Thyroid Stimulating Hormone; Clinical Practice Patterns; Medical Overuse

Funding: This research did not receive any specific grant from funding agencies in the public, private, or not-for-profit sectors.

Author Conflicts of Interest Statements: None.


Poster 545

A placebo shoe lift for clinical trials evaluating the correction of leg length discrepancy

T Mark Campbell, MD, MSc,1 Katherine Reilly,2 Mike Bryce, C. Ped,3 Robert Feibel,4 Guy Trudel, MD2

1 Department of Physical Medicine and Rehabilitation. Elisabeth Bruyère Hospital, Ottawa, Ontario, Canada.

2 University of Ottawa, Bone and Joint Lab – Ottawa, Ontario Canada

3 The Ottawa Hospital Rehabilitation Centre – Ottawa, Ontario Canada

4 The Ottawa Hospital – Ottawa, Ontario Canada

Acknowledgment of financial support: This study is funded by the Bruyère Academic Medical Organization Research Innovation Fund (BAM-16-001).

Conflict of interest: The declare no conflict of interest.

BACKGROUND/OBJECTIVE: A shoe lift is a commonly-used treatment for correcting of leg length discrepancy and associated morbidities but the evidence supporting this treatment is at high risk of bias and of low-quality due to lack of available control group for clinical trials. We describe a “placebo” shoe lift for potential use in a wide range of interventional clinical studies.

METHODS: Proof-of-concept control intervention using a convenience sample of two Participants: a 75.0kg male, and a 58.8kg female. We compared the lift effect of shoes without lifts, compressible 6.0mm “placebo” shoe lift, and standard 6.0mm ethylene vinyl acetate shoe lift to each participant. Outcome measures included amount of lift with each shoe radiographically comparing left and right femoral head height, and clinically measuring from level ground to lateral malleolus.

RESULTS: the compressible placebo shoe lift corrected the leg length of the male participant by 4.6mm measured radiographically and 5.0mm measured clinically compared to 8.0mm clinically-measured correction using the standard shoe lift. The female participant’s leg length was corrected by 5.3mm by the placebo measured radiographically.

CONCLUSIONS: A placebo lift will allow measuring the effect of various amounts of correction for LLD on many musculoskeletal conditions in a double-blind placebo-controlled fashion. The compressible shoe lift we described has the appearance of a standard shoe lift, provides less LLD correction than its apparent height, and will reduce risk of bias in clinical trials.


Poster 546

Patterns of muscle selection and associated outcomes of botulinum toxin injection for stroke-related ankle plantar flexor spasticity: a systematic review.

Emma Mauti1, Chetan Phadke2,3,4, Chris Boulias2,5, Farooq Ismail2,5

  1. University of Toronto, Toronto, ON, Canada; 2. West Park Healthcare Centre, Toronto, ON, Canada; 3. Department of Physical Therapy, University of Toronto, Toronto, ON, Canada; 4. Graduate Program in Kinesiology and Health Science, York University, Toronto, ON, Canada; 5. Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada.

Context: Spasticity involving the ankle plantar flexors frequently affects stroke survivors, and significantly impacts gait, independence, and quality of life. Treatment can involve botulinum neurotoxin (BoNT) injections, commonly into gastrocnemius (G), soleus (S), and/or tibialis posterior (TP). However, each of these muscles has its own unique structure and function, and it is not known which muscle targets are optimal to maximize benefits and minimize BoNT toxicity.

Objective: The primary review question is twofold: (1) in literature involving adult patients with ankle plantar flexor spasticity secondary to stroke, what are the most common patterns of botulinum toxin injection, including the frequency and combination of injected muscles, and (2) do spasticity outcomes differ depending on the muscle(s) injected?

Methods: The medical databases Medline, Embase, and Cochrane Central Register of Controlled Trials (up to October 2018) were searched using MeSH terms and keywords in four categories: spasticity, plantar flexors, stroke, and BoNT. Inclusion criteria were: original research; English; adult subjects with plantar flexor spasticity secondary to stroke; and treatment with intramuscular BoNT A or B to specified plantar flexors. Abstracts and full texts were screened by two independent reviewers, who also extracted data using a pre-developed form. Risk of bias was appraised using National Institutes of Health Quality Assessment Tools.

Results: The review is ongoing, at the stage of preliminary data analysis. The database search generated 90 records. Following eligibility screening, 40 studies were included in the narrative synthesis. The most common patterns of muscle selection were: G+S+TP (19/40, 47.5%), G+S (14/40, 35%), and G only (10/40, 25%). The majority of studies (30/40, 75%) did not provide an explicit rationale for their muscle selection. Doses and formulations of BoNT, as well as outcome reporting, were heterogeneous across studies. This considered, the proportion of study groups measuring a 1-point or greater improvement in mean modified Ashworth score at 4 weeks post-BoNT was 100% for groups injected in G+S, 65% for groups injected in G only, and 27% for groups injected in G+S+TP.

Conclusion: While this review is ongoing, preliminary results suggest that study heterogeneity limits the ability to draw conclusions about optimal muscles to inject with BoNT for post-stroke plantar flexor spasticity. Methods of selecting target muscles are inadequately reported across studies, and future work should be done to standardize this.

Keywords (MeSH): Ankle; Botulinum Toxins; Equinus Deformity; Muscle Spasticity; Stroke


Poster 549 First Place

Risk of falling on an inpatient stroke rehabilitation unit: Is the Stroke Assessment of Fall Risk tool the right one to use?

Christine Yang1 MD; Bahareh Ghaedi2 MSc; Nicole Rutkowski3 BSc; Mark Campbell4MD MSc; Hillel Finestone5 MD

1Department of Physical Medicine and Rehabilitation, Elisabeth Bruyère Hospital. 43 Bruyère St, Ottawa, ON, Canada K1N 5C7.

2Department of Physical Medicine and Rehabilitation, Bruyère Research Institute. 43 Bruyère St, Ottawa, ON Canada, K1N 5C7. Telephone number: 613-562-6262. Email: Bghaedi@bruyere.org

3School of Psychology, University of Ottawa, 451 Smyth Rd, Ottawa, ON Canada K1H 8L1. Email: nrutkowski@uottawa.ca

4Department of Physical Medicine and Rehabilitation, Elisabeth Bruyère Hospital. 43 Bruyère St, Ottawa, ON, Canada K1N 5C7. Telephone number: 613-562-6262. Email: tcampbell@bruyere.org

5Department of Physical Medicine and Rehabilitation, Elisabeth Bruyère Hospital. 43 Bruyère St, Ottawa, ON, Canada K1N 5C7. Telephone number: 613-562-6262. Email: Hfinestone@bruyere.org

Funding: The study was funded by Bruyère Academic Medical Organization, (Bruyère REB Protocol # M16-16-022)

Objective: To assess the feasibility of use of the Stroke Assessment of Fall Risk (SAFR) tool on an inpatient stroke rehabilitation unit and to evaluate the sensitivity and specificity of SAFR and the regularly applied Morse Fall Scale in predicting falls.

Design/Methods: A prospective observational study was conducted in an inpatient stroke rehabilitation unit at Elisabeth Bruyère Hospital, Ottawa, Canada from Jan 2017 to Sept 2018. Patients’ falls were captured by hospital Risk Incident Measures reports and medical records. The risk of falls was measured using both the SAFR tool and the Morse Fall Scale. We calculated sensitivity and specificity, and Univariable Logistic Regression was used to evaluate both tools as predictors for having fall using Receiver Operating Characteristic (ROC) curve.

Participants: Patients (N=220) who had imaging-confirmed and/or clinical evidence of acute stroke (ischemic or hemorrhagic) were recruited. Exclusion criteria were comorbid brain tumor, traumatic brain injuries, degenerative neurological disorders (e.g. Parkinson’s disease and multiple sclerosis) and language barrier (no English or French).

Results: Forty eight (21.8%) patients experienced falls during their inpatient rehabilitation stay. Six patients had repeated falls. There was no difference between fallers and non-fallers with respect to age, gender, side of stroke, location and type of stroke. The sensitivity and specificity of SAFR were 47.92% (95% CI (33.52, 62.64)) and 76.74 % (95% CI (69.58, 82.69)), respectively. The positive predictive value (PPV) was 36.51% and the negative predictive value (NPV) was 84.08%. The sensitivity and specificity of Morse were 45.83 (95% CI (31.64, 60.69)) and 68.02 (95% CI (60.42, 74.80)), respectively. The PPV was 28.57 and the NPV was 81.82. Subscale analysis of the SAFR showed that there was a statistically significant difference in hemi-neglect between fallers and non-fallers (p<0.05). This screening component is not present on the Morse scale. The area under the ROC curve (AUC-ROC) was 0.65 for SAFR, and 0.55 for MORSE. The AUC-ROC looked bigger for SAFR, but was not statistically significant (P=0.1915).

Conclusion: The stroke specific SAFR tool predicted falls equally compared to the regularly applied Morse Fall Scale. The SAFR tool had superior specificity with respect to falls screening. The hemi-neglect component of the SAFR was an independent falls predictor. Further studies evaluating whether incorporation of the SAFR screening tool can reduce the number of falls on a stroke rehabilitation unit are needed.

Keywords: Falls; prediction; stroke, rehabilitation


Poster 551

Knee flexion contracture is associated with leg length discrepancy in patients with osteoarthritis

Katherine Reilly1, Adnan Sheikh2, Guy Trudel3, Odette Laneuville4, Robert Feibel2, Hans Uhthoff1, T Mark Campbell5

1 University of Ottawa, Bone and Joint Lab – Ottawa, ON

2 The Ottawa Hospital – Ottawa, ON

3 University of Ottawa, Department of Biochemistry, Molecular Biology and Immunology – Ottawa, ON

4 University of Ottawa, Department of Biology – Ottawa, ON

5 Elisabeth Bruyère Hospital – Ottawa, ON

Acknowledgment of financial support: This study is funded by the Bruyère Academic Medical Organization Research Innovation Fund (BAM-16-001).

Conflict of interest: The declare no conflict of interest.

BACKGROUND/OBJECTIVE: A leg length discrepancy (LLD) occurs when the lower extremities are of unequal length. LLD is associated with increased pain, worse function and reduced balance. Osteoarthritis (OA) is the most common form of arthritis and affects millions of Canadians. Between one-third to half of patients with knee OA develop a knee flexion contracture (FC), that is, the inability to passively extend their knee to neutral. A unilateral knee FC functionally shortens the affected lower extremity, potentially leading to a LLD and compounding OA symptoms. To our knowledge, no study has evaluated the effect of knee FC on the presence or magnitude of LLD in OA patients. Our objective was to measure the degree of knee FC and any corresponding LLD in patients with severe knee OA.

METHODS/PARTICPANTS: Patients with 1° knee OA presenting for total knee arthroplasty were consecutively recruited from a tertiary care academic hospital. Demographic data, radiographic Kellgren and Lawrence (KL) OA severity and knee range of motion were collected. Participants were divided into FC and non-FC groups based on knee extension. Loss of >5° extension was considered a FC. Anatomic leg lengths were measured from the anterior superior iliac spine to the lateral malleolus bilaterally. LLD was calculated by subtracting the length of the limb of the surgical knee from that of the non-surgical knee. Correlation between knee FC and LLD was evaluated using linear regression.

RESULTS: Twenty participants with FC and fourteen without FC were recruited. There was no difference in demographics or KL grade between the two groups. FC participants demonstrated a greater loss of extension versus non-FC participants (10±4° versus 2±2°, p<0.001) as well as loss of flexion (108±14° versus 118±12°, p=0.048) in the surgical knee. Those with FC in the surgical knee had a greater LLD versus non-FC participants (10±9mm versus -0.3±2.8mm, p<0.001). There was a linear correlation between the degree of FC and the LLD magnitude (Pearson correlation=0.525, p=0.002).

CONCLUSIONS: Participants with knee OA and FC demonstrated a LLD. Knee FC severity was linearly correlated with LLD magnitude. Maintaining knee extension and/or correcting LLD in the OA population may help prevent LLD-associated morbidities and may represent an underappreciated OA treatment option.


Poster 552

The Effect of Listening to Personalized Music on Anxiety and Pain During Electrodiagnostic Studies: A Prospective Randomized Control Trial

Jad Serhan1, Stephanie B Muise1, Swati Mehta2, Steven Macaluso1

1 Schulich School of Medicine and Dentistry, London, ON, Canada

2 Parkwood Institute, London, ON, Canada

Context/Objective: Electrodiagnostic studies (EDX), including nerve conduction studies (NCS) and electromyography (EMG) are tests used to assess neuromuscular pathology. Pain is a frequent complication of EDX studies and has been cited as a common reason for altering or aborting studies, potentially reducing diagnostic accuracy (1-3). Music therapy is a low cost intervention that has been utilized as a tool to reduce anxiety and pain in many settings, including postoperatively, during many invasive procedures and during labor (4-7, 10). There have been only two studies assessing the role of music in reducing EDX-related pain and anxiety and these have found conflicting results (8). The objective of this study is to examine the effect of listening to personalized music on patient anxiety and pain while undergoing EDX studies.

Design/ Setting: This study is a prospective randomized control trial being carried out at Mount Hope Centre for Long Term Care in London, Ontario.

Participants: All patients referred for EDX studies at Mount Hope Centre for Long Term Care are considered for inclusion in the study. Patients with profound hearing loss or cognitive impairment are being excluded. Those who consent are randomly assigned to either the “music” or “no-music” group using the research electronic data capture (REDCap) software. A sample size of 45 patients in each group (90 patients) was calculated based on a moderate effect size = 0.6, a = 0.05 and power = 0.8.

Intervention: Patients assigned to the “no-music” group undergo EDX following usual protocol. Those in the “music group” wear sterilized headphones and listen to personalized music during the EDX by using a tablet-computer to navigate Spotify, a digital music service. Patients are communicated with via a Bluetooth connection to their headphones.

Outcome Measures: Anxiety and pain outcomes are compared pre and post EDX using Y-1 and Y-2 of the state-trait anxiety inventory (9) and visual analogue scale (VAS) for pain and anxiety. Differences between and within groups are compared using analysis of covariance and paired t-tests respectively. A p value < .05 is considered statistically significant.

Results: The use of music shows a promising trend regarding EMG and NCS test pain and anxiety.

Conclusions: Use of music delivered via Bluetooth headset to patients during EMG is a feasible, cost-effective way of addressing test pain and anxiety. It also addresses communication barriers by allowing the physician to speak directly to the patient via a Bluetooth microphone.

Keywords: music, pain, anxiety, electromyography

Funding Acknowledgement: The Department of Physical Medicine and Rehabilitation (internal research grant funding)


Poster 553 – Second Place

Rehabilitation and the Anterior Interosseous Nerve Transfer for Severe Ulnar Neuropathy Elbow.

Thomas A Miller, 1,2 Juliana Larocerie-Salgado, 2,3 Christopher D Doherty, 2,4 Douglas C Ross 2,4

Department of Physical Medicine Western University 1, Hand and Upper Limb Centre, St Josephs Health Care 2, Hand Therapist HULC 3 , Division Plastic Surgery Western University 4 , London, Ontario Canada

Introduction: Severe ulnar neuropathy at the elbow (UNE) has a significant impact on hand function and traditionally a poor outcome. We report on patients with McGowan III (severe) with axonal loss neuropathy treated with a proximal ulnar nerve transposition and a Reverse end-to-side (RETS) anterior interosseous nerve (AIN) transfer. We hypothesize the addition of this nerve transfer to a standard subcutaneous transposition will demonstrate early re-innervation of intrinsic musculature and improved strength and recovery. This early re-innervation requires a “new” or revised approach to their rehabilitation, highlighting the importance of initiating hand intrinsic function (with pronation) and outlines the unique post operative neuromuscular rehabilitation.

Methods: 30 consecutive patients who were undergoing subcutaneous ulnar nerve transposition plus reverse end to side AIN to ulnar neurorrhaphy for severe ulnar neuropathy are presented. All patients demonstrated severe ulnar neuropathy clinically (McGowan III) and confirmed electrophysiologically with axonal loss. Clinical parameters included duration of intrinsic muscle atrophy/dysfunction, as well as pre-operative and post-operative Medical Research Council (MRC) muscle strength, clawing and degree of wasting. Electrodiagnostic data included compound motor action potential (CMAP) amplitudes, and sensory nerve action potential (SNAP) amplitudes. Post-operative electrodiagnostic data include the time to detection of nascent potentials in hand intrinsics. Summary statistics were used for demographic and clinical data. Student t-test and Wilcoxon signed rank test were used where appropriate.

A structured rehabilitation protocol was introduced divided into 4 phases i) Motor relearning and cortical activation with education and re training neuroplasticity ii) sEMG triggered biofeedback once nascent units appear initiated by the donor nerve (ie pronation) followed by iii) neuromuscular stimulation, and neuroplasticity exercises and iv) endurance and hand intrinsic strengthening.

Results: 30 patients were followed an average of 18.6 months. Mean age 53 (SD 18.9) and 21 males. 5 of 7 patients with diabetes had a polyneuropathy. MRC grade significantly improved for FDI and ADQ (mean pre operative MRC 1/5) and 73% of subjects demonstrated grade 3 or greater and 7% achieved grade 5. Preoperatively 14 patients had a hypothenar MRC 0/5 and at an average of 2 years post surgery 16/30 had a hypothenar MRC score of 4 or 5. The mean Hypothenar (ADQ) CMAP amplitude improved from pre 1.0 mV (1.8) (8 absent responses ) to 2.6 mV (2.7) post . The time to nascent units observed in hand intrinsics was 8.5 (+/- 4.9) months. Seventy-seven percent of patients demonstrated an increase in the number of motor units with forearm pronation, thereby simulating the donor (AIN) function. All patients had improved grip and pinch strength.

Conclusion: Our study presents the largest homogeneous cohort of patients with severe compressive, ulnar neuropathy at the elbow (UNE) undergoing anterior interosseous supercharge transfer and a subcutaneous transposition at the elbow. The use of EMG as an outcome measure and as a tool to influence/initiate rehabilitation is highlighted. The Improvement in motor function and strength as well as increase in CMAP amplitude argue in favor of the implicit benefit of end to side transfer in severe ulnar axonopathy and highlight the importance of a structured post operative rehabilitation strategy.


Poster 554

Does the approach used to recommend active rehabilitation influence patient compliance to the program?

Lavpreet Khaira1, Jordan Raugust2

1 Schulich School of Medicine and Dentistry, London, ON;

2Department of Clinical Neurosciences, Division of Physical Medicine and Rehabilitation, Cumming School of Medicine, Calgary, AB

Objective: To determine if there is a difference in patient compliance to rehab recommendations based on the method used by the physician to communicate the recommendation. The secondary objective was to determine if there is any correlation between rehab compliance and demographic factors.

Design/Methods: All patients seen as new consults at an outpatient physiatry clinic in Calgary, AB, between July and Aug 2018 were enrolled. Following each assessment, physicians recorded the method they used to recommend an active rehab program: (1) Verbal recommendation to participate in physical therapy (V), (2) physical therapy prescription (Rx), (3) Home rehab program handout (HRP) and (4) therapy prescription + home rehab program handout (Rx+HRP). One month following assessment, patients were asked to report their compliance to rehab. Their reported compliance was then assessed for any correlation with demographic factors, including city quadrant of residence.

Participants: 941 total patients, with 212 recommended an active rehab program.

Results: There was no significant difference in rehab participation between the different rehab groups (p=0.42). However, the participation rate and average rehab sessions completed per week trended higher in the Rx+HRP group compared to the remainder of referral styles. There was no significant influence of the following factors on rehab participation: age (p=0.56), gender (P=0.20) or access to third party health insurance (p=0.47). The average number of sessions completed per week in NE Calgary was lower compared to the rest of the city (p=0.03). Individuals from rural areas tended to engage in rehab sessions at a higher rate compared with those from Calgary (p=0.02). Between quadrants, individuals in SW Calgary completed rehab at a higher rate than individuals in the SE (p=0.03). Individuals from rural areas also completed rehab at a higher average than in the SE (p=0.02).

Conclusion: There appears to be differences in likelihood of rehab participation based on location of residence in Calgary. Patients from the NE quadrant were less likely to participate in rehab, where those from SW and rural communities were more likely than other quadrants. This could be influenced by a variety of factors, including socioeconomic status, which seems to be indicated by correlation with average household income as per Canada census data. It appears that referral style does not impact the likelihood of patients initiating a rehab program. However, there was a trend to increased likelihood of rehab participation in the Rx+HPR group.


Poster 555

Reliability, Validity, and Agreement of the Full and Short-form Activities-specific Balance Confidence Scale in People with Lower Extremity Amputations

Katherine Fuller,1 Humberto Omaña, MSc,1 Courtney Frengopoulos, MSc,1 Michael W. Payne, MSc, MD,2,3 Ricardo Viana, OT, MD,2,3 Susan W. Hunter, PT, PhD3,4

1Faculty of Health Sciences, University of Western Ontario, London, ON, Canada;

2Department of Physical Medicine & Rehabilitation, Parkwood Institute, London, ON, Canada;

3Department of Physical Medicine & Rehabilitation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada;

4School of Physical Therapy, University of Western Ontario, London, ON, Canada.

Background: Falls in people with lower extremity amputation(s) (PLEA) are common and can lead to injury and a fear of falling that impacts activity engagement and quality of life. The Activities-specific Balance Confidence scale (ABC) is used by clinicians to understand how confident PLEAs are at completing a range of tasks. A short-form, the ABC-6, was developed in older adults using the six most difficult tasks from the full ABC scale. Currently, neither the test properties of the ABC-6 nor its agreement with the full-scale ABC have been explored in PLEAs.

Objective: To determine the test-retest reliability, minimal detectible change, construct validity and agreement for the ABC and ABC-6 in PLEAs.

Methods: A test-retest interval of 2 weeks was used. Statistical analysis for relative and absolute reliability measures were intraclass correlation coefficient (ICC), standard error of measurement (SEM) and minimal detectable change (MDC95). Bland-Altman plots measured agreement between the scales. Construct validity was evaluated against the L Test using a Pearson-product moment correlation, hypothesis being that higher balance confidence scores are associated with faster times to complete the L Test.

Participants: Participants were recruited from an outpatient amputee clinic, had a lower extremity amputation and at least 6 months of prosthesis walking experience.

Results: Sixty participants were recruited (age=58.2 ± 12.6 years, 80% male, time since amputation=13.2 ± 15.2 years). For the ABC, the ICC was 0.91 (95% CI: 0.85-0.95), SEM was 5.18 points and MDC95 was 14.36 points, while for the ABC-6 these values were 0.92 (95% CI: 0.87-0.95), 7.74 and 21.45, respectively. Hypothesized associations were observed for the ABC (r =-0.72, p<0.001) and ABC-6 (r =-0.68, p<0.001). Bland-Altman plots indicated good agreement within each scale, yet poor agreement between the scales.

Conclusions: In summary, both scales demonstrated excellent relative and absolute reliability and good support for construct validity. Absolute reliability of the ABC was consistent with studies in other patient groups (e.g., Parkinson’s Disease, stroke), whereas this value for the ABC-6 was a novel addition to the literature. Poor agreement between ABC and ABC-6 indicates these two measures should not be used interchangeably in this patient population.


Poster 556

Physical and Attitudinal Barriers to Health Promotion in Women with Multiple Sclerosis in Canada: A Web Based Study

Christine Short MD FRCPC FACP1,2, Emily Patterson, MD1

1Dalhousie University, Halifax, NS, Canada

2Nova Scotia Health Authority, Halifax, NS, Canada

Background: Many researchers have investigated the barriers to accessing health services faced by people with disabilities, however limited studies examine the barriers faced by the Multiple Sclerosis (MS) population and very few of these studies have been Canadian. Although previous studies have identified barriers for women with disabilities, the studies do not explore, nor further understand the experience of these women. In order to overcome barriers, it is essential to first understand these experiences to implement appropriate changes.

Objective: The objective of this study was to identify the barriers (physical and attitudinal) to accessing health promotion practices for women with MS in Canada.

Methods: The questionnaire was developed by our team and ethics approval was obtained from the Nova Scotia Health Authority. Canadian women over the age of 18, with MS, were invited to participate in the online questionnaire administered by Opinio, accessed through Dalhousie University. Descriptive analysis was conducted through the Opinio program and no tests of significance were run as the study was exploratory. Thematic analysis was performed to analyze open ended responses.

Results: Four hundred and fifty-six Canadian women completed the questionnaire. The majority of women were aged 41-60 (54.18%) and had MS symptoms for 5-15 years (42.6 %). From a mobility perspective, 58.06% of respondents were able to walk independently in the community.

Ninety seven percent of respondents had a family doctor, and of those, 20.38% indicated their family physician’s examining table was not accessible. Of those who were wheelchair users, 73.53% indicated that they were examined in their wheelchair greater than 50% of the time.

Physical barriers identified were: inaccessibility of examination table, transportation and inaccessibility of health professional office buildings.

Respondents’ perceptions of the attitudes held by health professionals compounded the barriers, these included: lack of knowledge of MS, lack of awareness of the impact of MS on sexual function, and assumption that without obvious signs of disability one is not disabled.

Conclusions: Women with MS have many physical and emotional health needs. This study identified common themes which women with MS experience when trying to access health services. This is one of the first Canadian studies to focus on barriers to accessing health services for women with MS. Future studies are needed to further explore the experiences of women with MS to then implement strategies to overcome the barriers identified in this study.


Poster 557

Web-based physiotherapist-guided home exercise program for moderate to severe multiple sclerosis: a pilot randomized controlled study

Shyane Wiegers1, Sarah Donkers2, Lorna Paul3, Darren Nickel4, Katherine Knox4,

1College of Medicine, University of Saskatchewan;

2School of Rehabilitation Science, College of Medicine, University of Saskatchewan, Saskatoon, Canada;

3School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK;

4Physical Medicine & Rehabilitation, College of Medicine, University of Saskatchewan, Saskatoon, Canada

Context: Research shows that web-based interventions may help to improve exercise adherence in people with mild to moderate MS over the short term. There is a gap in the research concerning web-based interventions lasting longer than 3 months with people with moderate to severe MS. The aim of this study was to assess adherence to a web-based exercise program (www.webbasedphysio.com) over 6 months.

Design: Pilot Randomized controlled trial

Setting: Community

Participants: Participants with moderate to severe MS were recruited through the Saskatoon MS clinic and MS Society of Canada. Those already exercising at least twice a week were excluded.

Interventions: Participants were randomly assigned in a 2:1 ratio to web-based exercise or hand out based exercise prescription group.

Methods: Additional exercises were added to the existing web-based platform with input from people living with MS and experienced physiotherapists. Participants in each group met with a physiotherapist at baseline to receive an individual exercise program. Participants in the web group could follow their programs through video and written instructions. Physiotherapists monitored web participant usage every two weeks, responded to queries and modified exercise programs as requested. Participants in the comparator group received a paper handout of their program and recorded their exercise in a diary. Both groups were encouraged to complete exercises twice a week.

Outcome Measures: Total exercise sessions over the six months were described using means and distributions were compared using Mann-Whitney U test.

Results: Forty-eight people participated in the study: 32 web, 16 comparator. Mean number of exercise sessions for the web group was 38.9 (SD=28.1) and for the comparator group was 34.6 (SD=40.8). These totals translate to means of 1.5 and 1.3 exercise sessions per week, respectively. There was no statistically-significant difference between groups (U=198.5; p=.208).

In total, 48% (23/48) exercised at least 2x/wk in at least 13/26 weeks. Wheelchair users in the web group had the highest adherence rate.

Conclusions: A web-based exercise program for people with moderate to severe MS showed no statistically-significant difference in exercise adherence compared to a hand out based exercise prescription. However, exercise levels improved in both groups compared to baseline. Limitations include a small number of wheelchair users and challenges with measuring physical activity adherence. Future research could examine for whom web-based interventions are most appropriate in order to further improve exercise adherence.

ClinicalTrials.gov Identifier: NCT03039400

Funding acknowledgements: This investigation was supported by the Hermes Canada | MS Society Wellness Research Innovation Grant.


Poster 558

Effect of shoulder and elbow position on nerve conduction in the ulnar nerve: a prospective observational study

Kevin Hsu1, Lawrence R. Robinson1

1University of Toronto, Department of Physical Medicine and Rehabilitation

Toronto, ON, Canada

Context: The ulnar nerve is not always stretched to its full length as it is in a slack position when the upper limb is straight by one’s side, but stretched when the elbow is flexed and the shoulder is abducted. Previous cadaveric studies have demonstrated a change in ulnar nerve length with elbow flexion. Similarly, measured ulnar nerve conduction velocity is known to vary with elbow position. The aims of this study were to determine the length of reserve that asymptomatic individuals have in their ulnar nerves to accommodate various arm positions, as well as evaluate the effect of shoulder position on ulnar nerve conduction studies.

Methods: Healthy subjects (n=22) underwent ulnar motor nerve conduction studies with recording from the abductor digiti minimi in four positions of shoulder abduction and elbow flexion. Compound motor action potentials were recorded and conduction velocities were calculated for each position.

Results: The mean increase in nerve conduction velocity from the slack position of shoulder adducted and elbow extended to the stretch position of shoulder abducted and elbow flexed was 2.9 m/s (P<0.01). Using this difference in nerve conduction velocity, the mean length of reserve in the ulnar nerve along the limb was found to be 28.3 (SD=13.8) mm. The redundant nerve across the elbow in the slack position was found to be 23.9 (SD=15.1) mm.

Conclusion: This study demonstrates an ulnar nerve reserve in healthy subjects that is taken up with shoulder abduction and elbow flexion. Clinically, there is a question of whether individuals with diagnoses such as thoracic outlet syndrome or ulnar neuropathy at the elbow may have less nerve reserve to accommodate aggravating positions. Future studies could investigate whether there is a difference in nerve reserve compared to healthy controls. Shoulder abduction was also found to impact measured ulnar nerve conduction velocities independent of elbow flexion, suggesting that shoulder position should be standardized during ulnar nerve conduction studies. Ultimately, it may be best to measure ulnar nerve conduction velocity in the fully stretched position, although new reference values would need to be developed.

Keywords: elbow; shoulder; ulnar nerve


Poster 560

Multiple Peripheral Neuropathies Secondary to Missed Compartment Syndrome: A Case Report.

McKyla H McIntyre1, Lawrence R Robinson1.

1University of Toronto, Toronto, ON, Canada.

Context: This is a 51-year-old, previously healthy man with a history of motorcycle accident (MCA) resulting in polytrauma. His injuries included complex right radius fracture with multiple fragments, extending from distal intra-articular surface to the mid third of the radius. His radius fracture was treated with open reduction and internal fixation (ORIF). He had a prolonged hospitalization including a 22 day stay in the ICU and had a left transfemoral amputation after prolonged efforts to save the limb.

He was referred for assessment for right brachial plexopathy versus peripheral nerve injury. Since his accident, he reported profound weakness and numbness involving his whole right hand. He regained some composite finger flexion but otherwise noticed no changes.

Findings: On manual muscle testing of the right upper extremity (RUE), proximal strength was full, but there was profound weakness of distal muscles innervated by median, radial and ulnar nerves. The sensory deficits correlated with these peripheral nerve territories.

On nerve conduction studies in the RUE, median and ulnar motor and sensory responses were unobtainable. On EMG, insertional activity was absent in extensor indicis, oppponens pollicis and abductor digiti minimi; there were also no voluntary motor units. Proximal forearm muscles demonstrated evidence of denervation and reinnervation.

On retrospective review of the operative summary, it was noted that the musculature of the extensor compartment of the forearm was non-viable, with the exception of brachioradialus and extensor carpi radialis longus. This was felt to be reflective of missed compartment syndrome. The third and fourth interossei were also non-viable, in keeping with partial compartment syndrome of the hand.

Conclusion/Clinical Relevance: The history, clinical examination and electrodiagnostic findings were consistent with complete right median, ulnar and radial neuropathies. However, the absence of insertional activity and information from the operative summary revealed missed compartment syndrome as the etiology for his deficits.

This case highlights the importance recognizing the implication of absent insertional activity on EMG. In this case, identification of compartment syndrome had important prognostic and treatment implications. The prognosis for reinnervation, even after nerve transfers, is guarded in the setting of muscles with absent insertional activity, and is especially poor in the setting of non-viable muscle tissue. In these cases, alternative treatment options should be considered.


Poster 561

Pressure Ulcer in Patients with Spinal Cord Injury: A Provincial Data Analysis

Ammar Al Khudairy 1,2 Janeen Al-Mallah 1,2 Matthew Short 1,2 , Sonja McVeigh1,2, Christine Short 1,2

1Dalhousie University, Halifax, Nova Scotia

2Nova Scotia Rehabilitation Center, Halifax, Nova Scotia

Objectives: Pressure ulcer (PU) represents a challenging problem for both patients with spinal cord injury (SCI) and their treating rehabilitation team. The aim of this study is to assess the impact of PU on inpatient rehabilitation at the Nova Scotia Rehabilitation Centre (NSRC).

Methods: This is a retrospective chart review, observational case-control study. Our study will include all SCI patients admitted to NSRC between 2011-2014. The primary objective is to examine the effect PU has on the length of stay in rehabilitation (LOS).

Results: We present the preliminary results of the first 126 patients. Using the National Rehab Reporting System database (CIHI), 30 patients had PU on admission. During the chart review process, 3 additional patients with PU were added. The incidence of PU was 33% of the traumatic and 21% in the non-traumatic groups. The average age of patients with PU and without PU was 49.9 and 53.8 years respectively. Presence of incontinence doubled the PU incidence. Average LOS in PU group was 240 days compared to 125 days in the non-PU group. Majority of PU were stage 4 (37.8%) and occurred at the community hospitals. Majority of PU did not heal at time of discharge or in the first clinic follow up. Medical notes reviewing process also included the rate of documentation of pressure ulcer in CIHI

Conclusion: The presence of PU was mainly in traumatic SCI and was affected by the presence of incontinence. PU prolonged LOS and the majority did not heal completely at the time of discharge. Results of this study will highlight the impact of PU and assist in the development of strategies to prevent and improve management of PU.


Poster 562

Attitudes and Practice Patterns of Canadian Physiatrists Surrounding Medical Cannabis

Harpal Chaudhary MD, Colleen ‘O’ Connell MD, FRCPC,

Alan Casey MD, FRCPC, Mayur Nankar, M.sc, M.PT, Karen Ethans MD, FRCPC

Background: Over the last 2 decades, use of cannabis for medical purposes has dramatically increased. several patients with pain and spasticity request physicians to authorize medical cannabis, thus our objective was to evaluate attitudes and practice patterns of Canadian physiatrists regarding medical cannabis.

Methods: A 24-item, web-based survey questionnaire was sent to 348 physiatrists in Canada covering following domains; clinician’s beliefs in efficacy of medical cannabis, frequency of requests for medical cannabis, physiatrist’s level of comfort and opinions related to training and current institutional guidelines.

Results: 109 physiatrists responded; most of them agreed that there is a medicinal value in cannabis although they preferred to keep it as a last option of treatment. 62% of responders felt comfortable talking to their patients yet only 32 percent felt comfortable signing medical documents authorizing medical cannabis. Overall, 41% of responders had authorized the medical document for the following conditions: Neuropathic pain (76%), musculoskeletal pain (67%) and spasticity (44%). More than 50 % agreed that these requests were for legal recreational use. Most responders agreed that there is insufficient educational exposure during medical school, residency and current governmental and institutional guidelines are unclear.

Conclusion: Based on this survey, more research, clear guidelines from the government and regulatory authorities and improved training during medical school and residency is needed to provide increased confidence to physiatrists at the time of discussion and authorization of medical cannabis.

Keywords: Medical cannabis, medical marijuana, physiatrists, attitudes, practice patterns, efficacy of medical cannabis, side effects of cannabi62


Poster 563

Diffuse positive sharp waves: Myopathy or EMG disease?

Rebecca Titman, MSc MD1, Lawrence Robinson MD FABPMR 1,2

1Department of Medicine, University of Toronto, Toronto ON

2Sunnybrook Health Sciences Center, Toronto ON

Context: Positive sharp waves (PSW) are an electrophysiologic phenomenon in needle electromyography (EMG) characterized by a biphasic, initial positive deflection and a slow return to baseline. Along with fibrillations, PSW reflect an unstable muscle fiber membrane potential and are associated with neuromuscular pathology. EMG disease, also known as diffusely increased insertional activity, is a rare clinical scenario of diffuse PSW without fibrillations in an individual with no evidence of neuromuscular disease. The etiology of this phenomenon is unclear, with the largest published case series including 10 patients. It is thought to follow an autosomal dominant inheritance pattern with a female predominance. We present a case of EMG disease in an individual referred for electrodiagnostic testing to rule out an inflammatory myopathy.

Findings: A 71-year-old man presented with a recent diagnosis of idiopathic pulmonary fibrosis (IPF), and weakly positive anti-Ro52, anti-SCL-100 and anti-Jo-1 antibodies. He denied any symptoms of weakness, sensory abnormalities or myotonia. His past medical history was positive for hypothyroidism and a new diagnosis of IPF. Family history included a son with cervical radiculopathy treated with surgical decompression. There were no abnormal findings on neurologic exam. Nerve conduction studies showed mild median neuropathy. EMG of 3 upper limb, 2 lower limb, and thoracic paraspinal muscles showed diffuse, waning PSW with no evidence of fibrillations. Motor unit action potentials had normal amplitude, duration and recruitment.

Conclusion/Clinical Relevance: With the isolated finding of diffuse PSW on EMG, the patient was given the diagnosis of EMG disease. These benign abnormal electrodiagnostic findings were discussed with the patient along with its inheritance pattern. This case demonstrates the importance of recognizing isolated diffuse PSW as an electrophysiologic phenomenon and avoiding the misinterpretation of these abnormalities as neuromuscular pathology. While it is unclear if the patient’s son had an erroneous diagnosis, this disorder can be confused with myopathy, motor neuron disease, polyradiculpathy and other disorders.

Funding Acknowledgement: None to report

Keywords: Electromyography, membrane potentials, muscle skeletal


Poster 564

Fear of falling as a cognitive distractor affecting mobility in people with a lower limb amputation: A cross-sectional study.

Humberto Omana1, Michael W Payne2,3, Ricardo Viana2,3, Susan W Hunter1,3,4

1Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada.

2Department of Physical Medicine & Rehabilitation, Parkwood Institute, London, Ontario, Canada.

3Department of Physical Medicine & Rehabilitation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada.

4School of Physical Therapy, University of Western Ontario London, Ontario, Canada.

Fear of falling as a cognitive distractor affecting mobility in people with a lower limb amputation: a cross-sectional study.

Background: Fifty-two percent of people with a lower limb amputation (PLLA) fall each year, most commonly while walking. A fear of falling can lead to minimized mobility, social isolation and a reduced quality of life. Walking is a complex motor task requiring cognitive resources. PLLA report having to focus on every step when using their prosthesis suggesting high cognitive demands. Psychological factors, such as anxiety about falling, can act as a cognitive distractor, increasing cognitive demands for walking and adversely affecting performance.

Objective: To determine the independent association of anxiety about falling on walking performance in PLLA.

Design: Cross-sectional study.

Setting: Inpatient care setting.

Participants: Twenty-four people discharged from inpatient prosthetic rehabilitation with a unilateral transtibial amputation participated (age: 62.7±8.6 years, 62.5% males, time from amputation: 133.5±69.5 days). Primary etiology was diabetes mellitus (66.7%).

Interventions: Not applicable.

Outcome Measures: Cognition was evaluated with the Montreal Cognitive Assessment (MoCA). Anxiety was quantified using the Activities-specific Balance Confidence (ABC) scale and the Generalized Anxiety Disorder 7-item (GAD-7) scale. Straight path and L-Test walking under single-(ST, walking alone) and dual-task (DT, walking while counting backwards by 3’s) conditions measured cognition-walking interaction. A preferred walking speed was used without task prioritization. Multivariable linear regression modelling was used to evaluate the objective.

Results: The average MoCA score was 26.25±2.80. For anxiety measures, the average ABC and GAD-7 scores were 70.94±13.19 (min:34.38, max:88.75) and 3.57±4.38 (min:0.00, max:18.00), respectively. A statistically significant performance decline upon dual-tasking for both straight path (ST: 14.22±13.14 s, DT: 17.38±14.97 s) and L-Test (ST: 56.12±33.86 s, DT: 67.01±39.89 s) walking was observed (p<0.001). Neither the ABC nor the GAD-7 were independently associated with straight path or L-Test performance (p>0.05).

Conclusions: Walking performance deteriorated in cognitive demanding tests, but anxiety about falling was not independently associated with walking performance in these PLLA who recently learned to walk with a prosthesis. We cannot rule out that under more anxiety provoking scenarios (e.g., improper lighting), fear of falling may act as a cognitive distractor. Future research needs to explore if fear of falling is a cognitive distractor in PLLA under more challenging situations.

Funding Acknowledgement: St Joseph’s Healthcare Foundation Cognitive Vitality and Brain Health Seed Funding operating grant (No. 070-1516).

Keywords: Amputation, Walking, Performance Anxiety, Multitasking Behavior


Poster 565

AUTOMATED SOFTWARE TO FILL CLINIC APPOINTMENT CANCELLATION SPOTS: A CASE STUDY

Jocelynn L Gray, MD1

1 University of Alberta, Edmonton, Alberta, Canada

ABSTRACT

Health care appointments that go unfilled due to late cancellation represent an inefficient use of health care resources and lost income for the clinic. Traditional methods of re-filling these appointments require clinic staff to sequentially contact wait-listed patients until a suitable person to fill the appointment is found. The use of automated software that contacts wait-listed patients as dictated by a pre-determined algorithm may improve success in filling cancelled appointments, as well as decrease burden on office administrative staff. This report evaluated the effectiveness of one such commercially available software (CancellationSpot) in filling cancelled appointments at a Physical Medicine & Rehabilitation clinic. The software allows clinicians to assign voluntarily subscribed patients to a specific calling pool depending on the type of appointment required. The patient supplies relevant information (such as preferred contact method, availability, and the amount of notice they require), which is then factored into the software’s algorithm. When a cancelled appointment arises, the clinic staff simply input the time, date, and type of appointment into the system, and an online broadcast system contacts patients in the appropriate pool. Unlike the traditional office system, no other staff involvement is needed until a patient calls to accept the appointment slot.

METHODS: Data were gathered from the electronic medical record and the software program records to determine how many appointments were filled using automated software and the length of time it took for these appointments to be filled. Further analysis of one physician’s data was undertaken to determine the wait time of patients who used the cancellation system versus those who were seen on the same day in a typically scheduled appointment slot.

RESULTS: The automated system was successful in re-filling over 80% of cancelled appointments. Wait times were shorter by about 40 days for the individuals who were successful in matching to a cancellation spot using the software as compared to patients who were seen in a regularly scheduled appointment on the same day.

CONCLUSIONS: Use of an automated software for filling cancelled appointments shows promise as an efficient method for successfully filling cancelled appointments while at the same time not increasing staff workload. Other benefits may include better resource utilization by optimizing clinic time.

KEY WORDS: Appointment, clinic, software


Poster 566

The association between changes in subjective and objective measures of mobility in lower limb amputees after inpatient rehabilitation: A prospective study.

Gabrielle Cieslak1, Humberto Omana1, Michael W Payne2,3, Ricardo Viana2,3, Susan W Hunter1,3,4

1Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada. 2Department of Physical Medicine & Rehabilitation, Parkwood Institute, London, Ontario, Canada. 3Department of Physical Medicine & Rehabilitation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada. 4School of Physical Therapy, University of Western Ontario London, Ontario, Canada.

The association between changes in subjective and objective measures of mobility in lower limb amputees after inpatient rehabilitation: a prospective study.

Background: People with a recent lower limb amputation (PLLA) undergo rehabilitation to achieve safe walking using a prosthesis. Objective measures of mobility (e.g., timed walks) are the gold standard and used to prognosticate long-term success. However, objective mobility tests in a controlled setting may not reflect PLLA’s perception of their own ability to move within their home and community. The inter-relationship between objective and subjective measures of mobility has yet to be explored in PLLA.

Objectives: To evaluate the association between subjective and objective measures of mobility after inpatient rehabilitation in PLLA.

Design: Prospective study.

Setting: Inpatient care setting.

Participants: Twenty-one people discharged from inpatient prosthetic rehabilitation with a recent unilateral amputation participated (61.6±8.2 years, 57.1% males). Testing occurred at discharge from inpatient rehabilitation and 4-months follow-up.

Interventions: Not applicable.

Outcome Measures: The L-Test, single-(ST: walking alone) and dual-task (DT: serial subtractions by 3’s), assessed objective mobility. The Prosthetic Evaluation Questionnaire (PEQ, section 4) measured subjective mobility. Paired t tests examined change over time and a Pearson product-moment correlation analysis evaluated the relationship between objective and subjective mobility.

Results: The L-Test improved for the single-(discharge= 82.3±52.6 s, follow-up= 55.0 ± 39.7 s; p=0.008) and dual-task (discharge= 102.4±74.3 s, follow-up= 63.6±44.1 s; p=0.02) conditions. There were no statistically significant changes in the PEQ changes after discharge (p>0.05). At discharge, only two of fourteen PEQ items correlated with mobility: prosthesis walking (ST:r= -0.45, p=0.041) and sidewalk walking (ST:r= -0.56, p=0.008). At follow-up, two items correlated with mobility: prosthesis walking (ST:r= -0.47, p=0.043), satisfaction with walking (ST:r= -0.61, p=0.006 and DT:r= -0.52, p=0.021). At discharge and 4-months, shorter L-Test times were associated with larger (better) self-reported mobility scores.

Conclusions: Objectively, PLLAs demonstrated improvement in walking between discharge and follow-up. However, subjective reporting of mobility indicated participants did not perceive gains. The lack of association between changes in objective and subjective measures of mobility supports collecting both measures in order to provide a holistic picture of clinical and patient relevant outcomes for PLLAs in-line with patient-centered care.

Funding Acknowledgement: St Joseph’s Healthcare Foundation Cognitive Vitality and Brain Health Seed Funding operating grant (No. 070-1516).

Keywords: Amputation, Gait Analysis, lower extremity, Self-Assessment


Poster 567 – First Place

Secondary stroke prevention: Are Canadian patients meeting blood pressure targets?

: Carolyn P. Sawicki1, Susan Marzolini2, Paul Oh2 Institution 1Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada; 2Toronto Rehabilitation Institute, Toronto, ON, Canada Context: Recurrent stroke and transient ischemic attack (TIA) account for a significant proportion of stroke/TIA events and are associated with higher disability and mortality than first time strokes. Blood pressure (BP) is the most important modifiable risk factor for recurrent stroke.

Objective: To perform a systematic review examining BP target attainment and use of anti-hypertensive medication in Canadian cohorts of patients with stroke or TIA.

Methods: MEDLINE (1946-Feb 2019) and EMBASE (1947-Feb 2019) were searched with MeSH terms ((Stroke OR Ischemic Attack, Transient OR Stroke Rehabilitation) AND Secondary Prevention AND Canada). Selected articles were assessed using the NIH Quality Assessment Tool.

Results: Six studies published between 2002 and 2017 were identified. Five studies were moderate quality and one was poor quality. Study designs included two prospective cohorts, two retrospective cohorts and two retrospective chart reviews. Number of subjects ranged from 119 to 118 362. Four studies included subjects with stroke and TIA; the proportion of TIA patients ranged from 17% to 68%. Inpatient Setting: one study found 55% (n=78/143) of hypertensive patients achieved BP target prior to hospital discharge. Another study found 90% (n=180/200) of patients were prescribed an antihypertensive medication. Outpatient Setting: One study reported 46% (n=298/647) overall attainment of BP target and 95% of patients with HTN were prescribed an antihypertensive. In a stroke prevention clinic, 76% (n=85/112) of patients met the BP target at the first visit and 86% (n=97/112) at the one-year follow-up. Outpatient antihypertensive prescription: one study found 64% of patients with stroke or TIA were prescribed an antihypertensive within 90 days of discharge. Another study found 77% (n=83825/108699) of patients with ischemic stroke and 69% (n=6632/9663) of patients with intracerebral hemorrhage filled an antihypertensive medication prescription within one year of hospital discharge.

Conclusions: The studies reviewed demonstrate variable, but overall sub-optimal achievement of BP target for secondary stroke prevention in Canada. This is in contrast to the high proportion of patients prescribed an antihypertensive. Barriers and facilitators to achieving BP targets should be examined. High quality studies examining BP control in consecutive patients in the acute and chronic phase post-stroke are required. Physiatrists, in conjunction with the health care team, have a role in optimizing post-stroke BP management.

Funding Acknowledgment: None.

Keywords: Blood Pressure, Guideline Adherence, Secondary Prevention, Stroke


Poster 568

Does Mindfulness Improve Outcomes After An Acquired Brain Injury: A Systematic Review.

: McDougall, Alexandre 1, Simchovich, Natan 2

1University of Toronto, Dept of Medicine Toronto Rehabilitation Institute – University Health Network 2. University of Toronto, Medical Doctorate Program

Context: Acquired brain injury (ABI) is a leading cause of morbidity and mortality worldwide. Mindfulness-based interventions (MBIs) have been identified as potential therapies to enhance recovery after ABI.

Objective: The purpose of this study is to complete a systematic review and synthesize the evidence regarding MBIs and their therapeutic effects in ABI. Methods: Databases searched include Medline, EMBASE, and PsychInfo. Using Covidence software, two reviewers independently screened titles, abstracts and full texts in a two-step screening protocol to determine final inclusion. Only randomized controlled trials were included in the systematic review. Quality appraisal was conducted by two independent reviewers using Cochrane-Risk of Bias Tool on Covidence. Abstracted data included study setting and outcome measures. MBIs included, but were not limited to, meditation, goal management, and mindfulness-based stress reduction.

Results: Quality appraisal demonstrated that five out of the nine abstracted trials had a low risk of bias. Blinding patients to MBIs proved particularly difficult in this literature and was only partially achieved by one protocol that did not inform the participants of which group was the intervention of greatest interest. MBIs were found to be feasible for ABI patients as evidenced by high attendance and satisfaction ratings from patients and administrating staff. MBIs were demonstrated to consistently improve mental health, attention, depression, and perceived stress in ABI patients. Additionally, the patients reported having improved self-efficacy, self-awareness and were better able to cope with ABI related symptoms. There were mixed results in terms of physical health and functional improvements. These improvements were found to be maintained long term (6-12 months after intervention) and the majority of patients continued daily use of at least some of the MBI strategies. Conclusion: MBI is a promising intervention for ABI patients and the results indicates a wide range of possible long-term benefits. In order for low risk of bias randomized controlled trials, we suggest that blinding of participants be approached similarly to Tornas et al. Furthermore, there was a lack of research investigating the role of MBIs in a subacute rehabilitation setting and larger multi-center trials. Funding: No funding acknowledgements.

Keywords: Brain Injuries, Meditation, Mindfulness

Granting Agency/Funding Source: The Academic Health Sciences Centre Alternate Funding Plan Innovation Fund, The Ottawa Hospital Academic Medical Organization


Poster 569

Determinants of REHABILITATION potential and improvement in severely DECONDITIONED PATIENTS: A Prospective Cohort Study

: Daniel Chan Chun Kong1, Odette Laneuville1,2, PhD & Guy Trudel1,3,4,5, MD, FRCPC

Affiliations: 1Bone and Joint Research Laboratory; 2Department of Biology, University of Ottawa; 3Department of Medicine, Division of Physical Medicine and Rehabilitation, 4The Ottawa Hospital Research Institute, 5Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON, Canada.

Background: Long stays in hospital acute care cause deconditioning that is amenable to rehabilitation. Few if any evidence-based objective criteria measure a patient’s level of deconditioning in order to determine who will most.

Objectives: 1) Measure biological variables of deconditioned patients and describe how they change throughout an inpatient rehabilitation intervention 2) Determine whether demographic, administrative and biological variables at rehabilitation admission correlate with functional improvement.

Design/Methods: This was a pilot prospective cohort design. Rehabilitation improvement was measured using the Functional Independence Measure (FIM) score, expressed as FIM Gain (FIM discharge-FIM admission) and FIM Efficiency (FIM Gain/days in rehabilitation). Demographic (eg. age), administrative and biological variables (e.g.; weight, BMI, complete blood counts) were serially recorded throughout the inpatient rehabilitation stay. Changes in FIM and biological variables were assessed over 4 weeks of rehabilitation treatment using Friedman’s ANOVA with post-hoc Wilcoxon test. Spearman’s correlation was used to determine which variables at admission were associated with FIM Gain.

Participants: Deconditioned patients (N=10) who spent >3 weeks combining hospital acute care and met the criteria for admission to a rehabilitation center. All patients received ≥4 weeks of interdisciplinary inpatient rehabilitation.

Results: All patients showed functional improvements with a mean FIM Gain of 26.4±11.0 and FIM Efficiency of 0.88points/day. Results from the Freidman’s ANOVA showed significant changes with FIM scores (p=0.001), white blood cells (WBC) (p=0.01), neutrophil concentrations (p=0.03) and red cell distribution width (RDW) (p=0.01) over rehabilitation. Wilcoxon test showed that as FIM significantly increased with rehabilitation (p=0.01), WBC (p=0.01) and neutrophil concentration (p=0.02) increased from Week 2 to Week 4 and RDW decreased from Admission to Week 2 (p=0.02) and to Week 4 (p=0.04). Spearman’s correlational revealed that older age at admission was significantly associated with a higher FIM Gain (r=0.63; p=0.05).

Conclusion: Inpatient rehabilitation was effective for deconditioned patients. Longitudinal assessment indicates WBC, RDW and neutrophil concentrations as potential indicators of rehabilitation improvement. Older age was not a detrimental factor to functional improvement. The results support the feasibility of larger scale study to identify objective criteria to predict inpatient rehabilitation success in these patients.

Keywords: Hospitals, Rehabilitation; Muscle Weakness; Pilot Projects; Biomarkers; Hospitalization; Health Status

Granting Agency/Funding Source: The Academic Health Sciences Centre Alternate Funding Plan Innovation Fund, The Ottawa Hospital Academic Medical Organization


Poster 570

The Role of the Diagnostic Motor Nerve Block in Guiding Novel Spasticity Treatment: An Algorithm

Alexandra W. Harvey BA1, Jonathan Rubenstein BSc1, Dr. Emily M. Krauss MD2, Daniel Vincent MD3, Paul Winston MD4

  • University of British Columbia, Faculty of Medicine, Island Medical Program, Victoria, BC, Canada
  • University of British Columbia, Division of Plastic Surgery, Victoria, BC, Canada
  • University of British Columbia, Department of Anesthesiology, Victoria, BC, Canada
  • University of British Columbia, Division of Physical Medicine and Rehabilitation, Victoria, BC, Canada

Context: Spasticity occurs as a result of injury to the central nervous system and is characterized by intermittent or sustained involuntary muscle contractions. Many patients continue to live with disabling spasticity that negatively affects their health and quality of life. For these patients traditional therapies such as bracing, medications, and botulinum toxin have failed to achieve satisfactory outcomes. Due to common complaints of pain, difficulty with limb positioning, and hygiene concerns there has been an increase in demand for novel adjunctive therapies that can improve patient outcomes. This retrospective case series review addresses the efficacy of using a selective diagnostic motor nerve block (DNB) to help predict patient outcomes and to guide the following appropriate novel therapeutic approaches: selective microfascicular surgery, tenotomy, and cryoneurotomy.

Methods: A multidisciplinary team consisting of a physiatrist, hand surgeon, and an interventional anesthesiologist collaborated on patient assessment. Ultrasound (US)-guided e-stimulation DNB with 1% lidocaine was used as a screening tool to determine the most responsible muscle(s) for the spastic limb as well as whether there could be an increase in maximum active and passive range of motion in the spastic muscle group, or conversely whether fixed contractures existed. Outcomes were collected using the Tardieu Scale, Modified Ashworth Scale (MAS), and video comparisons. Patients were differentiated into one of four treatment streams: surgical microfascicular neurectomy, percutaneous cryoneurotomy, surgical tenotomy, or unlikely to benefit from further procedures.

Results: Twenty-five patients with conditions such as stroke, cerebral palsy, traumatic brain injury, multiple sclerosis, and Parkinson’s disease were assessed. DNB targeted nerves included the musculocutaneous, median, ulnar, tibial and pectoral nerves. Of the 25, 21 had positive responses such as increases in active and passive ROM, decreased clonus, improved Tardieu and MAS scores, as well as better carrying angles, gait, and personal hygiene. The patients were triaged as follows: 8 to surgical microfascicular neurectomy, 15 to cryoneurotomy, 1 to tenotomy, and 3 to unlikely to benefit. Two patients were referred for multiple procedures.

Conclusions: The US and e-stim selective DNB is a useful tool to triage patients into suitable treatment streams and predict patient responses to novel interventional treatments. Video capture was particularly useful for demonstrating meaningful change.

Funding Acknowledgement: No funding was provided for this study.

Key Words: cryotherapy, muscle spasticity, nerve block, neurectomy, tenotomy


Poster 571

Examining near fiber motor unit parameters in 3 muscles using decomposition-based quantitative electromyography (DQEMG)

: Nilufer Nourouzpour1, Syed M Ibrahim1, Matti D Allen1,2,3, Daniel W Stashuk4, Benjamin R Ritsma1,2

Institution

1School of Medicine, Queen’s University, Kingston, ON

2Department of Physical Medicine and Rehabilitation, Queen’s University, Kingston, ON

3School of Kinesiology and Health Studies, Faculty of Health Sciences, Queen’s University, Kingston, ON

4Department of Systems Design Engineering, University of Waterloo, Waterloo, ON

Objective: Decomposition-based quantitative electromyography (DQEMG) is a software program that can provide detailed quantitative data in conjunction with standard needle EMG. That is, in addition to providing traditional motor unit potential (MUP) parameters (e.g. MUP size and complexity) by high-pass filtering, it provides quantification of near fibre motor unit potentials (NF MUPs). The objective of this study was to compare novel DQEMG-derived NF MUP values across a range of muscles, assessing for variations in their quantitative properties. Methods: Intramuscular electromyographic signals were collected via a concentric needle electrode in 12 healthy participants (mean age 25.3±0.6 years, 11 males and 1 female). DQEMG was used to analyze EMG signals collected during volitional sub-maximal contractions in 3 muscles: deltoid (DELT) first dorsal interosseous (FDI), and tibialis anterior (TA). Preliminary data from 3 participants were analyzed using a one-way ANOVA.

Results: Our preliminary data show that there were significant differences in MUP morphologic parameters: i) peak-to-peak voltages between TA (648.97±453.14 mV), DELT (342.14±204.63 mV), and FDI (225.76±169.70 mV) (p < .001) were all significantly different; ii) TA (11.40±3.74 ms) and DELT (10.86±2.56 ms) both had longer durations compared to FDI (225.76±169.70 ms) (p < .001); iii) TA and DELT also showed higher mean MUP complexity (p < .001), Using the DQEMG software also allowed us to analyze and compare novel near fibre motor unit potential parameters. TA showed significantly higher means with regards to size parameters, such as NF MUP Area and NF Duration, compared to DELT and FDI (p < .001). When assessing stability, NF Jiggle and NF Jitter means were significantly lower in TA and DELT, compared to FDI (p < .001).

Conclusion: In this study, we were able to compare novel NF MUP values across three different muscles. Our preliminary results demonstrated significant variability across muscles in several standard MUP and novel NF MUP parameters. The cause of divergence is not yet clear, however may be reflective of inherent differences in neuromuscular properties between muscles. Awareness of these differences is important to note for future investigations which may use DQEMG in the study of clinical populations, perhaps highlighting the need to develop a normative database across various muscles. Future work will include analysis of a larger dataset to further establish the differences across these and other muscles, as well as include data from a broader participant demographic.

Keywords: Motor unit, near fiber, decomposition-based quantitative electromyography

Funding Acknowledgement: No funding received for this project.


Poster 572

Delayed wound healing in lower extremity amputees: An area of ongoing concern.

Amarjit s. Arneja MD, FRCPC1, Harpal Chaudhary MD2, Patrick Gross B.PT3, Arvinder S. Thethi B.Sc4.

Abstract

Introduction: The majority of lower limb amputations occurring in Canada are related to vascular causes, specifically diabetes and peripheral vascular disease. The overall incidence of amputations in Manitoba per 100,000 has been reducing from 51.64 in 1991 to 35.36 in 2016 with 90% of these procedures related to vascular complications. Delayed stump wound healing in lower extremity amputees continues to be a very common complication which leads to increased morbidity and healthcare costs.

Objectives: Due to the paucity in literature concerning time frames and incidence rates of delayed stump wound healing, we performed a retrospective review of our database from 2014 to 2017 with primary end point of healing time; secondary end points including gender, age, community of residence, and other comorbidities.

Methods: A retrospective, database review of our academic tertiary care centre (2014-2017) of 273 individuals with major lower extremity amputations. Delayed wound healing was treated with mechanical, chemical debridement, and antibiotics were prescribed for infected wounds.

Results: Age range of amputees was 25 to 85. Mean age was 58.23, overall 87.60% of patients had dysvascular causes while 12.40% were non-dysvascular. 73.79% were males and there was overall evidence of delayed stump wound healing in 53% of amputees.

Conclusions: Delayed wound healing is a common and concerning complication which warrants further prospective studies to re-visit our treatment approaches and learn about incidence rates.

Key words: Amputees, Delayed, Stump, wound healing.


Poster 573

The role of respiratory training in improving athletic performance among wheelchair athletes—a review.

: Natalie D Daly1, MD and Steven M Dilkas1,2, MD FRCPC

Institution Affiliations:

  1. Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada
  2. West Park Healthcare Centre, Toronto, ON, Canada

Context: For adaptive athletes with spinal cord injuries, decreased respiratory function can limit athletic performance. Respiratory training improves exercise performance in able-bodied subjects across multiple sports.

Objective: In wheelchair athletes, does participation in a respiratory training program compared to no training program lead to improved athletic performance?

Methods: A database search of MEDLINE, EMBASE, CENTRAL, and SPORTDiscus was conducted using MeSH headings ([Breathing Exercises OR Respiratory Muscles] AND [Wheelchairs OR Paraplegia OR Quadriplegia OR Spinal Cord Injuries] AND [Athletes OR Sports] OR Sports for Persons with Disabilities) and key words. References of articles meeting criteria were reviewed. Studies were critically appraised for quality and risk of bias.

Results: The search generated 24 articles, with six meeting criteria: four randomized controlled trials, one prospective cohort study, and one baseline control trial. The studies had (n=71) participants with spinal cord injuries (n=64) or other neurological disorders (n=7) involved in a variety of wheelchair sports. Interventions included respiratory muscle endurance training or inspiratory muscle training, lasting four to ten weeks. Controls included baseline tests, placebo inhaler, or regular training. Outcome measures were pulmonary function testing and sport specific testing. In five trials, respiratory muscle strength had statistically significant improvement in the intervention group. Sport performance showed no significant difference between groups. Limitations included small sample size, lack of randomization or control group, and heterogeneity of the trial populations.

Conclusion: There is preliminary evidence for improving respiratory muscle strength with respiratory training. Statistically significant improvement of wheelchair athlete performance following respiratory training was not identified.

Funding Acknowledgement: No funding was provided for this project.

Key Words: Athletes, Breathing Exercises, Respiratory Muscles, Sports for Persons with Disabilities, Spinal Cord Injuries


Poster 574

Category of abstract submission: Original research

Inter- and intra-rater reliability of near fibre motor unit potential analysis in upper and lower limb muscles – a preliminary normative study

: Syed M Ibrahim1, Nilufer Nourouzpour1, Matti D Allen1,2,3, Daniel W Stashuk4, Benjamin R Ritsma1,2

Institution

1School of Medicine, Queen’s University, Kingston, ON

2Department of Physical Medicine and Rehabilitation, Queen’s University, Kingston, ON

3School of Kinesiology and Health Studies, Faculty of Health Sciences, Queen’s University, Kingston, ON

4Department of Systems Design Engineering, University of Waterloo, Waterloo, ON

Objective: To assess the inter-rater and intra-rater reliability of decomposition-based quantitative electromyography (DQEMG)-derived electrophysiologic data, particularly novel near fibre (NF) motor unit potential (MUP) parameters, in different muscles of young, healthy participants.

Methods: Twelve healthy participants were recruited from the Queen’s University community. Concentric needle electromyography (EMG) was performed by two independent operators in six muscles including the tibialis anterior (TA), deltoid (DELT), and first dorsal interossei (FDI). Retests were performed by one of the operators. Electrophysiologic parameters were extracted using DQEMG, and data were processed independently by two analysts. The EMG parameters included standard MUP measures such as amplitude, duration, area, phases, and turns. Novel NF MUP parameters of interest were derived through high-pass filtering and consisted of NF jiggle, which measures NF MUP shape variability, and NF MUP segment (MS) jitter, which measures NF MUP temporal variability.

Results: For this preliminary analysis, data from three participants (mean age 25.3+/0.6; 2 males, 1 female) were analyzed. At present, 556 motor units from the three participants have been processed (244 TA, 247 DELT, 65 FDI). The TA (NF jiggle ICC = 0.957, NF MS jitter ICC = 0.845) and FDI (NF jiggle ICC = 0.988, NF MS jitter ICC = 0.979) contractions showed excellent inter-rater reliability, whereas DELT contractions had lower inter-rater reliability (NF jiggle ICC = 0.631, NF MS jitter ICC = 0.234). However, both muscles retested by the same operator (TA and DELT) showed excellent intra-rater reliability (Pearson’s correlation > 0.99 for all combinations, P < 0.001).

Conclusion: Our preliminary results show that DQEMG provides high test-retest reproducibility, but levels of inter-rater reliability varied across muscles. The source of this variability is not yet clear but may relate to operator subjectivity or muscle-specific motor unit properties (e.g. the DELT may feature more complex units than in the FDI or TA). As only a small set of data has been processed so far, it is clear further data must be collected and analyzed to better characterize the inter- and intra-rater reliability of these novel forms of EMG assessments.

Funding Acknowledgement: No funding received for this project.

Keywords: Decomposition-based quantitative electromyography (DQEMG), Jiggle, Jitter, Near fibre, Reliability


Poster 575

Quality improvement: Faculty involvement in Physical Medicine & Rehabilitation academic half day at the University of Alberta

Jocelynn Gray MD1, Trevor Lashyn MD1, Zaheera Jassat MD1, Jaime Yu MD FRCPC1

1University of Alberta, Edmonton, AB, Canada

Background: Academic Half Day (AHD) is protected group-based educational time for medical residents known to enhance perceived learning for residents and to improve resident wellness (Zapoustil et al., 2017). The AHD for the Physical Medicine & Rehabilitation (PMR) program at the University of Alberta is primarily resident run, in contrast to other AHDs across Canadian residency programs, such as neurology (Clark, 2004). As faculty involvement with AHD was identified as an inter-program difference with potential detrimental effects, we assessed the perceived importance of and satisfaction with faculty involvement in AHD for both staff and residents within the U of A PMR residency program. Suggestions for improving faculty involvement were requested, with a goal to initiate a Plan-Do-Study-Act (PDSA) cycle based on these recommendations.

Methods: This was a single institution educational quality improvement project; ethics approval was waived. Anonymous online surveys were created in Google Forms (one for residents and one for faculty) and distributed to 33 faculty and 16 residents. Descriptive statistics were used to compare responses.

Results: Response rate was 75% for residents and 30% for faculty, of which 50% had mixed or community-based practices and 50% had hospital or research-based practices. All respondents received AHD notices via e-mail, and most felt this was the most effective method. All respondents considered meeting the Royal College educational objectives as one of the top 3 roles of AHD. The majority of respondents felt the two most important roles of faculty in AHD were to provide relevant clinical information and to clarify areas of confusion for residents. Mean faculty satisfaction with current AHD involvement was 3.0, while mean resident satisfaction with faculty involvement was 2.2 (maximum 5). The most common barrier to increased faculty involvement was conflicting clinical or research duties. Common suggestions for improving faculty involvement were mandatory attendance, assigning faculty to topics, and making requests for faculty to attend further in advance.

Discussion: Responses from both faculty physiatrists and PMR residents indicate that faculty involvement with AHD is valued, but could be improved. We identified that the most common barrier to faculty participation was scheduling conflicts. Many respondents suggested that making requests far in advance may help to circumvent this barrier. Consequently, a PDSA cycle in which requests to faculty are made at the beginning of the academic year is a reasonable next step.

Key Words: Physical and Rehabilitation Medicine, Quality Improvement, Medical Residency, Education


Poster 577

An Interdisciplinary Quality Improvement Project to Decrease Post-operative Complications following Intrathecal Baclofen Pump Implantation

Viet H Vu1,2, Andrea F Townson1,2

1 University of British Columbia, Vancouver, BC, Canada

2 GF Strong Rehabilitation Centre, Vancouver, BC, Canada

Objective: Intrathecal baclofen (ITB) pumps are used in Canada to treat refractory spasticity of spinal or cerebral origin. There are 13 ITB clinics across Canada.

In British Columbia, GF Strong Rehab Centre is the main ITB treatment clinic for people across all health authorities. Surgery to implant the pumps is performed at Vancouver General Hospital. In general, surgical implantation and medical management of these pumps are routine. However, the need for a post-operative management algorithm came to light when a critical incident occurred resulting in respiratory failure following a pump implantation.

Design/Methods: Using the Plan-Do-Study-Act (PDSA) methodology for Quality Improvement, we engaged an interdisciplinary team of surgeons, physicians, nurses, and managers to review post-operative monitoring of ITB pump patients. We developed a SMART Aim statement with a goal of reducing the number of post-operative complications following pump implantations.

Participants: The interdisciplinary team consisted of a Surgical Operations Director, Spine Clinical Nurse Specialist, Spine Service Manager, PACU Manager, Anesthesia Manager, Nursing Patient Care Coordinator, ITB Physiatrist, ITB Nurses, ITB Manager, Neurosurgeons, and Orthopedic Spine Surgeon.

Results: Mapping out the post-operative process revealed a diverse protocol for post-op management. The pumps were being implanted by three different surgeons working in two different departments. After several meetings, we developed an algorithm consisting of an order set and checklist for post-operative management of these patients to be used by all surgeons and departments involved. We also found discrepancies with a flow sheet used to program the ITB pump. The flow sheet was changed to follow the same screen and inputs as those found on the ITB programmer.

A year later, we reviewed the number of post-operative complications and have found that the changes made were effective in detecting complications. There have been no critical incidences since implementing the protocol.

Conclusions:

Multiple care providers working across different departments increases the need for clear communication and standardization of care protocols. Implementing a post-operative checklist and standardizing an ITB pump programming flow sheet reduced the number of post-operative complications following ITB pump implantation.

Below is a description of the post-operative process for all patients requiring either Baclofen pump initiation or replacement.

Priming of the pump 3 hrs stay in PACU Transfer to Neuro ICU/Neuro step down or Spine step down unit once PACU criteria met Downgrading to a lower level of care Discharge of patients

1) Priming of the pump: We will start counting the time of monitoring once the priming of the catheter is complete. That time is calculated by the clinic RN and will be communicated to the PACU staff and charted for easy reference. This usually takes 40-45 minutes, depending on dose and rate.

2) 3 hrs stay in PACU: The 3 hours in PACU will start from the time the priming of the catheter ended and identified by the clinic RN.

3) Transfer to Neuro ICU or Spine step down unit once PACU criteria met: After 3 hours, the transfer out of PACU will be confirmed as per PACU criteria. We recommend that the length of stay in the NICU/Neuro step down or the Spine step down be 5-8 hours. The kind of monitoring to be provided is left to the respective care teams to decide based on their clinical judgement. The goal of the higher level of care is to closely monitor for signs and symptoms of CNS depression.

4) Downgrading to a lower level of care: We recognize that many factors will come into play to influence the length of stay in NICU/Neuro step down or Spine step down. We will rely on the clinical assessment of the care team to determine the appropriateness to transfer the patient to a lower level of care.

5) Discharge of patients: We recommend that all patients be discharged the next day, but clinical judgement still applies and the decision to discharge remains at the discretion of the MRP.


Poster 578

Neuralgic Amyotrophy – a review of the literature

Cale A Templeton1 – ctempleton@qmed.ca

1Queen’s University School of Medicine, Kingston, ON

Abstract

Neuralgic amyotrophy (NA) is a peripheral nervous system disorder typically featuring acute onset severe shoulder region pain, followed 1-2 weeks later by upper limb weakness and muscle wasting/atrophy along with subacute, patchy upper limb hypoesthesia/paresthesia. Traditionally, NA was thought to be relatively rare (1-3 per 100,000 per year). A recent study, with a focus on educating general practitioners regarding NA diagnosis, found a significantly higher incidence rate (1 per 1000 per year). The etiology is not fully understood, but the pathophysiology is most likely immune-mediated; approximately 50% of patients report an antecedent event that may trigger the immune system. Often, patients seek medical attention and receive an alternative diagnosis (e.g. bursitis or muscle strain). Many patients experience persistent pain and functional impairment. The mainstay of acute treatment has been pain control (e.g. NSAIDs and long-acting opioids). A short course of high dose oral corticosteroids during the acute phase (e.g. first 4 weeks) may result in earlier pain reduction, improved strength, and superior functional recovery. Given weakness, patients often develop maladaptive compensatory upper limb movement patterns, which contribute to ongoing pain and impairments. A multidisciplinary rehabilitation approach focusing on scapular coordination and self-management may improve function. This essay serves as a review of NA in the current literature.


Poster 579

Integrating music therapy into neuro-rehabilitation for improved patient experience and outcomes: A QI project

Plamondon, SA. Clinical Associate Professor, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada

Grant, C. Clinical Assistant Professor, Departments of Clinical Neurosciences and Critical Care, University of Calgary, Calgary, AB, Canada

Debert CT. Clinical Assistant professor, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada

Mercier LJ. Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada

Joyce J. Faculty of Science, Department of Clinical Neurosciences, University of Calgary, Canada, AB, Canada

Buchanan J. Certified Music Therapist, JB Music, Calgary, AB, Canada

Robinson S. Certified Music Therapist, JB Music, Calgary, AB, Canada

Dukelow, SP. Associate Professor, Department of Clinical Neuroscience, University of Calgary, Calgary, AB, Canada

Objective: Neurological inpatients have suffered devastating life-changing injuries or illnesses. Many experience depression, pain or anxiety and have limited ability to communicate. Music provides a means of nonverbal expression and connection with caregivers, and can be a powerful motivator in therapies. Strong evidence for the use of music therapy exists in neuro-rehabilitation, but it is not part of standard health professional training or care. We aimed to integrate music therapy into inpatient Neuro and Neurorehab teams by March 2019 to improve patient experience and outcomes.

Methods: A baseline staff survey was conducted March 2018 to identify frequency and reasons for music use, and perceived barriers to using music therapeutically. The gap analysis indicated music was not used frequently. Most staff felt they lacked knowledge of the benefits, access to music therapists, the skills and equipment to use music in practice. Referral and communication processes, patient education and aphasia-friendly feedback tools were developed; staff education in-services, e-blasts, videos and posters were created; books, musical instruments and Ipads were purchased for patient and rehab therapy use. A graduated rollout to maximum 20hours/wk of direct 1:1 or group music therapy began in April 2018. Formal feedback is being collected from patients, families, and multidisciplinary team members pre and post-therapy sessions.

Participants: Adult ICU, acute neurological, acute neuro-rehabilitation, and palliative care patients (7 units) received weekly access to music therapy sessions lasting between 20-75 minutes.

Results: From April 2018-February 2019, there were 1045 patient visits, and 703 family and staff either participating in music therapy or attending education in-services on the 7 inpatient units. In the subgroup of Neuro and Neuro-rehab patients, there were >100 pre-post session patient surveys collected indicating an overall 97% satisfaction rate with music therapy. Ninety-five percent of patients agreed that they were more satisfied with their hospital stay because of music therapy, while 5% were neutral. Mood/anxiety was reported to improve in 88%, motivation improved in 74%, while no one felt worse. Pain was reported to improve in 26%, while 2% felt worse.

Conclusion: The integration of music therapy into the inpatient neurological setting has a strong positive impact on patient experience, and there is evidence to support improved mood, anxiety, motivation, and pain. There were little if any negative outcomes reported by patients, families or staff.


Poster 580

Pediatric rehabilitation practice survey of the Canadian pediatric physiatry group: A new Canadian initiative.

Anna M McCormick1, Hana Alazem1, Kelsey A Crawford2, Jordan Sheriko3, Jan Willem Gorter4, Peter L Rosenbaum4, Camille K Costa5, Beverly Moylan6, Émilie Croteau7, John Andersen8, Matthew Prowse8, Jacqueline Purtzki9, Monique Taillon10, Joe M Watt8

1 University of Ottawa, Children’s Hospital of Eastern Ontario, The Ottawa Hospital Rehabilitation Centre, Ottawa, ON, Canada

2 University of Ottawa, The Ottawa Hospital Rehabilitation Centre, Ottawa, ON, Canada

3 Dalhousie University, IWK Health Centre, Halifax, NS, Canada

4 McMaster University, CanChild Centre for Childhood Disability Research, Hamilton, ON, Canada

5 McGill University, Shriners Hospital for Children, Montreal, QC, Canada

6 University of Toronto, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada

7 Université Laval, Centre Hospitalier Universitaire de Québec, Centre de Réadaptation en Déficience Physique de Québec, Québec, QC, Canada

8 University of Alberta, Glenrose Rehabilitation Hospital, Alberta Health Services, Edmonton, AB, Canada

9 University of British Columbia, BC Children’s Hospital, Vancouver, BC, Canada

10 Dalhousie University, Stan Cassidy Centre for Rehabilitation, Fredericton, NB, Canada

Background: A 2009 US survey published in Physical Medicine & Rehabilitation (PM&R) identified challenges in the field of Pediatric Physiatry, including a geographic concentration of pediatric physiatrists near training centers, lack of training programs and federal funding, and slow research progress [1-4]. There is little understanding of the Canadian profile of Pediatric PM&R.

Objectives: To collect baseline data on physician training, patient populations, practice facilities, and services reported by Canadian Pediatric PM&R specialists. To establish a strong community of pediatric PM&R practice in order to promote a National approach to training, clinical care and academic advancement.

Design: A 12-question survey was completed at the 1st Annual Canadian Pediatric PM&R Meeting in 2017.

Participants: Surveys were completed by 16 physicians from 12 cities in 7 provinces. Participants’ years of experience: nine < 10 yrs, four 10-19 yrs, and three > 20 yrs.

Results: Training & Academic Affiliations:

PM&R residency training was reported by 10

Participants: 3 completed Pediatric PM&R fellowships and 3 Developmental Pediatric fellowships with rehabilitation focus. Academic ranking included 1 full, 3 associate and 7 assistant professors, with 4 holding instructor positions. Two were Medical Directors and 2 Program Directors representing 2 of the 3 pediatric PM&R fellowships available in Canada.

Patient Population: 19 patient diagnoses were reported, including but not limited to Cerebral Palsy, Spina Bifida, and Spinal Cord Injury.

Practice Capture:

15 reported > 50% outpatient focus. The majority reported 10% of time in education, research and/or administration. 9 programs offer inpatient services, the majority in a consultant capacity. 10 report day programs. 6 hospitals admit < 10 patients per year, 5 report 10 designated rehabilitation beds, > 50% have an average length of stay of 30 days and > 50% have standardized admission criterion.

Botulinum toxin injection was the most common treatment modality (14/16 physicians). Other procedures: Intrathecal Baclofen prescription (5/16), phenol injection (2/16) and EMG (3/16).

Conclusion: In Canada, a group of 16 physicians who practice Pediatric PM&R reported variable practices, likely due to a diversity in program funding and associated complementary services. Capturing this diversity may assist in advocating for rehabilitation program needs.

Many participants are early in their careers, highlighting the small yet growing field of Pediatric Rehabilitation Medicine. With a group established, we aim to grow and strengthen this physician community of practice. We will carefully assess our function, identify essential pediatric PM&R roles and adjust focus of training accordingly. This will allow us to address existing gaps and enhance care for children with physical disabilities across the nation. There is a plan to update our survey annually, and to advance a National approach to training, clinical care, academic advancement, research and innovation.


Poster 581

Hypothermia and atrial fibrillation at index presentation of multiple sclerosis in a young male: A case report

Gabrielle Hayduk-Costa1, Ahmed Mokhtar2

1Dalhousie University, Department of Medicine, Division of Physical Medicine & Rehabilitation, Halifax, NS, Canada

2Dalhousie University, Department of Medicine, Division of Cardiology, Halifax, NS, Canada

Context: Here we present an unusual presentation of multiple sclerosis, a condition commonly managed by Physiatrists.

A 24-year-old man presented to the emergency department with chills, vertigo, nausea and malaise. He was found to be hypothermic (temperature was 34.8C) and had an irregularly irregular heart rate confirmed to be rapid atrial fibrillation on an electrocardiogram. Further assessment revealed a four-week history of migrating paresthesias and right-sided weakness. Magnetic resonance imaging of his brain revealed several T2 hyperintensities, including a large lesion in his left medulla. He was discharged home with a new diagnosis of demyelinating disorder, likely multiple sclerosis (MS). Cerebrospinal fluid was later reported to be positive for oligoclonal banding. The patient subsequently developed progressive symptoms, and there was radiological evidence of new demyelinating lesions one month later. On outpatient review by neurology, given these findings, he was formally diagnosed with relapsing-remitting MS.

Findings: Although MS can have a heterogeneous presentation, cardiac arrhythmia as the first manifestation of MS is extremely rare, with only three cases reported in the literature in female patients exclusively. Similarly, hypothermia in MS is rare and is generally associated with longstanding disease and decreased level of consciousness. Hence, this patient’s index clinical presentation with concurrent atrial fibrillation and hypothermia is extremely unusual. Although hypothermia itself can certainly contribute to cardiac arrhythmias, this is more commonly associated with ventricular arrhythmias and at lower core temperatures. It is therefore reasonable to postulate that these were independent entities.

Conclusion/Clinical Relevance: This case contributes to the literature in reporting two rare clinical presentations in MS: hypothermia and atrial fibrillation. The patient’s case is particularly unusual because he was male, his symptoms were of brief duration, and the two unusual presenting phenomena occurred together.

Funding Acknowledgement: None

Keywords: atrial fibrillation; hypothermia; multiple sclerosis; multiple sclerosis, relapsing-remitting


Poster 582 – First Place

To Baker and beyond – an unusual case of posterior knee pain and flexion restriction, a case report.

Jennifer K McDonald1, Andrew M Round2, Renata J Frankovich3, Joel M Werier4

1University of Ottawa, Faculty of Medicine, Department of Medicine, Division of Physical Medicine and Rehabilitation, Ottawa, ON, Canada

2University of Ottawa, Faculty of Medicine, Department of Medicine, Division of Physical Medicine and Rehabilitation, Ottawa, ON, Canada

3University of Ottawa, Faculty of Medicine, Department of Family Medicine, Sport and Exercise Medicine, Ottawa, ON, Canada

4University of Ottawa, Faculty of Medicine, Department of Surgery, Division of Orthopedic Surgery, Ottawa, ON, Canada

Context: Dr. William Morrant Baker first described 8 cases of periarticular cysts in the popliteal fossa in 1877. Baker’s (or popliteal) cysts are very common in the sport medicine population. The typical popliteal cyst is an enlargement of the synovial-lined gastrocnemius-semimembranosus bursa, which communicates by a small opening with the posterior capsule of the knee. When symptomatic, they often present with posterior knee pain and restricted end-range knee flexion. Baker’s cysts must be differentiated from less common causes of popliteal pain and knee flexion restriction. This includes synovial osteochondromatosis, osteochondroma, a loose osteochondral body and synovial sarcoma.

Case Summary: A 37 yo healthy, active male presented with insidious onset mild posterior right knee pain and progressive restriction in knee flexion over a 5-10 year period with no clear inciting event. On exam, there was obvious fullness in the popliteal fossa on inspection, moderate tenderness to palpation in this region and a mechanical block restricting the last 10 degrees of knee flexion. X-ray revealed a large cloudy calcification in the popliteal fossa, presumed to be an osteochondral body, but with no clear donor site. Bedside ultrasound was carried out, which quickly ruled out the presence of a baker’s cyst and confirmed the hyperechoic calcified structure deep to the gastrocnemius heads and popliteal vessels. An urgent MRI of the knee was arranged to rule out a malignant process. The MRI was suggestive of an osteochondral loose body within a cyst adjacent to the posterior knee capsule. An ultrasound-guided biopsy confirmed a benign process. Surgical resection of the mass was arranged. The large 6 x 4 cm osteochondral loose body was identified within a synovial outpouching at the posterior aspect of the knee joint. It was removed without complication with full return of knee ROM.

Clinical Relevance: We present a rare case of a popliteal mass causing posterior knee pain and knee flexion restriction. In addition to a Baker’s cyst, a large osteochondral body should be considered on the differential. Benign and malignant tumours can also present in a similar fashion. Symptomatic popliteal cysts are commonly treated with an intra-articular knee injection. This case outlines the importance of diagnostic imaging prior to consideration of any interventional procedures. Bedside ultrasound complemented the clinical assessment to expedite formal diagnostic imaging and ensure accurate diagnosis.

Funding acknowledgement: Not funded

Keywords: Knee pain, popliteal cyst, joint loose bodies, osteochondromatosis, synovial sarcoma


Poster 583 – Second Place Resident Contest

Predicting Morbidity in Lower Extremity Amputees Based on Discharge 2-Minute Walk Test Performance: A Cross Sectional Study

Lindsey E. Woodrow1,2, Karen E. Litman2, Sharon E. Grad1,2

  1. McMaster University, Hamilton, ON, Canada; 2. Hamilton Health Sciences, Hamilton, ON, Canada

Objective: Walk tests are used as surrogate markers for aerobic capacity and as a tool to assess functional capacity in a variety of medical populations, including lower extremity amputees (LEAs). The 2-minute walk test (2MWT) is currently used in the Hamilton Health Sciences Amputee Rehabilitation Program (HHS-ARP), with results recorded at discharge. Although a distance of at least 113 metres on 2MWT is required for patients to likely have community ambulation potential, many patients – depending on their reason for amputation, level of amputation and comorbidities – may never achieve that ambulation potential. However, it may be possible that a lower standard on 2MWT predicts reduced mortality in LEAs and can be used to identify potential survivors. Given the poor prognosis associated with dysvascular amputations, a tool to predict which patients survive would have valuable clinical applications.

Design: Retrospective chart review.

Setting: Amputee rehabilitation unit (combined inpatient and outpatient program) at tertiary rehabilitation hospital in Hamilton, ON.

Participants: LEAs enrolled in the HHS-ARP between February 2014 and February 2018 (n = 260).

Interventions: Standard LEA rehabilitation program, including prosthetic fitting, edema management, gait training, general strengthening and conditioning, prevention of contractures and other complications, and ADL training. 2MWT was performed by participants at discharge.

Outcome Measures: Post-discharge mortality, admissions and macrovascular events (heart attack, stroke, revascularization surgery, amputation).

Results: 2MWT at discharge is significantly correlated with mortality (p < 0.05) and post-discharge admissions (p < 0.05), but not post-discharge macrovascular events. We are currently developing a statistical model to determine a 2MWT distance cut-off that predicts reduced mortality.

Conclusion: 2MWT is a quick, inexpensive and well-tolerated test that is widely administered at discharge in LEA rehabilitation programs. Although based solely on the HHS-ARP population, results of this study allow us to identify survivors who would benefit from more aggressive/invasive medical interventions or more advanced components for their prostheses. Additionally, this data will aid in goal setting during rehabilitation and promoting ongoing physical activity after discharge from rehabilitation in LEAs.

Funding Acknowledgement: None

Keywords: Amputees, Lower Extremity, Mortality, Walking Speed, Walk Test

Poster 584 accepted after deadline.

Exercise rehabilitation and non-pharmacologic management of postural orthostatic tachycardia syndrome (POTS)

Matti D. Allen1

1Department of Physical Medicine and Rehabilitation, School of Medicine, Faculty of Health Sciences, Queen’s University, Kingston, Ontario, Canada

Postural orthostatic tachycardia syndrome (POTS) is a condition featuring excessive tachycardia without hypotension experienced in orthostasis (i.e. sitting up or standing). The causes of POTS have not been completely elucidated, but factors similar to profound deconditioning are often present, including poor cardiac function, hypovolemia and decreased venous return. It can be associated with presyncope, weakness, anxiety, difficulty thinking and headache, amongst other symptoms. It is debilitating, limiting an individual’s ability to work, attend school or engage in physical activity. Pharmacologic management options (e.g. midodrine, beta blockers) are given with the intention of improving symptoms, but they often have very limited benefit and are accompanied by intolerable adverse effects. Multiple non-pharmacologic management options are recommended. These are designed to address the underlying cause of symptoms. Of these options, exercise training is safe and appears to be the most effective at improving symptoms, physical activity tolerance and quality of life. In fact, exercise rehabilitation may be curative in most people with POTS who can complete a training regimen. At present, few studies have explored the effects of exercise training. Future investigations should address the clinically relevant limitations in the literature to allow for optimal strategies in the rehabilitation of people with POTS.

Keywords: cardiovascular rehabilitation, orthostatic intolerance, exercise therapy

Funding: No funding was received for the creation of this essay.


Poster 585

Mobility levels of Adults with Spina Bifida: A Scoping Review

Cristina A. Batey1, MD MSc

Emma A. Bateman1,2, MD

Caitlin Cassidy, FRCPC MD

1Department of Physical Medicine & Rehabilitation, Schulich School of Medicine & Denstiry, Western University, London, Ontario, Canada

2Parkwood Institute, St. Joseph’s Health Care, London, Ontario, Canada

Context – Maintenance of ambulation among adults with spina bifida is often an important focus of the transdisciplinary rehabilitation management of this population. With aging, however, the mobility of these patients often declines, though the precise reasons for this decline is unclear.

Objective – To evaluate the factors associated with mobility levels in adults with spina bifida and to gain a better understanding of what factors, if any, contribute to a change of mobility in adulthood.

Design – Scoping review.

Methods – Literature searches were performed in MEDLINE, EMBASE, PsychINFO, Cochrane Database of Systematic Reviews, CINAHL, and open grey literature using combinations of keywords and MeSH Terms relevant to spina bifida and mobility. Searches were limited to studies in English and humans. Studies focused on mobility outcomes in adults (age > 18) with spina bifida, excluding the pediatric population and interventional trials. Articles were reviewed by two independent reviewers, and data was extracted using a standardized form.

Results – The scoping review yielded 812 records (318 duplicates). 60 full text records were reviewed; 22 met eligibility for inclusion. These studies evaluated the influence of multiple factors on mobility in adults with spina bifida. Non-modifiable risk factors included level of dysraphism, hydrocephalus and shunt malfunction; modifiable risk factors included development of pressure sores, hip flexion contracture >10o, and tethered cord syndrome.

Conclusion – Loss of mobility in adulthood is multifactorial in persons with spina bifida. Although loss of mobility is common, it is not inevitable. Importantly, many of the factors that may lead to loss of mobility are preventable or potentially treatable.


Poster 586 First Place

Time is function: Improving access to inpatient stroke rehabilitation at Holy Family Hospital

Category: QI

Evan H. Kwong1-4, Maria Cooke5,6, Sutinder Kaba2, Claudia Friess2,3, Socorro Laurel2, Milana Smith2, Chelsey Funk2, Beena Parappilly3, Mirjana Besir3, Kelly Sharp4, Allison Chiu4, Selina Wong4

Affiliations

1Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC, Canada

2Holy Family Hospital, Providence Health Care, Vancouver, BC, Canada

3St. Paul’s Hospital, Providence Health Care, Vancouver, BC, Canada

4Vancouver Coastal Health, Vancouver, BC, Canada

5BC Patient Safety and Quality Council Summer Student, Vancouver, BC, Canada

6Bachelor of Commerce Student, University of British Columbia Sauder School of Business, Vancouver, BC, Canada

Body of abstract

Background: At Providence Health Care (PHC) in Vancouver, BC, St. Paul’s Hospital (SPH) cohorts patients who have sustained a stroke to the medical unit. Patients may then be transferred to Holy Family Hospital (HFH) for further inpatient stroke rehabilitation. Earlier stroke rehabilitation improves functional outcomes. At PHC (2017/18 Quarters 1-3), the median time between acute hospital admission to inpatient rehabilitation hospital admission was 26 days. Baseline data from the SPH medical unit (June 2017 to July 2018) was 24.1 days (mean) or 17.5 days (median). The regional rehabilitation scorecard target is a median of 14 days or less.

Objectives: By July 2019, patients with a stroke at SPH who would benefit from further inpatient rehabilitation will be transferred to HFH within 14 days of their acute admission.

Design/Methods: This quality improvement (QI) project was started in June 2018. The model of improvement and various tools were used including process mapping, liberating structures, and driver diagrams. The primary outcome measure was the time from SPH admission to HFH admission. Control charts and run charts were used to analyze outcome, process, and balancing measures. The first Plan-Do-Study-Act (PDSA) in August 2018 consisted of 3 changes focused on decreasing the time to submit the HFH rehabilitation application form: (a) physician order by physiatrist to signify readiness for submitting the application; (b) optimized HFH rehabilitation application form; and (c) improved data monitoring. PDSA cycle #2 is pending for June 2019 and focused the physiatry consultation process.

Participants: Multidisciplinary team members at both SPH and HFH were engaged throughout this project. This collaborative team included operational managers, a patient partner, administrative staff, occupational therapists, physiotherapists, speech language pathologists, social workers, nurses, and physicians.
Results: Data up to May 2019 has been collected thus far. The time between SPH to HFH admission decreased from 24.1 to 20.2 days (mean), or from 17.5 to 14 days (median). The process measure of the physician order occurred only 30% of the time. The balancing measure, the length of stay at HFH for patients admitted from SPH, decreased from 42.1 to 19.4 days (mean), or from 38.5 to 18 days (median). PDSA cycle #2 is focused on the physiatry consultation process at SPH. Currently, the time it takes for physiatry to be consulted is 4.8 days (mean), or 4 days (median), following the acute hospital admission.
Conclusion: The model of improvement was used with various tools to engage a multidisciplinary team at SPH and HFH in a collaborative manner, leading to system-level change initiatives. These change initiatives can be used to decrease the time it takes for a patient at SPH to be transferred to HFH for intensive inpatient stroke rehabilitation, aiming towards the regional rehabilitation scorecard target of 14 days or less. A second PDSA cycle as well as spread and sustainability plans are currently under development. Stroke rehabilitation outcomes will also need to be considered in future analyses. This project was supported by the Specialist Services Committee Physician-Led Quality Improvement Initiative (EHK) and the BC Patient Safety and Quality Council 2018 Summer Student Internship (MC).

MEDLINE keyword

1 Stroke Rehabilitation

2 Quality Improvement

3 Referral and Consultation


Poster 587

Movement Medicine: A Systematic Review on the Effect of Early Aerobic Exercise Initiation on Symptom Recovery Following Concussion

Ainsley Kempenaar MD, Mark Bayley MD

University of Toronto, Department of Medicine, University Health Network – Toronto Rehabilitation Institute, Toronto, ON, Canada

Context: The concussion management paradigm has recently shifted away from rest until symptom resolution towards more active rehabilitation approaches. While there exists mounting evidence for aerobic exercise as a promising treatment option for individuals experiencing persistent post-concussion symptoms beyond four weeks, less is known about the utility of such interventions in the earlier acute and subacute stages following concussion.

Objective: To determine whether initiating structured aerobic exercise soon after concussion (within the first two weeks) affects symptom recovery or risk of developing persistent post-concussion symptoms compared to standard care or minimally active control.

Methods: A systematic literature search was performed using MEDLINE, EMBASE, PsycINFO and CENTRAL databases. A combination of subject headings and keywords were used including: (brain concussion, post-concussion syndrome, mild traumatic brain injury) AND (exercise, exercise therapy, physical activity, kinesiotherapy). Results were limited to Randomized Controlled Trials (RCTs) and the English language. Reference lists were screened to optimize retrieval of studies meeting eligibility criteria. Selected articles were evaluated for quality and risk of bias.

Results: The search generated 112 unique abstracts, of which 5 met inclusion criteria. Sample sizes ranged from 16 to 103 participants and subjects spanned children to young adults. Four studies examined only athletes with sport-related concussions. All included studies were randomized trials with diverse intervention and control groups. Aerobic exercise interventions were initiated as soon as one day post-injury. Of the four studies that were able to analyze between-group differences, one showed significantly faster recovery in the early aerobic exercise group compared to control, while three showed no significant difference. Two studies demonstrated a trend toward faster initial symptom resolution in the early exercise group compared to control.

Conclusion: There is preliminary RCT evidence to suggest that aerobic exercise initiated in the early post-concussion period does not exacerbate symptoms or prolong recovery time, and may potentially hasten recovery. Larger RCTs with more diverse populations are required to improve generalizability and better define the optimal exercise parameters to facilitate symptom recovery.

Keywords: Brain Concussion, Exercise, Post-concussion syndrome


Poster 589

Idiopathic Respiratory Synkinesis: A Case Series

Daniel Chan Chun Kong1,2, Ariel Breiner2,5, MD, FRCPC & Gerald Wolff1,2, MD, FRCPC

1University of Ottawa Medical School, Ottawa, ON, Canada; 2Department of Medicine, Division of Physical Medicine and Rehabilitation, The Ottawa Hospital Rehabilitation Center, Ottawa, ON, Canada; 3Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, ON, Canada.

Background: “Breathing arm” or respiratory synkinesis (RS) is a syndrome in which there is synchronous contraction of an upper limb muscle or muscles with each inspiration. This phenomenon can occur after trauma to the brachial plexus or cervical roots, resulting in aberrant connections with the phrenic nerve. Idiopathic causes of RS are extremely rare and have only been reported once before.

Objective: Present two cases of spontaneous RS of unknown etiology.

Design: Case Series

Participants/Results:

Case 1: 52-year-old female with a 1-year history of left sided RS involving the pectoralis major muscle (PMM). This was associated with left anterior chest pain. The pain gradually progressed over time impairing her ability to work, and the pain was only relieved with Botox injections into the PMM. There was no history of trauma, neuralgia amyotrophy, viral illness preceding her symptoms, or other neurological diseases. Physical exam showed obvious contractions of the left PMM with each inspiration. There was normal muscle bulk and tone with 5/5 strength for all upper limb muscles. Upper extremity reflexes were 1+ throughout. Hoffman’s sign was negative and sensory exam was normal. There was no Horner’s syndrome and no dystonia. Ultrasound showed contraction of the sternal and clavicular heads of the PMM that coincided with inspiration. EMG of the left PMM showed rhythmic contraction of normal motor units, but no other abnormalities. EMG studies of the left triceps, flexor digitorum indices, and mid deltoid were normal.

Case 2: 23-year-old female with a 3-year history of painless right sided RS involving the PMM. This did not interfere with her daily routine. This was first noted by an observer when she was wearing a tank top and was breathing heavily after completing a run. She did not have any upper extremity weakness, numbness or paresthesia, and did not pursue any treatment for the RS. There was no prior history trauma, viral illness preceding her symptoms, and she had no family history of any neuromuscular disorders. Neurologic examination was unremarkable with absent Horner’s, 5/5 strength, 2+ reflexes, and normal sensation throughout. MRI of her right brachial plexus and cervical and thoracic spinal cord were normal. EMG of the right PMM showed rhythmic contraction of normal motor units with each inspiration but was otherwise normal.

Conclusion: These represent the first cases of RS where the patients present with no other neurologic deficits. Although rare, physicians should recognize idiopathic RS as a differential diagnosis for this syndrome.

Keywords: Brachial Plexus Neuropathies, Nerve Regeneration, Respiration, Phrenic Nerve, Electromyography


Poster 590 essay contest

Narrative Practice within Physical Medicine and Rehabilitation

By Caroline Dance

It’s common in physiatric practice to encounter patients who have experienced profound loss. This loss may have far reaching impact – affecting a person’s functional abilities, relationships, quality of life and sense of self. However, these challenges may not be readily apparent when meeting patients in clinical scenarios that are often constrained by time and outside of the patient’s natural context. Through narrative practice – in which care providers ask patients about their stories, listen mindfully and engage authentically with their patients – physicians may learn about deeper issues, create informed plans and develop a supportive therapeutic relationship. This is of significant benefit in the area of physiatry, where complex external and social factors may not be immediately apparent but play an important role in the process of rehabilitation. Additionally, care providers in the field of physiatry may experience high levels of empathy fatigue and burnout due to their own experiences of loss within practice. Through engaging in reading, writing and other reflective exercises, physicians may be able to find meaning in their experiences and remain empathetic in the face of loss.