PM&R Vol. 6, Iss. 8S2, 2014 S107

NEUROLOGICAL REHABILITATION

No. 54 A Rare Reversible Case of Anton Syndrome andthe Role of Amantadine in Management: A Case Report.Bamidele Oyebamiji Adeyemo; Jordan Howard.

Disclosures: None. Setting: Inpatient neurology service. Patient: A76-year-old femalewith visual anosognosia.Case Description: 76-year-oldfemale with history of alcohol abuse presented to the emergency room withaltered mental status. CT revealed left occipital hemorrhage. Early neuro-logical assessments were remarkable for behavioral abnormalities includingconfusion, limited orientation, irritability, agitation, and removal of intra-venous access lines. Given suspicion of encephalopathy, EEG was performedand ruled out seizure activity. Altered mental status resolved during course,however, patient continued to perform poorly during physical therapysessions. During course patient was noted to be unable to consistently trackvisually, required frequent cues with tasks identifying locations of objectsand rooms, reported visual hallucinations of seeing animals or demonstrateability to draw, count, or name objects. It became clear during the hospitalstay the patient was cortically blind and even demonstrated no blink toocular threat bilaterally. Patient adamantly denied blindness and confabu-lated frequently using auditory cues to guess her answers. She was diag-nosed with cortical blindness and visual anosognosia (“Anton’s syndrome”)based on her deficits. Results: Patient was subsequently initiated onamantadine 100 mg bid to assist with focus during physical therapy.Interestingly she also improved in her visual deficits and blink to threateventually resulting in resolution of blindness and restoration of her visionto baseline acuity in 5 days. Though she was also supplemented withvitamin B12 prophylactically during course it is unlikely to explain hersymptoms given her normal levels throughout her hospitalization. She wassuccessfully rehabilitated with physical therapy to an independent state.Discussion: Though her description did not classically fit the originalAnton syndrome, this patient presented with a rare case of visual anosog-nosia in setting of hemorrhagic stroke. To our knowledge this is the firstcase demonstrated to be reversible with a neurostimulant agent such asamantadine.

No. 55 Effectiveness and Safety of Non-PharmacologicalInterventions for Spasticity in Multiple Sclerosis: ASystematic Review.Bhasker Amatya; Fary Khan, MBBS MD FAFRM (RACP);Loredana La Mantia Marina Demetrios, MBBS FAFRM (RACP);Derick T. Wade, MN MN BCHIR FRCP MD.

Disclosure: None. Objectives: To investigate the effectiveness andsafety of non-pharmacological interventions for the management of spasticityin people with MS in improving patient outcomes. Design: Systematicreview. Settings: Inpatient and ambulatory rehabilitation settings. Meth-ods: A comprehensive literature search was performed using the CochraneMS Group Trials Register which among other sources contains CochraneCentral, Medline, Embase, Cinahl, Lilacs Pedro in June 2012. All rando-mised controlled trials (RCTs) that reported non-pharmacological inter-vention/s for treatment of spasticity in adults with MS and compared themwith some form of control intervention were included. Four review authorsindependently selected the studies, extracted data, and assessed themethodological quality of the studies for best-evidence synthesis.Results: Nine RCTs (n ¼ 341 participants 301 included in analyses)investigated various types and intensities of non-pharmacological inter-ventions for treating spasticity in adults with MS. All studies scored “low”on the methodological quality assessment implying high risk of bias. Theincluded trials were heterogeneous in terms of: type of intervention,outcome measures, and study quality. Hence quantitative synthesis was notpossible and a qualitative synthesis of “best evidence” was provided. Thereis “low level” evidence for: addition of active physiotherapy after BONTinjection in reducing spasticity up to 12 weeks; “intermittent theta burst

stimulation” as a single intervention or in combination with exercisetherapy reduced spasticity after 2 weeks of treatment; short-term benefits of“repetitive transcranial magnetic stimulation” and “pulsing magnetic fields”for improved spasticity. There was no evidence of benefit to support theuse of transcutaneous electrical nerve stimulation, sports climbing, andvibration therapy for treating spasticity. Conclusions: A range of non-pharmacological interventions are used for the treatment of spasticity inpeople with MS. More robust trials are needed to build evidence for theseinterventions.

No. 57 Rehabilitation Goals and Its Relation to the UKVersion of the Functional Assessment Measure: AnExploratory Study.Sunil J. Ankolekar; Dr Zacchaeus Falope.

Objective: To review neurological rehabilitation goals and study theirrelation to the UK version of the functional assessment measure (UK FIMFAM). Design: All goals were assessed on a particular day and the numberof goals per patient and the therapy group leading on each goal recorded.Finally every goal was recorded against one of the 36 UK FIM FAM items.Setting: Regional neurological rehabilitation unit. Participants: Neuro-logical rehabilitation inpatients. Interventions: Not applicable. MainOutcome Measure: Rehabilitation goals and UK FIM FAM. Level ofEvidence: Level 3. Results: A total of 65 (n¼65) goals were identifiedfrom 25 patients. The number of goals set for each patient varied from 1 to8. Around 41% goals were occupational therapy led, 38% physiotherapyled, 11% speech and language therapy led, and 5% by nurses andpsychology. When assessed against the UK FIM FAM, most goals werearound locomotion, stairs, and transfers. Other goals included meal prep-aration, eating, speech, orientation, and expression. There were no goalsprimarily for concentration, memory, problem solving, leisure activities,emotional status, and social interaction. Conclusion: Most goals wererelated to physical tasks. Goals for extended item like work, financialmanagement, shopping, and laundry were not set. Goal setting is animportant aspect of rehabilitation and an ideal goal should be specific,measurable, achievable, realistic, and time orientated (SMART). Patientsachieve better outcomes when the team works together towards the samegoal. Most clinicians find goal setting challenging, however this doesimprove with experience. The UK FIM FAM covers 36 items and can act asa template for setting goals.

No. 58 Inappropriately Delayed Discharges Froma Regional Specialist Inpatient NeurologicalRehabilitation Unit: Prospective Study.Sunil J. Ankolekar; Prof Abdel Magid Bakheit.

Objective: An important aspect of the successful management of health-care resources is to prevent unnecessary hospitalisation and to reduce thelength of patients’ hospital stay. The study of the utilisation of hospital bedsin specialist neurological rehabilitation units has received little attention. Theprimary aim of this study is to establish the frequency and reasons of theinappropriately delayed discharges from a neurological rehabilitation unit.Design: Prospective study over six-months. Setting: Regional specialistinpatient neurological rehabilitation unit. Participants: Inpatients ata regional specialist neurological rehabilitation unit. Interventions: Notapplicable. Main Outcome Measures: Shortly after hospitalisationa multidisciplinary rehabilitation team in conjunction with patients and theircarers identified goals to enable the patient’s discharge. Patient’s stay inhospital after the goals have been achieved was considered inappropriatelydelayed discharges. Level of Evidence: Level 2. Results: Fifty-one of 67patients admitted to the unit were included in the study. Only 19 (37.3%) ofthem were discharged from hospital on time. The discharge of 32 (62.7%)patients was delayed, and the delay was inappropriate in 18 (56.2%) ofthe 32 cases. The discharge from hospital was inappropriately delayed byan average of 51 days in nearly a third of all patients who were admittedduring the study period resulting in loss of 1015 hospital bed-days.

S108 PRESENTATIONS

Conclusions: The reason for inappropriately delayed discharges was thelate provision of home care packages, equipment, home adaptationsand transfer to institutional care by social services. This occurred despitethe fact that the discharge process was started early and was supportedby discharge coordinators who liaised early with social services and moni-tored the discharge process. Strategies to reduce the numbers of inappro-priately delayed discharges should focus on more integration of health andsocial care.

No. 59 Ischemic Stroke After Coronary-Artery BypassGrafting Operation: A Case Report.Koray Aydemir; Serdar Kesikburun, MD; Umut Guzelkucuk;Yasin Demir (Gulhane Military Medical Academy, Departmentof Physical Medicine and Rehabilitation, Turkish Armed ForcesRehabilitation Center, Ankara, Turkey).

Disclosure: None. Setting: Tertiary care university hospital. Patient: A67-year-old female with left hemiplegia. Case Description: The patientpresented to our clinic with left hemiplegia. 8 days prior to the admissionshe had a coronary-artery bypass grafting (CABG) operation. On the post-operative first day after extubation motor deficit on the left side wasexamined. A right frontoparietal cerebral ischemic infarctus was detected.On physical examination, cognitive status was moderate, cooperation wasestablished, left upper extremity was flaccid Brunnstrom stage 1, lowerextremity was Brunnstrom stage 4. Sitting balance was preserved butstanding balance was poor; she was unable to mobilize independently.Assessments/Results: She had a history of diabetes mellitus andhypertension. Premorbid neurological and cognitive status was understoodto be mild. Multiple chronic lacunar infarcts and gliotic changes were seenin preoperative brain MRI. Preoperatively a 90% occlusion of major coro-nary arteries, pathologic Q waves and a 60% left ventricle ejection fractionwere detected. Left hemithorax pleural effusion which was drained bya chest tube was the other major postoperative complication. We obtainedimprovements by ongoing neurological and cardiac rehabilitation processes.Discussion: Stroke is a major adverse neurologic outcome after cardiacsurgery. Intraoperative decrease in blood pressure may lead to the stroke inour patient. Mild neurological deficits before surgery may be a marker forcerebrovascular disease and increased risk for patients undergoing CABG.Conclusion: A case of ischemic stroke after CABG is herewith presented.Clinicians should be aware of neurologic complications after cardiacsurgery. Identification of neurologic deficits is important in order to planand initiate an appropriate rehabilitation program in a timely manner.Reprinted with permission.

No. 60 Falling and Fall-Related Factors Among Parkinson’sDisease Patients.Koray Aydemir; Erhan Ali Ozturk, MD; Ibrahim Gundogdu;Fatma Aytul Cakci (Diskapi Education and ResearchHospital, Department of Physical Therapy and Rehabilitation,Ankara, Turkey).

Disclosure: None. Objective: To investigate the relationship betweenpotential risk factors for falling and the number of falls in the previous yearand to determine the efficacy of performance based tests among Parkinson’sdisease (PD). Design: Cross-sectional cohort study. Setting: Tertiary careuniversity hospital. Participants: 114 ambulatory non-demented subjectswith PD were included. Interventions: Not applicable. Main OutcomeMeasures: Previous history of falls, performance based balance and gaittests were used for evaluating the risk for falling. Reported recurrent fallsduring the previous year were recorded. Functional reaching test (FRT),timed stand-up and sit test (TSST), timed up and go test (TUGT), 4 meterwalking time, and Berg balance survey (BBS) were used. The relationshipbetween potential risk factors for falling and the number of previous fallswere assessed by using univariate and multivariate linear regression analysis.Level of Evidence: Level 3. Results: 54 male and 60 female wereinvestigated; mean age was 66.52�10.34 years; mean duration of thedisease was 61.55�56.13 months. Average Hoehn & Yahr (H&Y) scale was

1.86�0.76 during ‘on’ period. Mean number of falls in previous year was3.74þ8.75. Univariate linear regression analysis showed a significant rela-tionship between the increased number of falls and the duration of thedisease, H&Y stage, unified PD rating scale part II and III scores, FRT, TSST,TUGT, walking speed, and the decrease of BBS. Multivariate linear regres-sion analysis showed a significant relationship between the number of fallsand FRT (0.399 (0.111); p<0.001) and BBS (-0.865 (0.082); p<0.001).Conclusions: These findings suggest that easily measured features can beused prospectively for defining the risk for falling in PD. Reprinted withpermission.

No. 61 Falls Among Parkinson’s Disease Patients.Erhan Ali Ozturk, MD1; Ibrahim Gundogdu, MD1;Koray Aydemir, MD2; Fatma Aytul Cakci, MD1 (1DiskapiEducation and Research Hospital, Department of PhysicalTherapy and Rehabilitation, Ankara, Turkey); (2Gulhane Mili-tary Medical Academy, Department of Physical Medicine andRehabilitation, Ankara, Turkey).

Disclosure: None. Objective: To investigate the potential riskfactors for falling and the frequency of falls among Parkinson’s Disease(PD). Design: Cross-sectional study. Setting: Tertiary care universityhospital. Participants: 114 ambulatory non-demented subjects withPD were included. Interventions: Not applicable. Main OutcomeMeasures: Reported recurrent falls (2 or more) during the previous yearwere described as falls. The relationship between potential risk factorsfor falling and the reported recurrent falls were assessed by single andmultiple logistic regression models. Level of Evidence: Level 2.Results: 54 male and 60 female were investigated; mean age was66.52�10.34 years; mean duration of the disease was 61.55�56.13months. 40 patients (35.1%) reported recurrent falls during the previousyear. Single logistic regression model showed that duration of the disease,daily levodopa dosage, Hoehn & Yahr stage, unified PD rating scale(UPDRS) part II and III scores, chronic low back pain presence, and serumvitamin D levels were significantly related with falling. When multiplelogistic regression model is used; chronic low back pain (odds ratio [OR]:4.99 95% confidence interval [CI]: 1.39-19.15 p¼0.019) and serumvitamin D levels (OR: 1.12 95% CI: 1.00-1.25 p¼0.044) were significantlyrelated with falling. Conclusions: These results imply that chronic lowback pain and serum vitamin D levels are related with falls in PD.Longitudinal studies are warranted to gain an increased understanding ofpredictors for falling in PD. Reprinted with permission.

No. 62 Muscular Deficit in Childhood: When the Falls StopBeing Accidental.Idoya Barca; Concepcion Cuenca; Rocio Vacas; Isabel Flores.

Location: Out-patient University Hospital. Patient: 16-year-old femalepatient. No allergies or risk factors. Scoliosis during infancy corrected byuse of corset. Various operation “on the feet” over a period of 10 years.The last in October of 2012: osteotomia of the 5o mt bilateral. No treatment.No previous family history. Case Description: Referred by orthopedicdepartment due to several falls and pain in the lumbar region with severalyears of evolution. Summer 2012: fracture of sacra. October 2013: sprainedankle. Since 2006 has had regular revisions in the neuromuscular unitfor fatigue, weakness, and atrophy muscular distal MMII started in 2001.Suspicions of polinueropatia. Evaluation: motor system. Muscle balanceMMII: psoas and quadriceps 4/5. Calf muscles 4þ/5. Front of tibiaand extensors toes mid 3/5 feet. Distal atrophy, muscular tone and rot(BTR): conserved symmetrical stable march thallus no obtained ball offoot with difficulty monopodal support: 2sg. Romberg negative. Others:bilateral lumbar para vertebral pain, no apofisalgias, hyperlordosis, rightdorsal hump. Not dismetrías. Complementary tests: xray, EMG and biopsymuscular. Results: Disferlina deficit: muscular dystrophy recessiveautosomica inheritance caused by a mutation in gene of the disferlinaprotein in membrane of muscular fiber involved in repair of membraneand regeneration and muscular differentiation. Discussion: Our suspicion