PM&R - Articles in Press

Incidence and Identification of Intrathecal Baclofen Catheter Malfunction - Corrected Proof

Eric M. Dvorak, John R. McGuire, Mary Elizabeth S. Nelson — 2010-07-05

Objective: A retrospective chart review was undertaken of cases of intrathecal baclofen (ITB) pump/catheter malfunction and the diagnostic tests performed to identify the problem. An internal review was performed to develop a diagnostic flow chart to have a systematic method for identifying ITB pump and catheter complications.Design: Retrospective chart review.Setting: Tertiary care hospital.Participants: A total of 167 adult patients currently followed in outpatient clinic with intractable spasticity and ITB pump implanted between 1994 and May 2009.Interventions: None.Main Outcome Measures: Catheter malfunction was identified either by anterior/posterior and lateral thoracic/lumbar radiographs, fluoroscopic guided side port access, contrast agent injection followed by CT (fluoro/CT) scan or indium radionucleotide studies.Results: During the study period, 33 patients had 37 catheter revisions. Radiographs were obtained in all cases; fluoro/CT studies in 22, and indium studies in 6. Four cases had both fluoro/CT and indium studies. A total of 13 cases (35.1%) were diagnosed with radiographs; 9 cases (24.3%) were diagnosed by inability to withdraw cerebral spinal fluid from the side port; 13 cases (35.1%) were diagnosed with fluoro/CT studies; and 2 cases (5.4%) were diagnosed with indium studies. Fluoro/CT studies demonstrated subdural catheter location in 7 cases. A total of 2 of 4 cases with both fluoro/CT and indium studies had normal-appearing indium scans and an abnormal fluoro/CT study confirming subdural catheter placement.Conclusions: On the basis of an internal review of the diagnostic studies used to identify patients with suspected ITB pump/catheter malfunction, a troubleshooting flow sheet was developed. Timely identification and correction of potential ITB complications could improve the clinical effectiveness of ITB and may reduce unnecessary health-care costs.

Aquatic versus Land-based Exercises as Early Functional Rehabilitation for Elite Athletes with Acute Lower Extremity Ligament Injury: A Pilot Study - Corrected Proof

Eunkuk Kim, Taegyu Kim, Hyunyong Kang, Jongha Lee, Martin K. Childers — 2010-07-05

Objective: To compare outcomes between aquatic and land-based exercises during early-phase recovery from acute lower extremity ligament injuries in elite athletes.Design: A single-blinded, covariate adaptive randomized, controlled study.Setting: National training center for elite athletes.Participants: Twenty-two athletes with isolated grade I or II ligament injury in ankles or knees were randomized into either an aquatic or land-based exercise group.Interventions: Early functional rehabilitation program (ranging, strengthening, proprioceptive training, and functional exercises) was performed in both groups. All exercises were identical except for the training environment.Main Outcome Measurements: Data were collected at baseline and at 2 and 4 weeks using a visual analog scale (VAS) for pain; static stability (overall stability index [OSI] level 5 and 3); dynamic stability (TCT), and percentage single-limb support time (%SLST).Results: Both groups showed decreases in VAS, OSI 5 and 3, and TCT, with a concomitant increase in %SLST at 2 and 4 weeks (P < 0.05). No significant differences were detected between the 2 groups in any of the outcome measures. However, the line graphs for VAS, OSI 3, TCT, and %SLST in the aquatic exercise group were steeper than those in the land-based exercise group indicating a significant group by time interactions (P < .05). These data indicate that the aquatic exercise group improved more rapidly than the land-based exercise group.Conclusions: For elite athletes with acute ligament sprains in the lower limb, aquatic exercises may provide advantages over standard land-based therapy for rapid return to athletic activities. Consequently, aquatic exercise could be recommended for the initial phase of a rehabilitation program.

Accuracy of Ultrasound-Guided versus Unguided Pes Anserinus Bursa Injections - Corrected Proof

2010-07-05

Objective: The purpose of this study was to compare the accuracy of ultrasound (US)-guided versus unguided pes anserinus bursa injections in a cadaveric model.Design: Single blind, prospective study.Setting: Academic institution procedural skills laboratory.Participants: Twenty-four unembalmed, unpaired adult cadaveric lower extremity specimens.Methods: A single investigator performed 12 US-guided and 12 unguided pes anserinus bursa injections using colored liquid latex into 24 unembalmed adult cadaveric lower extremity specimens. The order of the injection techniques was randomized. The specimens were subsequently dissected by a co-investigator blinded to the injection technique used for each injection.Main Outcome Measures: The injections were graded for accuracy as follows: accurate (all injectate contained within the pes anserinus bursa), accurate with overflow (injectate within the pes anserinus bursa but also located in adjacent structures), or inaccurate (injectate not within the pes anserinus bursa). The accuracy of the 2 approaches was compared using Pearson χ2 test with Williams' correction for the small sample size (P = .05).Results: The accuracy rate was 92% (11 of 12 specimens) in the US-guided condition and 17% (2 of 12 specimens) in the unguided condition. One US-guided injection was considered accurate with overflow, whereas 4 unguided injections were accurate with overflow. The US-guided injection technique was significantly more accurate than the unguided technique (Williams-corrected χ2 = 12.528, P < .01).Conclusions: Despite its superficial location, unguided pes anserinus bursa injections rarely place the injectate within the pes anserinus bursa, whereas US-guided pes anserinus bursa injections have a high degree of accuracy. Therefore, clinicians should consider using US-guidance for diagnostic or therapeutic pes anserinus bursa injections when indicated.