Faculty Category Award Winner
The Influence of Strength on Jump Landing Biomechanics during Maturation in Females – Implications for ACL Injury Risk and Prevention
Daniel C. Herman, MD, PhD; Giorgio Negron, BS; Kyle Fallgatter, BS; Heather K. Vincent, PhD
Objective: Anterior cruciate ligament (ACL) ruptures are potentially devastating injuries that have a significant detrimental impact on short and long term musculoskeletal health and physical function . Altered neuromuscular control during relatively high-risk athletic tasks such as jump landing has been demonstrated as a compelling risk factor for ACL injury. Groups at high risk for injury have neuromuscular characteristics such as high frontal plane motion at the knee and trunk and low sagittal plane motion at the knee and trunk during jumping landing . Furthermore, such neuromuscular characteristics have the capacity to predict ACL injuries , and improvements in neuromuscular control have been shown to reduce ACL injury risk .
There is a well-known sex-bias in ACL injury risk, with females having up to eight times the risk of injury as males . This difference in risk emerges during maturation, and is in part due to sex-based alterations in neuromuscular control that also occur during maturation . This divergence in neuromuscular control may be secondary to inadequate strength development during maturation. It is well-established that females do not gain muscle strength during maturation at similar rates or amounts compared to males . Compensatory neuromuscular control strategies to accommodate this relative lack of strength may result in increased injury risk. These altered neuromuscular control patterns will persist even after engaging in strength training as adults . As such, strength training during maturation may represent an opportunity for injury prevention through preventing altered neuromuscular control patterns from developing. But even though these different aspects of development have been previously studied, neuromuscular control and strength have not been explicitly associated in maturational populations, nor have specific measures of strength been identified as related to neuromuscular control development.
The purposes of this study were to examine strength and neuromuscular control across maturation stages in females, and to identify strength measures associated with poor neuromuscular control. We hypothesized that 1) females would not show any differences in strength measures at the knee and hip across maturation; 2) females would demonstrate worse neuromuscular control at the end of maturation; and 3) neuromuscular control would be correlated with strength measures at the knee and hip in post-pubescence.
Design: Healthy female middle school participants (N=56; 1.56±0.1m, 45.3±9.6kg) were grouped into Pre-Pubertal (PRE; N=18 Age=11.7±0.6), Pubertal (PBL; N=21 Age=12.3±1.3), and Post-Pubertal (POST; N=17 Age=13.7±1.3) categories using the Puberty Maturation Observational Scale. This scale has high reliability and can be used to differentiate between pubertal stages based on indicators such as growth, breast development, menstruation status, body hair, acne, and sweating during physical activities . Neuromuscular control during a jump landing was evaluated by using two-dimensional videography and a scoring tool called the Landing Error Scoring System (LESS) . The LESS has high validity for categorizing neuromuscular control using an eighteen-point checklist for evaluating motion in the frontal and sagittal planes (higher LESS = worse neuromuscular control), and has the capacity to predict ACL injuries in adolescents . Maximal voluntary isometric contraction (MVIC) strength testing of knee extension, knee flexion, hip extension, and hip abduction was assessed using handheld dynamometry which has similarly been shown to be accurate and reliable . Comparisons between groups were made using independent samples t-tests, and correlations between LESS and strength measures were assessed using Pearson’s r (alpha=0.05).
Results: The POST group demonstrated higher knee flexion compared to PRE (4.10±0.85 vs 3.34±0.61 Nm/kg; p=0.005). No other differences were observed between groups for any of the MVIC strength measures. LESS grades were found to be higher in POST compared to both PRE (6.4±1.1 vs 5.7±1.0, p=0.050) and PBL (6.4±1.1 vs 5.0±1.1; p < 0.001) maturation groups. Strong negative correlations were found between knee extension and LESS (r=−0.555, p=0.021) and hip abduction and LESS (r=−.521, p=0.032) for the POST group.
Conclusions: Our findings of 1) few differences in strength across maturation groups; 2) reduced neuromuscular control in the POST maturation group; and 3) strong negative correlations between LESS and knee extension and hip abduction strength all largely confirm our study hypotheses. This is the first study to our knowledge that explicitly demonstrates a correlation between specific measures of lower extremity strength and neuromuscular control over maturation. Our data suggest the critical period for the development of neuromuscular control patterns is during the PBL stage before transitioning into the POST stage of maturation.
These results provide evidentiary support for the concept of implementing middle school-based strength training programs. Such strength training would potentially be particularly emphasized at the lower middle school grade levels in order to target the PRE and PBL maturation stages with the goal of preventing the development of altered neuromuscular control patterns observed in the POST maturation stage. This injury prevention model would have the advantage of potentially being implemented in a mandated or systematic fashion through the existing networks (e.g. physical education classes) that could be done on a large scale. Furthermore, strength training is a very basic and easily understood concept for physical education teachers to incorporate into their curricula with low-cost equipment , and may avoid documented compliance and knowledge issues demonstrated with coaches in various sports .
Given the significant impact ACL injuries have on musculoskeletal health and function and the opportunity that may be present to engage in true primary injury prevention on a large scale, further research using prospective cohort and cluster-randomized interventional designs are warranted.
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This study was funded by the Richard S. Materson New Investigator Grant through the Foundation for Physical Medicine and Rehabilitation, and the Rehabilitation Medical Scientist Training Program.
Fellow Category Award Winner
Neuromotor Blockade Using Transcutaneous Direct Current Block
Fustaf M. Van Acker, III., MD, PhD; Nilov Bhadra, MD, PhD; Tina L. Vrabec, BS; Narendra Bhadra, MD, PhD; John Chae, MD; Kevin L. Kilgore, PhD
Spasticity is a significant cause of functional limitation and pain following upper motor neuron injury or disease. Existing spasticity management primarily involves systemic or local administration of pharmacological neuromuscular blocking agents. These agents are associated with negative side effects and significant cost, limiting desirability for long-term treatment. Alternatively, neuromuscular blockade using electrical current can be applied to an anatomically-focused area with minimal-to-no systemic side effects, be turned on and off nearly instantaneously, and be dose-dependently modifiable through a stablepartial block that may be applied to conserve muscle tone for functional purposes. However to date, true nerve conduction block has not been achieved using non-invasive electrical methodology.
Here we developed a novel means of blocking peripheral nerve transmission using electrodes placed on the skin surface. This non-invasive transcutaneous direct current block (tDCB) applies a constant current, leaving cells refractory to repeated depolarization. By doing so, tDCB may be purely inhibitory depending upon waveform characteristics. This is a fundamentally different principle than existing clinically available non-invasive electrical stimulation-based approaches that use alternating current (AC), such as transcutaneous electrical nerve stimulation (TENS) or spinal cord stimulation (SCS). Specifically, these methods produce effects through indirect means, presumably by activating either inhibitory or competitive circuits within the nervous system. tDCB produces a direct block of nerve conduction at the delivery site. It is analogous to a local neuromuscular blocking agent, except that it is produced electrically and has the unique capability of nearly instantaneous and reversible titrating and tapering for optimal efficacy. DC has a good safety profile, and has been used extensively for clinical and research applications in both transcranial (tDCS) and transspinal (tsDCS) direct current stimulation. However, to our knowledge transcutaneous DC has never been investigated for block of action potential conduction in peripheral nerve.
Data were collected from adult Sprague Dawley rats. For each procedure, general anesthesia was maintained using isoflurane. Surgical exposure of the sciatic nerve was performed, from one centimeter lateral to midline to the tibial and peroneal nerve bifurcation. The sural branch was crushed to eliminate conduction to the gastrocnemius, leaving conduction through the common peroneal and tibial nerves intact. A platinum bipolar J-cuff electrode was placed circumferentially to encompass approximately 270° of the exposed sciatic nerve proximally. This proximal stimulating electrode provided biphasic cathode- or anode-leading stimulus pulses at 1 Hz and 20 μs per phase, to evoke muscle activity and foot dorsiflexion. Force output was monitored via force transducer attached to the foot. The stimulus amplitude at which maximal sciatic nerve activation occurred was delineated by monitoring the force output, while incrementally increasing the stimulus current until the force output plateaued. This stimulus amplitude subsequently was applied concurrently with tDCB. With the proximal stimulating electrode in place, muscle and skin were sutured closed.
tDCB was applied to the skin overlying the tibial and common peroneal nerves distal to the proximal stimulating electrode, through Ag/AgCl ring electrodes with inner and outer diameters of 0.6 and 1.2 cm, respectively (EL-TP-RNG Sintered; Stens Biofeedback Inc, San Rafael, CA). Conductive gel (Signa, Parker Laboratories Inc., Fairfield, NJ) was placed in a thin layer between the electrode and skin surface. Four general electrode geometric configurations with respect to the nerve were investigated: 1) active and return electrodes placed on opposing sides of the leg/nerve, oriented perpendicular to the target nerve; 2) active and return electrodes placed on opposing sides of the leg/nerve, at acute or obtuse angles relative to the target nerve; 3) active and return electrodes on the same side relative to the leg/nerve, oriented parallel to, and directly overlying, the target nerve; and 4) active and return electrodes on the same side with respect to the leg/nerve, oriented perpendicular to the target nerve.
Each tDCB waveform consisted of 1) a 2-second ramp-up phase from zero current to 2) a 4- to 10-second phase at a constant current, followed by 3) a 2-second ramp-down phase. Ramping prevented generating action potentials in the nerve at current onset/offset. Maximum current intensity applied was 20 mA.
Complete neuromotor block, manifested by complete elimination of stimulus-evoked force, was routinely achieved at stimulus amplitudes at or below 20 mA, and as low as 5.5 mA. A direct relationship was found between tDCB stimulus amplitude and percent of motor block. These partial blocks were consistent for the duration of tDCB. Maximal stimulus-evoked force returned once tDCB was stopped. No evidence of the generation of action potentials was observed when the ramp-up and ramp-down was applied.
Electrode geometric configuration #1, with active and return electrodes placed on opposing sides and perpendicular to the leg/nerve, had the greatest blocking effect. Block was obtained, though less robustly, in configuration #2, in which active and return electrodes were placed on opposing sides, though not directly perpendicular, to the leg/nerve. Configurations #3 and #4, in which the active and return electrodes were placed on the same side with respect to the leg/nerve, did not yield nerve conduction block up to current intensities of 20 mA. Effective nerve conduction block may rely on geometric configuration that directs current flow from one side of the nerve to the other, thereby affecting all nerve fibers in a cross-sectional area. No signal attenuation indicating nerve damage was observed. No evidence of skin irritation, such as redness, black marks or blistering, was seen at the conclusion of each study.
Successfully blocking neuromuscular activity in the periphery using tDCB may provide an inexpensive, non-pharmacological alternative for spasticity treatment. The ability to provide stable incomplete block may provide the ability to modulate the optimal spasticity block amount, allowing residual muscle tone to conserve functionality. Delineating factors that impact successful transcutaneous nerve block, such as stimulus parameters, electrode placement and electrode design, is important for future nerve block applications.
Resident Category Award Winner
Ten Year Trends in Pediatric Inpatient Rehabilitation: Predicting Length of Stay and Rehabilitation Outcomes Using WeeFIM Data
Tracy Knippel, MD; Amy Houtrow, MD, PhD, MPH
Objectives: With the changing landscape of health care, it is important to determine how to make rehabilitation as efficacious as possible in an efficient, cost-effective manner. There is no consensus on the optimal delivery of rehabilitation care, especially in pediatrics. Recent studies have highlighted discrepancies in the structures and processes of pediatric rehabilitation care both within and between different rehabilitation facilities. Other researchers have attempted to define outcome and length of stay (LOS) determinants for children admitted to inpatient rehabilitation programs. Taken as a whole, these have shown age, diagnosis, and admission functional status are all predictive of LOS and functional outcomes. However, national data trends are not available. This project intends to help fill the gaps in our knowledge and has several objectives. First, we sought to evaluate overall trends in pediatric inpatient rehabilitation over a ten year period to examine how care is changing with regard to patient demographics, their health and functional characteristics, as well as characteristics of facilities in which care is delivered. Secondly, we sought to identify characteristics of patients and facilities that predict LOS and rehabilitation efficiency. Finally, we characterized regional variations in rehabilitation care.
Design: We used a retrospective analysis of existing Uniform Data Systems (UDS) WeeFIM data collected from all participating pediatric inpatient rehabilitation programs in the United States from 2004–2104. Descriptive statistics were calculated for inpatient pediatric rehabilitation facilities and patients over the study period. Variability in LOS over the entire decade was examined. At the patient level, changes over time in LOS, admission WeeFIM scores, WeeFIM gain, and WeeFIM efficiency were analyzed using one-way ANOVAs and Tukey HSD post hoc comparisons. We examined the effects of patient age and diagnosis on the outcomes variables (LOS, admission WeeFIM scores, WeeFIM gain, and WeeFIM efficiency) using one-way ANOVAs and Tukey HSD post hoc comparisons. Hierarchical linear modeling was used to determine predictors of WeeFIM efficiency using 11 different independent variables [LOS, age (0–3, 3–5, 5–7, 7–10, >10), number of medical comorbidities (0–6), gender, race, facility region (Northeast, Midwest, South, West), insurance type (public, private), admission WeeFIM score, facility type (freestanding, hospital unit based), facility size (based on number of beds), and discharge year]. At the facility level, we examined the growth of hospital-based rehabilitation units compared to freestanding inpatient rehabilitation facilities over time. Specific impairment groups were then evaluated. We analyzed how each impairment group changed as a percentage of total inpatient rehabilitation admissions over time. For all analyses in the study, missing data were excluded from the models.
Results: Between 2004–2014, 67 facilities reported WeeFIM data to UDS, representing 42,702 inpatient rehabilitation admissions over the study period. At the individual level, LOS varied widely. The mean length of stay was 28 days, median 19 days, range 1 to 944 days. Just over 10% of children had a length of stay of 60 days or longer. From 2004 to 2014, mean LOS decreased significantly (F = 27.6, p < 0.0001). The average LOS in 2014 was 24 days compared to 31 days a decade earlier.
Admission mean Total WeeFIM Score was relatively stable over the 10 year period (range 49.62 – 52.36). WeeFIM efficiency improved significantly over time (F = 23.3, p < 0.0001) but WeeFIM gain decreased significantly over the 10 year period (F=6.9, p < 0.0001). The average WeeFIM gain in 2004 was 24.6, compared to 22.5 in 2014. WeeFIM efficiency showed a nearly linear increase over the study period.
Using hierarchical linear modeling, length of stay, age, region, insurance type, admission WeeFIM score, facility type, number of comorbidities, facility size and discharge year were significant predictors of WeeFIM efficiency (R2=0.22). The strongest correlations with higher WeeFIM efficiency were older age, having private insurance, shorter LOS, and facilities in the Northeast.
At the facility level, the total number of freestanding units remained stable over time, but decreased as a percentage of total facilities providing pediatric rehabilitation services (from 26% in 2004 to 20% in 2014). The majority of freestanding inpatient pediatric rehabilitation units are located in the Northeastern United States.
Certain impairment groups are becoming more or less commonly admitted to inpatient rehabilitation over time. In 2004, debility accounted for 0% of inpatient rehabilitation admissions, and increased to 5% by 2014. In 2004, musculoskeletal disorders accounted for 15% of admissions, and decreased to 8.6% by 2014. By comparison, acquired brain injury represented 49% of inpatient rehabilitation admissions in 2004 and 47.7% in 2014.
Conclusions: The way in which pediatric inpatient rehabilitation services are being delivered is changing over time. In our study period, we found that while LOS is quite variable on an individual basis, overall LOS is decreasing. There is a trend toward delivery of rehabilitation care in a hospital unit based setting versus in a freestanding facility. While children have shorter stays, they are not necessarily being admitted with higher functional levels, as shown by the relatively stable admission WeeFIM scores over time. WeeFIM efficiency is improving over time but this rate of change is not keeping pace with the decreasing LOS, as evidenced by decreasing WeeFIM gains over time. This means that children were being discharged home with more functional limitations, shifting recovery to the outpatient sector.
In our hierarchical model, nine of the eleven variables entered were significant predictors of WeeFIM efficiency, but LOS, facility region and insurance type were the most predictive. More research is needed to precisely define and quantify these factors and their interrelationships. Doing so will advance our understanding of variables that impact pediatric rehabilitation LOS and rehabilitation efficiency. Understanding how the various factors that impact WeeFIM efficiency may provide a starting point for interventional measures aimed at reducing length of stay and improving efficiency across pediatric rehabilitation units nationwide. We believe this is important because health care as a whole is moving toward standardizing the processes of care delivery.
Medical Student Category Award Winner
Ryan Sankovic, BS; Ameya Nanivadekar, MSE; Ahmed Kashkoush, BS; William F. Cusack, PhD; Lee Fisher, PhD; Robert A. Gaunt, PhD
People with spinal cord injury (SCI) face significant challenges with urinary tract function resulting from the loss of supraspinal control. These complications have led to the development of several clinical devices focused on improving bladder management, with the goals of decreasing urinary tract infections and healthcare costs and improving the quality of life for people with SCI. However, many of the clinical methods and devices to control and manage bladder function are imperfect. Electrical microstimulation could be an effective method to address these issues, but no devices are currently available. One potential location for microstimulation of afferent fibers involved in the lower urinary tract (LUT) are the dorsal root ganglia (DRG). Feline LUT reflex pathways primarily travel through the S1-S3 DRG. Previous research has shown that electrical stimulation of pudendal nerve afferents can elicit continence reflexes through activation of the dorsal nerve of the penis (branch of pudendal nerve). Sensory input from the pelvic nerve is important to fully void the bladder through LUT reflexes. The primary aim of these experiments was to identify recruitment patterns of LUT afferents in response to DRG microstimulation. A second aim of these experiments was to combine single channels with the same physiological function and stimulate them to attempt to elicit greater physiological responses (both micturition and continence).
All experimental protocols were approved by the University of Pittsburgh’s Institutional Animal Care and Use Committee. Detailed surgical procedures and experimental methods common to the aims have been described previously (Bruns et al. 2015) and are summarized briefly here. Surgical procedures were performed under isoflurane anesthesia and the animals were mechanically ventilated. The abdomen was opened and a dual-lumen catheter was placed in the bladder to monitor bladder pressure and to control bladder volume. While the abdomen was open, a custom nerve cuff electrode was placed on the pelvic nerve. The abdomen was closed in layers, the animal was placed in a prone position, and the pudendal nerve and its branches were dissected free. Custom nerve cuff electrodes were placed on the pudendal, rectal perineal, sensory, caudal rectal and deep perineal nerves. After a sacral laminectomy, microelectrode arrays (Utah arrays, 32 channels per device, 400 μm interelectrode spacing) were implanted into the S1 and S2 DRG unilaterally. Microstimulation was delivered through individual DRG electrodes with stimulus amplitudes ranging from 3 to 50 μA. Electroneurogram (ENG) signals were recorded from the nerve cuffs and stimulus-triggered averaging was used to examine peripheral nerve activity for the presence of compound action potentials. Functional testing to determine bladder and EUS responses were conducted under alpha-chloralose anesthesia to avoid suppression of spinal reflexes. Functional testing involved single channel stimulation of each of the electrodes on the arrays in both S1 and S2 at different stimulus parameters from 2 – 50 Hz and 3–50 μA. Additionally, combinations of channels that elicited similar physiological responses were tested to note changes in the physiological response.
ENG data showed selective recruitment of the pelvic nerve by 8 electrodes at an average threshold of 9.6 μA +/− 3.0 μA. The pudendal nerve was selectively stimulated by 5 electrodes at an average threshold of 18.7 μA +/− 10.0 μA. The branches of the pudendal that were selectively stimulated include the sensory nerve, with 12 selective electrodes at an average threshold of 17.1 μA +/− 8.5μA, and the deep perineal branch, with one selective electrode at a threshold of 15.6 μA. No selective responses were seen on the caudal rectal and rectal perineal nerves.
Results from the functional testing of the two animals showed that single channel stimulation evoked contractions of the bladder without simultaneous EUS contraction on 45/128 electrodes from S1 and S2 of both animals. Amplitudes of at least 20 μA were needed for 97% of the bladder contractions to occur. The average magnitude of bladder contraction was 6.3 mmHg +/− 2.4 mm Hg. The largest magnitude bladder contraction observed was 14 mm Hg. Combining two channels that individually showed large bladder contractions at 10 μA and 30 Hz for a duration 30 seconds showed a sustained 8 mmHg bladder contraction. These results demonstrate that micturition reflexes can be evoked through microstimulation of sensory neurons in the sacral DRG. Single channel microstimulation did not elicit selective EUS contractions on any electrode. We also found that in some cases, simultaneous stimulation on multiple channels at subthreshold currents could elicit a physiological response similar to stimulation at suprathreshold currents on individual channels.
Several limitations occurred in this study. In the second experiment it was challenging to record reliable intraurethral pressures due to challenges in placing the transducer. Instrumentation of the various nerve branches was also difficult and led to poor recording performance in several cases. It is also possible that difficulties in eliciting large functional responses could have been due to compression of the nerves from the nerve cuffs themselves. A possible way to improve on this research in the future would be to include the L7 DRG in the study as we found some evidence in our study that stimulation of L7 could elicit EUS contractions.
SCIENTIFIC PAPER PRESENTATIONS Friday, February 19, 2016
Analysis and Management of Diabetic Hypoglycemia Incidence in an Acute Rehabilitation Facility
Xiaoli Wang, MD, PhD; Rachel Levihaiem, PharmD; Adrian Cristian, MD
Objectives: Untreated diabetic hypoglycemia can cause medical emergencies such as seizures and loss of consciousness leading to interruption of rehabilitation treatment. The goal of this study is to monitor hypoglycemia events in KJMC’s acute rehabilitation facility and evaluate the efficacy of the hypoglycemia treatment protocol in the management of diabetic hypoglycemic events.
Design: Hypoglycemic events of diabetic patients admitted to acute rehabilitation facility were documented from Feb, 2015 to May, 2015. According to KJMC’s hospital-wide hypoglycemia treatment protocol, hypoglycemia is defined as glucose level less than 70mg/dL detected with glucometer. Patients with different glucose levels were treated respectively either with oral glucose supplement, IV dextrose supplement, IM glucagon or combined treatment. Related information was collected including symptoms, glucose level before and after treatment, treatment strategies, weather the treatment protocol was repeated, related events including PT/OT treatment interruption, medical CODE, acute patient transfer. All the information was reviewed and analyzed at the end of research.
Results: During a 4 month period, 99 diabetic patients were admitted to KJMC’s acute rehab facility and 28 hypoglycemia incidences were noted. Among the 28cases, 24 cases were asymptomatic; 11 cases had repeated the treatment protocol; 3 cases were symptomatic and got combined treatment. All 28 cases repeated finger stick glucose levels were optimized to normal level after treatment and no PT/OT treatment were interrupted. There was no medical CODE initiated and no related acute transfers.
Conclusions: Hypoglycemia in diabetic patients is a common phenomenon with high incidence in KJMC’s acute rehabilitation facility. The hypoglycemic events were optimally managed with KJMC’s hypoglycemia treatment protocol. The protocol is a good tool for quality improvement in patient safety and health care.
Association Between Time-to-Rehabilitation and Outcomes Following Traumatic Spinal Cord Injury
Kurt Herzer, MSC; Yu-Ying Chen, MD, PhD; Allen Heinemann, PhD; Marlis González-Fernández, MD, PhD
Objectives: The benefits of earlier rehabilitation following traumatic spinal cord injury (SCI) remain uncertain. The objective of this study was to examine the relationship between time-to-rehabilitation (TTR) following SCI and rehabilitation outcomes, as measured at discharge and 1-year post injury.
Design: We conducted a retrospective study using data from 23 Spinal Cord Injury Model Systems across the United States. Patients experiencing a traumatic SCI between 2000 and 2014, who were 18 years or older, and who were admitted to a Model System within 24 hours of injury, comprised our study population (N = 3,937). TTR was measured as the number of days between injury and admission to inpatient rehabilitation. Pre-specified outcome measures included the Functional Independence Measure (FIM) motor score at discharge and 1-year post injury (Rasch-transformed), a dichotomous measure of discharge to a private residence, and the Craig Handicap Assessment and Reporting Technique (CHART) Physical Independence and Mobility scores (scaled 0–100) at 1-year post injury. Instrumental variables regression was used to reduce confounding from unobserved severity of illness/comorbidities. All models controlled for sociodemographic and injury characteristics (including injury severity), FIM motor score at admission, and rehabilitation length of stay.
Results: After adjusting for health status, a 10% increase in TTR was associated with a 1.50 lower FIM motor score at discharge (95% CI, −2.43 to −0.58; P=0.001) and a 3.92 lower CHART Physical Independence score at 1-year post injury (95% CI, −7.66 to −0.19; P=0.04). Compared to the mean FIM motor score (37.5) and CHART Physical Independence score (74.7), these represent relative declines of 4.0% and 5.3%, respectively. There was no association between longer TTR and the likelihood of discharge to a private residence, 1-year FIM motor score, or the CHART mobility score.
Conclusions: Efforts to promote earlier rehabilitation following traumatic SCI may improve patients’ functional status at discharge.
Changes in Upper Limb Use and Motor Coordination in Children with Hemiplegic Cerebral Palsy after Combined Botulinum Toxin-A and Constraint-Induced Movement Therapy: A Pilot Study
Joyce Oleszek, MD; Joanne Valvano, PhD, PT; Patty Kenyon, MA, OTR, CHT; Nancy Denniston, MS, MA; Jerry Clayton, PhD; Amy Kanallakan, MD; Lisa Brenner, PhD; Julie Steiner, MA
Objectives: Botulinum toxin-A (BoNT-A) and constraint-induced movement therapy (CIMT) are known treatments in children with hemiplegic cerebral palsy (CP). Few studies have evaluated the combined effects. Objectives of this study were to examine potential changes post-BoNT-A, as well as post-CIMT in: 1) subjective reporting of affected arm use (Pediatric Motor Activity Log [PMAL]); and 2) coordination of reach to grasp movement (three-dimensional kinematic analysis). The relation between changes in PMAL scores and kinematic measures was also explored.
Design: Eight children with hemiplegic CP (4 boys, 4 girls, 6.5-12y) were recruited from a pediatric rehabilitation clinic. Inclusion criteria: need for upper limb BoNT-A, grasp and release, and good cognition. Exclusion criteria: upper limb contractures or surgery, and upper limb BoNT-A in previous 6 months. Participants received upper limb BoNT-A followed by a 3 week CIMT program. Measures included the PMAL and three-dimensional kinematic analysis of thorax and arm segments during reach to grasp of a kaleidoscope. Measures were performed at baseline, 4 weeks post-BoNT-A, and 3 weeks post-CIMT.
Results: There were no significant group differences between baseline and post-BoNT-A mean scores in the PMAL How Often (HO) or How Well (HW) domains. There were statistically significant improvements in the PMAL means between post-BoNT-A and post-CIMT (p=0.008 HO, and p=0.02 HW), and baseline and post-CIMT (p=0.008 HO, and p=0.008 HW). Kinematic analysis revealed individual patterns of motor coordination change with relatively greater improvement post-CIMT. Moderate associations between changes in specific coordination patterns and changes in PMAL scores were identified.
Conclusions: Subjective reports of arm use indicated significant improvement in the cumulative effects of BoNT-A and CIMT, but not with BoNT-A alone. Although generalization is limited by the small sample and individual patterns of change, findings support further study of combined BoNT-A and CIMT, as well as the association between upper limb kinematic changes and daily function.
Combined Cerebral and Spinal Non-Invasive Direct Current Stimulation on Upper Limb Recovery in Chronic iSCI: A Case Series
Jessica M. Beardsley; Zafer Keser, MD; Gerard E. Francisco, MD; Nuray Yozbatiran, PhD
Objectives: The objective of this study is to evaluate the effects of non-invasive anodal transcranial direct current stimulation (tDCS) and non-invasive anodal transcutaneous spinal direct current stimulation (tsDCS) combined with robotic-assisted training (R-A training) on upper limb motor function in adults with chronic tetraplegia due to incomplete spinal cord injury (iSCI). The literature and preliminary data suggest that non-invasive brain and spinal cord stimulation with R-A training will significantly increase arm and hand function compared to treatment with combined brain stimulation and R-A training.
Design: This study uses a matched case-control design. Four adults with chronic, cervical iSCI (AIS C and D levels) are assigned to receive either tDCS and tsDCS combined with R-A training or tDCS combined with R-A training. Treatment is administered five sessions per week for two weeks. Assessment of upper extremity motor behavior for the training arm is performed at baseline and at the end of ten sessions. The primary clinical measurement for motor behavior is the Jebsen-Taylor Hand Function Test (JTHFT). The ASIA Upper Extremity Scale for motor and sensory assessment, the Modified Ashworth Scale (MAS), and grip and pinch strength are secondary clinical measurements.
Results: Two subjects have been enrolled in the study and are undergoing treatment. Subject 1 is a 59 year-old male with a history of traumatic, C3-C4 ASIA D SCI. Time since injury is 84 months. Subject 2 is a 64 year-old male with a history of traumatic, C3-C6 ASIA D SCI. Time since injury is 60 months. Baseline assessment of upper extremity motor and sensory behavior in the training arm has been measured for both subjects.
Conclusions: This study is ongoing. Data will continue to be collected in order to verify whether non-invasive brain stimulation combined with non-invasive spinal cord stimulation and R-A training will improve upper-limb motor function compared to brain stimulation and R-A training.
Effect of AbobotulinumtoxinA (Dysport®) Injections on Functioning in Children with Dynamic Equinus Foot Deformity Due to Cerebral Palsy: Analysis of Treatment Goals, Gait and Quality of Life from a Phase 3 Study
Mauricio R. Delgado, MD; Barry Russman, MD; Mark Gormley, MD; Jorge Carranza, MD; Nigar Dursun, MD; Marcin Bonikowski, MD; Resa Aydin, MD; Umit Dincer; Ozlen Peker, MD; Zbigniew J. Lipczyk, Doctor, Ortopedist Surgeon; Anissa Tse, BM, BS; Philippe Picaut, PharmD/PhD
Objectives: To evaluate the efficacy of AbobotulinumtoxinA (ABO, Dysport®) ABO in improving the functional ability and quality of life of focal/segmental spasticity in cerebral palsy (CP) patients.
Design: An international, double-blind, placebo-controlled study in children (aged 2–17 years) with dynamic equinus foot deformity due to CP was performed. Patients were randomized (1:1:1) to injections of ABO 10U/kg/leg, ABO 15U/kg/leg or placebo into the gastrocnemius-soleus complex (1 or 2 legs injected).
Functional outcomes included Goal Attainment Scaling (GAS) at Week 4, change from baseline to week 4 in Observational Gait Scale (OGS; initial foot contact) and change from baseline to week 12 in the Paediatric Quality of Life Inventory (PedsQL).
Results: 235 patients were included in the ITT population and 226 completed the study. The most frequently chosen goals were improved walking pattern (70.2% patients), improved balance (32.3%) and decreased falling (31.1%). Whereas patients in the ABO groups showed better than expected goal achievement (GAS score 50.9 for ABO 15U/kg/leg, 51.5 for ABO10 U/kg/leg; score of 50 represents goal achieved as expected), patients in the placebo group did not reach the expected level (score 46.2). Treatment effects for GAS were significant for both ABO groups versus placebo (p=0.0031 & p=0.0006, respectively). Improvements in gait were also observed for 15U/kg/leg (treatment difference vs. placebo: 1.1 [0.3, 1.9]; p=0.01) and 10U/kg/leg doses (1.5 [0.7, 2.2]; p=0.0003). Significantly more ABO-treated patients had ≥1 grade improvement in OGS initial foot contact scores than placebo (odds ratios of 9.8 & 7.8 vs. placebo, respectively, both p=0.0001). The fatigue subscale in the PedsQL CP module showed statistically significant improvement at Week 12 for both ABO groups vs. placebo (p=0.037 & p=0.030, respectively).
Conclusions: This large placebo-controlled study in pediatric CP patients demonstrated that improvement in muscle tone/decrease in spasticity provided by ABO treatment directly translated into functional benefits and reduction of fatigue.
Efficacy and Safety of Repeated IncobotulinumtoxinA Injections for Upper-Limb Post-Stroke Spasticity
Ziyad Ayyoub, MD; Angelika Hanschmann, MSC; Reinhard Hiersemenzel, MD; Michael C. Munin, MD
Objectives: To investigate efficacy and safety of repeated incobotulinumtoxinA (Xeomin®) injections for upper-limb post-stroke spasticity.
Design: This 36-week open-label extension (OLEX) evaluated subjects (18–80 years of age) with upper-limb post-stroke spasticity, who completed the 12-week randomized, double-blind, placebo-controlled main period (MP) of a Phase III trial (NCT01392300). Subjects received 3 treatments with incobotulinumtoxinA (400U), injected into the affected muscles of one upper-limb at fixed 12-week injection intervals. Main outcome measures included: evaluation of muscle tone [Ashworth Scale (AS)]; Disability Assessment Scale (DAS); Carer Burden Scale; and incidence of adverse events (AEs).
Results: Nearly all subjects (296/299) who completed the MP received incobotulinumtoxinA in the OLEX; 248 subjects completed the OLEX. The proportion of subjects with ≥1 point improvement in AS score from each incobotulinumtoxinA treatment to the respective 4-week post-injection visit was 52.3%–59.2% for wrist flexors, 49.1%–52.3% for elbow flexors, 59.8%–64.5% for finger flexors, 35.5%–41.2% for thumb flexors, and 37.4%–39.9% for forearm pronators (p < 0.0001 for all). The mean DAS score for the principal target domain significantly improved from each incobotulinumtoxinA treatment to the respective 4-week assessment (p < 0.0001 for all). From the MP baseline to the study-end visit (week 48), significant improvements in Carer Burden Scale scores were seen for ‘cleaning palm’ (58/108 subjects, 53.7%; p < 0.0001), ‘cutting fingernails’ (65/125 subjects, 52.0%; p < 0.0001), ‘cleaning armpit’ (50/112 subjects, 44.6%; p=0.0023), and ‘putting arm through sleeve’ (59/116 subjects, 50.9%; p < 0.0001). ‘Applying splint’ improved in 8/14 subjects (57%; p=0.1484).
Treatment-related AEs were reported by 9/296 subjects (3.0%), most frequently pain in the extremity (n=2, 0.7%) and constipation (n=2, 0.7%). Serious AEs were reported by 22 subjects (7.4%); none were treatment-related.
Conclusions: Repeated incobotulinumtoxinA treatment is well-tolerated, significantly reduces upper-limb spasticity and led to significant improvements in muscle tone that translated into meaningful clinical improvements in disability and carer burden.
Electrophysiological, Behavioral, and Imaging Analysis of Neuromuscular Function in Aging C57BL/6J Mice
W. David Arnold, MD; Kajri A. Sheth; Vicki L. McGovern, PhD; Arthur H. Burghes, PhD
Objectives: This study was designed to investigate the impact of aging on neuromuscular function in C57BL/6J mice to understand the timing of motor unit loss and the interaction between motor unit function, grip strength and muscle mass. We are also testing if overexpression of a specific protein can prevent aging-related deficits.
Design: Electrophysiological measures of motor unit function (compound muscle action potential amplitude, CMAP and motor unit number estimation, MUNE) were performed at 10, 13, 15, 17, and 20 months (m) in 9 male mice. This longitudinal cohort and a younger cohort were also assayed with grip strength and hindlimb MRI and electrical impedance myography (EIM) for muscle size/quality. Mice with overexpression of a specific protein will be assessed for protection against motor unit loss.
Results: CMAPs at 10m (50.7±12.4mV), 13m(43.6±11.2mV), 15m (47.5±6.7mV), and 17m (45.3±5.7mV) were unchanged, but at 20m CMAPs are reduced (36.1±6.1mV) (p < 0.05). Similarly, MUNE is stable at 10m (341±93), 13m (302±98), and 15m (314±51), but at 17m MUNE shows slight but non-significant reduction (271±51). At 20m, MUNE is reduced (225±77) (p < 0.05). Forelimb and all-limb grip normalized to body weight at 20m (3.11±1.10g and 5.7±0.86g, respectively) were unchanged versus 11m old mice (3.06±0.69g and 5.62±0.92g). Overexpression of a specific protein shows protection against motor unit loss following nerve injury thus presenting an avenue for sarcopenia treatment.
Conclusions: Preliminary data show motor unit loss prior to deficits in grip strength suggesting that motor unit loss may be an important and early determinant of aging-related sarcopenia. Further longitudinal assessment and analyses of muscle size/quality are ongoing. We have identified an effect of improved nerve regeneration following overexpression of a specific protein. We are testing overexpression of this protein as a potential treatment because of the putative role of motor unit loss in aging-related loss of muscle mass and function.
Elevated Serum Estrone Levels Predict 6 Month Mortality in Patients Undergoing Traumatic Brain Injury
Milap Rakholia, BA; Byung-Mo Oh, MD, PhD; Raj Kumar, MPH; Amy Wagner, MD
Objectives: Recent clinical trials on the use of progesterone to improve long-term outcomes in patients having undergone traumatic brain injury (TBI) proved unsuccessful despite preclinical evidence suggesting its ability to mitigate secondary damage following TBI. The purpose of this study was to expand findings on how changes in the steroidogenesis pathway downstream of progesterone impacts long term prognosis by characterizing the effect of estrone (E1), an estradiol precursor, on 6 month mortality following TBI.
Design: A prospective cohort study was conducted on patients aged 18–75 years who had undergone treatment for a TBI at a level 1 trauma center. Demographic data had been collected on age, sex, best in 24hr Glasgow Comma Scale (GCS) score, hospital length of stay, mechanism of injury, and injury type on a CT scan. Blood samples had been collected daily for up to 7 days, centrifuged, aliquoted, and stored at −80°C. 101 patients and eight healthy control subjects, aged 21–62, were selected for the study. Competitive ELISA kits were used to measure serum E1 levels. Day 0–3 results were averaged for analysis.
Results: Average E1 levels in TBI cohort were over 3 times higher than control (359.9 pg/mL vs 99.2 pg/mL, p < 0.001). There were no significant differences in demographic variables by both E1 quartile and 6 month survival. The covariates of age, sex, and best 24hr GCS were controlled for when determining the association between 6-month mortality and E1 quartile. We found that for any increase in E1 quartile, there was a 1.7 times increased odds for mortality (odds ratio, 1.695 [95% CI, 1.197 to 2.193]; p=.034).
Conclusions: Serum E1 levels are elevated in TBI compared to controls. Furthermore, elevation within the TBI cohort is associated with an increase in 6 month mortality. Acute serum E1 serves as a predictor of long-term mortality and could provide insight into guiding future hormone-targeted therapies for TBI.
Enhancing Motor Learning with a Light-Weight 3-D Cable-Driven Arm Exoskeleton (CAREX)
Syed Z. Ali, BS; Viswanath Aluru, MD; Xin Jin; Raj K. Dalsania, BS; Sunil K. Agrawal, PhD; Preeti Raghavan, MD
Objectives: The CAREX is a novel lightweight upper limb robotic exoskeleton with a cable design which can eliminate gravity and provide path assistance using a force-field. The objectives of this study were to determine the extent of motor learning on a circle drawing task with CAREX in healthy controls and in chronic stroke subjects at earlier and later stages of post-stroke recovery, as defined by their upper extremity Fugl-Meyer (FM) scores.
Design: Seven healthy subjects and nineteen subjects with chronic post stroke right hemiparesis performed 3-sets of 3-D circle drawing using CAREX under 3 randomly assigned conditions: (a) gravity elimination alone, (b) path assistance alone, and (c) path assistance and gravity elimination together. subjects made a total of 20 circles, 10 clockwise and 10 counter-clockwise, under each of the 3 experimental conditions during a single session.
Results: The path deviation on the circle-drawing task was significantly greater in subjects with stroke across all conditions compared to controls. subjects were stratified by stage of recovery based on their FM scores into low FM (FM score +3.56) and high FM (FM score >55) (61.6±1.32) subgroups. The high FM subgroup showed least path deviation (0.11±0.04) with path assistance and gravity elimination together comparable to controls (0.08±0.04, p>0.1). In contrast the low FM subgroup showed greatest path deviation under this condition compared with controls (0.26±0.11, p2=−0.53). Control subjects showed no difference in path deviation across the three conditions.
Conclusions: The results suggest that robotic training strategies to control movement trajectory are best provided once sufficient recovery of movement has taken place. Stratification of subjects with stroke based on stage of recovery can determine optimum robotic treatment strategies to improve performance and enhance motor learning post stroke.
Examining the Psychological Effect Among Physiatrists Treating Patients with Traumatic Injury: The Role of Secondary Traumatic Stress
Ann Marie Warren, PhD; Megan C. Reynolds, MS; Simon Driver, PhD; Jacob Christiansen, BS; Monica Bennett, PhD; Rita Hamilton, DO
Objectives: Studies have shown that secondary traumatic stress (STS), an indirect form of posttraumatic stress disorder (PTSD), can occur in clinicians as a result of caring for patients who have experienced a traumatic injury. However, STS remains unexplored among physiatrists in the rehabilitation setting. Therefore, the objective of the current analysis was to examine the relationship between STS, personality characteristics, and resilience among physiatrists.
Design: Surveys were distributed to the membership list of the Association of Academic Physiatry, as well as a local private group practice of physiatrists, between January-June 2015. Eligibility included physiatrists providing direct care to patients with traumatic injury. Surveys included: (1) 21-item Secondary Traumatic Stress Scale (STSS), (2) Conner Davidson Resilience Scale (10-item), and (3) Ten-Item Personality Inventory (TIPI). Demographic and career-related information were also collected.
Results: Of 102 surveys returned, 89 were completed in full and included for analysis. The average age of participants was 41.7±11.2, including 44 males (49%) and 45 females (51%). Using the cutoff score ≥47 to indicate moderate or severe STS, 18 (20.2%) participants screened positive. Physiatrists with STS symptoms had significantly lower TIPI scores in the personality traits of extraversion (p=0.0242), emotional stability (p=0.0351), and openness (p=0.0105) and significantly lower resilience (27.4±5.0) compared to physiatrists without STS (32.1±4.9, p=0.0005). No significant difference was found in demographic and career-related variables.
Conclusions: A substantial number of physiatrists endorsed moderate to severe symptoms of STS, consistent with previous research among clinicians working in a trauma setting, with both groups reporting significantly greater STS symptoms than the general population. Further, resilience and personality traits may be useful in identifying physiatrists at risk of STS. These findings provide a foundation for developing preventative measures and treatment for STS in order to improve the well-being of physiatrists (e.g., quality of life) and also likely improve patient care and patient satisfaction.
Facility Type and Functional Outcomes During Pediatric Inpatient Rehabilitation
Molly M. Fuentes, MD; Nathalia Jimenez, MD, MPH; Frederick P. Rivara, MD, MPH; Susan Apkon, MD
Objectives: To compare functional scores between children receiving inpatient rehabilitation at children’s hospitals versus other facilities.
Design: Retrospective cohort study using the Uniform Data System for Medical Rehabilitation national database of the Functional Independence Measure for Children (WeeFIM®) instrument for the years 2004–2014. Outcomes were the total, cognitive and motor Developmental Quotient Scores (DQS, WeeFIM® scores/age-based normative score] x 100) and WeeFIM® efficiency (change in total WeeFIM® score during admission/ length of stay). Linear regression models examined the association between facility type (children’s hospital versus other facilities, based on facility self-identification) and motor, cognitive, and total discharge DQS and WeeFIM efficiency. Regression models utilized robust variance estimates to account for within-facility correlation and adjusted for age, gender, race, insurance status, region, baseline function, impairment type, discharge year, and (except for the WeeFIM efficiency model) length of stay.
Results: A total of 28,793 children, 6 months to 18 years old, were included; 12,732 received inpatient rehabilitation at children’s hospitals and 16,061 at other facilities. Brain dysfunction (traumatic and non-traumatic) represented a larger proportion of patients at children’s hospitals compared to other facilities (54.0% versus 43.6%). Patients at children’s hospitals had lower functional scores at admission (total DQS 43.5 versus 47.3, motor DQS 38.5 versus 42.2, cognitive DQS 56.7 versus 60.7, all plengths of stay (median 16 days versus 22 days, pefficiency (1.9 versus 1.2, pRehabilitation in a children’s hospital was independently associated with higher discharge cognitive DQS (regression coefficient 2.29, 95% confidence interval 0.35-4.23) and more efficient rehabilitation admissions (regression coefficient 0.34, 95% confidence interval 0.08-0.59).
Conclusions: Children who receive inpatient rehabilitation at children’s hospitals have a small but significantly better improvement in cognitive function and more efficient inpatient rehabilitation admissions than children at other types of facilities.
Factors Associated with Hospital Re-Admission Six Months after Stroke Rehabilitation
Katherine Yao, MD, BS; Joan Toglia, PhD, OTR/L, FAOTA; Michael Taub, MA; Michael O’Dell, MD
Objectives: To identify predictors of readmission 6 months (m) post-stroke rehabilitation
Design: A retrospective analysis of a clinical database from an inpatient rehabilitation unit (IRU) at a tertiary medical center. Of 204 stroke rehabilitation discharges, 83 (41%) with 6m follow-up were analyzed (no differences based on follow-up status.) The 83 subjects were 42% women, 59% white, and 80% with ischemic stroke with a mean (standard deviation) acute length of stay (LOS) of 13.3(16.5)d and rehabilitation LOS of 15.8(8.3)d. The dependent variable was “hospital readmission - yes or no” assessed by phone interview a mean of 6.4m post-discharge. Based on sample size and clinical applicability, 4 independent variables (IV) were chosen: age, National Institute of Health Stroke Score (NIHSS) via emergency or neurology service, modified Charlson Comorbidity Index (mCCI) score at IRU admission, and total Functional Independence Measure (FIM-D) at IRU discharge. Logistic regression assessed the ability of the IV to predict hospital readmission (p < .05 considered statistically significant.)
Results: 25/83 (30%) patients were readmitted by 6m post discharge. Mean IV scores: age=68.3(14.5), NIHSS=8.2(6.7), mCCI 1.6(2), and FIM-D=84.2(20.8). Only mCCI was significant (B=.29, SE .12, Wald X2=5.5, p=.02; Odds Ratio=1.33; 95% CI (1.0, 1.7). The model including these 4 variables demonstrated a readmission predictive accuracy of only 20% but a non-readmission predictive accuracy of 93%, with overall predictive accuracy of 71%.
Conclusions: Relative to age, functional status and stroke severity, medical complications better predict hospital readmission 6m post-stroke rehabilitation. These 4 factors, all potentially available at rehabilitation discharge, accurately identified those patients at low risk for re-admission. Our readmission rate is higher than other reports but otherwise the findings are consistent with previous studies after both acute stroke and stroke rehabilitation discharge. Our study is limited by a small sample size. Future studies should include more participants and predictor variables.
Functional Independence Restoration for Pediatric Chronic Pain on an Inpatient Rehabilitation Unit
Sara E. Williams, PhD; Andrew Collins, MD; David W. Pruitt, MD; John B. Rose, MD
Objectives: Pediatric chronic pain research shows that function improves before pain. However, children with high levels of pain and disability struggle to make functional gains in outpatient care. Inpatient pain rehabilitation allows for increased intensity and frequency of therapies in a specialized setting. This abstract examines initial outcomes of the Functional Independence Restoration (FIRST) Program for inpatient pediatric chronic pain rehabilitation.
Design: Fourteen inpatients with diagnoses of chronic amplified musculoskeletal pain conditions were admitted to the inpatient pediatric rehab unit in Year One of the program. Patients ranged in age from 10 to 17 years old; 79% of the sample was female. Average length of stay was 2 weeks. Inpatients received daily therapies from specialists in nine disciplines: physicians, nurses, psychologists, physical/occupational/recreational therapists, school teachers, and holistic health and child life specialists. Clinical outcomes were measured at baseline (Day 1) and discharge (typically Day 12). Children rated average pain levels on the Numeric Rating Scale (NRS) on a 0–10 scale; higher scores indicate more pain. The Functional Disability Inventory (FDI) measured children’s physical limitations secondary to pain; higher scores indicate more disability. The Functional Independence Measure for Children (WeeFIM) assessed performance across domains of self-care, sphincter control, transfers, mobility, communication, and cognition. Scores on the WeeFIM range from 18 (total assistance required in all domains) to 126 (complete independence in all domains).
Results: Overall, patients’ pain and functional ability improved. Pain decreased from baseline (M=7.36, SD=1.86) to discharge (M=5.86, SD=2.68), t=3.22, p < .01. FDI scores significantly decreased from baseline (M=36.21, SD=7.32) to discharge (M=17.5, SD=10.33), t=7.51, p < .001. WeeFIM scores significantly increased from baseline (M=103.29, SD=7.26) to discharge (M=119.5, SD=5.03), t=11.89, p < .001.
Conclusions: A focus on improving function was successful in helping children overcome significant disability associated with chronic pain in the context of an inpatient pediatric pain rehabilitation program.
Impact of Distraction on Brain Computer Interface Control of a Robotic Arm during a Motor Task
Lucas Brane; John Downey, BS; Michael Boninger, MD; Jennifer Collinger, PhD
Objectives: Our goal was to examine how distractions affect the performance of a brain-computer-interface (BCI) driven prosthetic arm and whether any neural correlates of distraction could be observed. We hypothesized that with increasing distraction, there would be a decrease in performance and an increase in neural firing rate.
Design: The Subject had two intracortical microelectrode arrays (MEA) implanted in her primary motor cortex. Firing rates were transformed into two-dimensional endpoint velocity command signals for a robotic arm. The Subject was instructed to move the arm between two targets as many times as possible during a 60 second trial. The following distraction variables were introduced: background noise, counting and subtracting, counting backwards by 3, using a chin joystick, and answering questions. The title’s performance (number of targets/minute), perceived difficulty rating, and neural and kinematic data were recorded.
Results: The number of targets hit, as well as, the title’s perceived difficulty rating did not show a statistically significant difference between distraction variables. The Subject reported the joystick operation distraction variable as the most difficult overall, although this rating was not statistically significant over other variables when compared across days. A significant decrease in firing rate was observed while the Subject counted backwards by 3 during the motor task. (p < 0.005) Without motor task, a decrease in firing rate was observed during background noise, counting and subtracting, and moving the chin joystick, compared to baseline (p < .005).
Conclusions: Counter to our hypotheses, no changes in performance were observed, and the only changes in neural firing showed a decrease during distraction. It is possible that the distractions were not difficult enough to impact performance on a fairly simple BCI task. In some cases, the Subject may have been more relaxed during the distraction. Overall, this is encouraging, as it appears that BCI control is robust to these types of distractions.
Impaired Memory Performance in Endothelial Nitric Oxide Synthase Knock-Out Mice after Ischemic Stroke
Shanshan Li, BS; Yao Wang, MD, MS; Yaping Huai, MD, PhD; Ze Jiang, MD; Ross Zafonte, DO; Lisa Wood, PhD, RN; Qing M. Wang, MD, PhD
Objectives: Background: Dementia is one of the most disabling deficits after stroke. Endothelial nitric oxide synthase (eNOS) has been found to play an important role in neurological function and cognition. However, it is not clear if eNOS mediates the recovery of memory after stroke.
Design: Method: We utilized the eNOS knockout mice (eNOS−/−) to study the function of eNOS during stroke recovery. Fifteen c57 BL/6 adult wild type (WT) and 17 eNOS−/− mice were titleed to 60 minutes of transient middle cerebral artery occlusion (MCAO). Functional outcomes include neurological score, limb asymmetry (cylinder test), sensory motor function (adhesive removal test), and spatial memory (Morris water maze test) were measured throughout the course of 4 weeks. The level of microglia was measured using immunohistochemistry staining.
Results: eNOS−/− MCAO mice had significantly higher number of non-performers compared to the WT MCAO mice during MWM (p=0.014). In addition, eNOS−/− MCAO mice had significantly longer time to complete the spatial memory test of MWM compared to WT MCAO mice (p=0.0042). However, the decreased performance in MWM in eNOS−/− MCAO mice was not associated with neurological or motor deficit. There were no significant differences in neurological score, adhesive removal test and lateralization index between the two groups at the third week after stroke when MWM testing was performed, even though eNOS−/− MCAO mice had higher motor deficit during the first week after stroke. Furthermore, the number of microglia in the striatum on the lesion side was significantly higher than those on the normal side in WT MCAO (p=0.020); however, such elevation was attenuated in eNOS−/− MCAO mice (p=0.38).
Conclusions: The data suggest that eNOS may play an important role in the recovery of memory after stroke. This finding may lead to development of novel intervention to enhance memory.
Inpatient Rehabilitation Outcomes of Patients Diagnosed with Venous Thromboembolism
Shanti M. Pinto, MD; Gary Galang, MD
Objectives: Investigate the impact of venous thromboembolism (VTE) on inpatient rehabilitation (IPR) transfer to acute rate, length of stay, and FIM score change.
Design: This is a retrospective case-controlled study. Patients discharged from a single IPR facility within an academic medical center between January 1, 2013 and June 30, 2014 were included. Those admitted less than 24 hours were excluded. Main outcome measures included transfer to acute hospital rate, IPR length of stay, and change in FIM scores. Initial univariate analysis was conducted using Chi-square for nominal variables. Continuous variables were analyzed with Mann–Whitney u test for nonparametric data and t-test for parametric data. All variables were entered into multivariate analyses, and non-predictive variables were eliminated using backward elimination if p-value > 0.200.
Results: During the period studied, 2312 patients were discharged from IPR, of which 113 were diagnosed with VTE prior to IPR admission and 145 were diagnosed with VTE during IPR admission. Controlling for sex and admission FIM scores, those with VTE were nearly twice as likely to be transferred to the acute hospital than those without VTE. IPR length of stay was over 4 days longer for those diagnosed with VTE prior to IPR admission and over 1.5 days longer for those diagnosed with VTE during IPR admission. There was a trend towards decreased FIM mobility score change for those with VTE diagnosed during IPR admission, but this was not significant (p = 0.100). There was no difference in total FIM score change for those with VTE diagnosed prior to IPR admission.
Conclusions: Patients diagnosed with VTE were more likely to be transferred to the acute care hospital and have longer IPR length of stay independent of admission FIM scores. There was no difference in change in FIM scores based on diagnosis of VTE.
Novel Approach to Understand Cerebral Contribution to Neurological Impairment in Patients with Cervical Spondylotic Myelopathy
Carmen M. Cirstea, MD, PhD; Joseph Burris, MD; Sorin C. Craciunas, MD, PhD
Objectives: Cervical spondylotic myelopathy (CSM) is the most common spinal cord dysfunction in adult over 50 and given the progressive aging of society, the burden of CSM is likely to increase in the future as our population ages. Although the effect of surgical treatment is likely to be beneficial, an unexplained variability in recovery remains. Because this variability appears to be influenced, at least in part, by remote brain injury or dysfunction, we investigated whether neurochemical integrity (as measured by proton magnetic resonance spectroscopy, 1H-MRS) of remote primary motor cortices (M1) is altered and correlated to neurological impairment in patients with CSM.
Design: Twenty-one patients with CSM and 16 age- and sex-matched healthy controls underwent 1H-MRS imaging assessments (volume of interest of 15x15x15 mm3 placed in hand representation in each M1). Three neurochemicals deemed most likely to be involved in brain injury/dysfunction: N-acetylaspartate (marker of neuronal mitochondrial integrity), myo-inositol (glial marker), and choline (marker of cell membrane integrity/inflammation), were quantified and compared to those in controls. Relationships between neurochemical concentrations and neurological impairment (9-Hole Peg Test, modified Japanese Orthopedic Association Scale) were also evaluated.
Results: Patients with CSM showed generally lower N-acetylaspartate and significantly higher choline across left and right M1 compared to control (p≈0.1-0.3; p=0.009 and p=0.005 respectively). Variable changes in myo-inositol concentrations were observed, albeit not statistically different from controls. Left M1 N-acetylaspartate and choline were significantly correlated with neurological impairment (r=0.56, p=0.01 and r=0.47, p=0.04 respectively).
Conclusions: Our preliminary data demonstrated significant inflammatory reaction and moderate neuronal alterations in remote M1, with the left M1 alterations related to neurological impairment. Thus, 1H-MRS might be a sensitive method to quantify relevant remote neurochemical changes in CSM, and consequently increase our knowledge of the factors leading from these changes in remote motor cortex to clinical deficits in these patients.
Personalised Pressure Ulcer Prevention in Spinal Cord Injury: Developing a Multivariate Biomarker Approach
Kath Bogie, DPHIL; John McDaniel, PhD; Jennifer Graebert, BS; Tykie Theofilos, BS; M. Kristi Henzel, MD, PhD
Objectives: Pressure ulcer (PU) development remains a highly significant source of morbidity for many with spinal cord injury (SCI). Essentially, PU development is prevented by maintaining healthy tissue under applied load. Pressure relief regimes are prescribed based on standardized thresholds. However, the continued high incidence of pressure ulcers in the SCI indicates that these regimes are inadequate.
Changes in muscle composition and functional response to applied load may provide the key to personalized risk status which the clinician can employ to determine each individual’s optimal PU prevention regime. The central hypothesis to be tested is that muscle quality is a critical objective indicator of increased PU susceptibility following SCI.
Design: Pelvic CT scans with contrast are obtained with the participant lying supine with a cushion placed under the legs to minimize soft tissue compression. Gluteal muscle composition is determined together with tissue health outcomes, including transcutaneous oxygen (TcPO2) and laser Doppler blood flow (LDF). Unloaded TcPO2 and blood flow are monitored with the individual side-lying for 10 minutes to obtain TcPO2 levels and blood flow bilaterally over the unloaded IT.
Results: Muscle composition was found to vary throughout the gluteal muscle in the current cohort of 17 individuals with SCI. The region under the ischial tuberosities had less lean muscle and more intramuscular fat infiltration (IMAT) than the proximal muscle (p < 0.05). Those with greater than 20% IMAT under the ischial tuberosities were likely to have a history of severe or recurrent PU. Mean TcPO2 decreased as IMAT increased (p < 0.05, r2=0.84). Spectral analysis showed that muscle composition primarily impacted the metabolic component of blood flow, with significant correlations between both percentage IMAT (p < 0.01,r2=0.87) and percentage lean muscle (p < 0.01, r2=0.81).
Conclusions: Changes in muscle quality impact tissue health even when the tissues are unloaded. Persons with a history of severe or recurrent PU have higher IMAT. Detailed analysis of muscle characteristics and tissue health responses can provide personalized indication of risk status. Improved risk assessment for PU development will positively impact each individual’s health status and quality of life. Current work in progress includes evaluation of biomarkers for muscle quality, inflammatory and damage status together with tissue response under load. Longitudinal follow-up will provide the basis for development of a personalized pressure ulcer risk predictive model.
Physical Medicine and Rehabilitation in the Shock Trauma Intensive Care Unit at a Level 1 Trauma Center: A Retrospective Study
Cole Linville, DO, MBA; Noelle Reyes, MS3; Joel E. Frontera, MD; Gerard E. Francisco, MD
Objectives: The objectives of this retrospective study were:
1. To determine the disposition pattern for acute trauma patients admitted to the shock trauma intensive care unit (STICU) at a level 1 trauma center with an acute care stay of least 14 days in the STICU.
2. To determine if there was a difference in patient characteristics and length of stay for patients with and without a physical medicine and rehabilitation (PMR) Consult.
Design: A retrospective clinical study was conducted of acute trauma patients admitted to the STICU at a level 1 trauma center with acute care stay days of at least 14 days. Patients admitted from January 1, 2013 through December 31, 2013 who were 16 years of age or older and had a stay in the STICU for at least 14 days were included in this study. General demographics, characteristics, and disposition were then recorded and analyzed for the 126 patients included in this study.
Results: The general demographics for the 126 acute trauma patients included in this study are as follows: average age – 42; 97 male, 29 female, Average Emergency department Glasgow coma scale (GCS) – 9.4; Injury Severity scale – 31.8; Average ICU stay – 23.6 days; Non-ICU days – 13.9 days; Length of stay – 37.5 days; Vent days – 18.3 days.
The disposition pattern for the 126 acute trauma patients included in this study are as follows: Rehabilitation (Rehab) – 33%, Long Term Acute Care (LTAC) – 27%, Home – 23%, Skilled Nursing Facility (SNF) – 10%, Death – 4%, Psychiatry/Hospitalist/Hospice – 0.7%.
Characteristics of patients with a PMR consult (64%): Injury Severity Scale - 33.4, Average ICU stay - 24 days, Vent Days - 19 days, Average Length of Stay - 39 days.
Conclusions: Multi-trauma patients comprise a significant portion of the population admitted to trauma intensive care units, and PMR consults are generally placed for these patients. Over 50 percent of these patients being discharged from a level 1 trauma center STICU are going either to Rehab or LTAC. Over 80 percent of patients are going to Rehab, LTAC, or home, which shows the importance of the PMR consult on determining where to send acute trauma patients on discharge from the acute care hospital.
Secondly, patients in the STICU with a PMR consult had a worse injury severity scale and were on the ventilator for 2 days longer compared to those without a PMR consult (19 vs 17 days). While the average length of stay was longer for those with a PMR consult (39 vs 36 days), the average ICU stay was 24 days for both groups. This retrospective study shows that patients with a PMR consult have worse injuries, but have an equal acute stay in the STICU.
Presence of Overflow Movements in Children with Traumatic Brain Injury Correlates with Corpus Callosum Segment Size
Jamie A. Schub, BA, MS; Stacy Suskauer, MD; Deana Crocetti, BS
Objectives: Children with traumatic brain injury (TBI) often have grossly normal physical exams despite persistence of cognitive and behavioral concerns. The primary objectives of this study were to characterize subtle motor movements in children TBI and to evaluate the relationship between overflow movements and corpus callosum (CC) morphology.
Design: Data were collected from 24 children at least one year after mild-complicated to severe TBI and 19 age and sex-matched controls (ages 9.93-18.65 years). Overflow movements were assessed using the Physical and Neurological Examination for Subtle Signs (PANESS). Using MPRAGE images, the CC was divided into five segments using an automated algorithm, and segment areas were computed. Independent t-tests evaluated between-group differences for PANESS scores and CC areas. Partial correlations controlling for age evaluated the relationships between PANESS scores and a) CC segment areas and, b) secondarily, performance on speeded cognitive tasks.
Results: Children with TBI had more proximal overflow movements than controls (p= 0.011). Children with TBI had smaller areas for four of five CC segments (rostral body p= 0.018, midbody p= 0.009, isthmus p= 0.043, splenium p= 0.044). In children with TBI, there was a negative correlation between proximal overflow and area of three CC segments (midbody r= −0.535, p= 0.022; isthmus r= −0.548, p= 0.018; splenium r= −0.482, p= 0.043). In children with TBI, there was also significant correlation between proximal overflow and speeded cognitive tasks (r=−0.481 to −0.663, p= 0.001-0.027).
Conclusions: Children with TBI show subtle motor exam findings in the chronic phase of recovery which are associated with CC size in regions that project to premotor and primary sensorimotor cortices and also correlate with cognitive performance. This provides an opportunity to increase sensitivity of physical examination both for milder motor effects of TBI and as a screening to determine which children may benefit from more extensive cognitive/behavioral evaluations.
Rectal Temperature: An Effective Screening Tool for Infection in Brain Trauma Unit Admissions
Yuriy Shepelyak, MD; Sara Cuccurullo, MD
Objectives: Improve detection of febrile patients being admitted to brain trauma unit (BTU).
Design: Improve fever detection among patients being admitted to BTU by performing rectal temperature measurements on patients with oral temperatures greater than 99.0. In addition, all patients being admitted had stat comprehensive metabolic panel (CMP) and complete blood count (CBC) collected as soon as they arrived to the unit, as opposed to waiting until the morning after admission. This study assessed 44 BTU admissions with 29 traumatic brain injuries, 10 strokes, 2 brain tumors, 2 anoxic encephalopathies and 1 normal pressure hydrocephalus.
Results: Oral thermometer had a fever detection rate of 1/44, while rectal thermometer had a fever detection rate of 6/44. Of these 6 patients 1 had a negative work up, and 5 had positive workups – 2 pneumonias, 2 urinary tract infections and 1 soft tissue infection. Furthermore, doing stat cbc and cmp revealed that the most common metabolic abnormalities are: anemia (28/44=68.0%), hypoalbuminemia (17/44=38.6%), elevated alkaline phosphatase [ALP] (14/44 pts = 31.8%), elevated alanine aminotransferase [ALT]/aspartate aminotransferase [AST] (13/44 pts = 29.5%). Elevated ALP together with ALT/ AST was found in 8/44 patients (18%). Subdividing patients into fever and non-fever groups revealed that these metabolic abnormalities occurred with greater frequencies among fever group compared to non-fever group; Odds ratio (OR) – Anemia (OR=1.7), hypoalbuminemia (OR=2.6), elevated ALP (OR=1.7), elevated ALT/AST (OR=1.9), and combined liver function tests (OR=3.3).
Conclusions: This is the first reported quality improvement study on stat admission labs combined with rectal temperatures in BTU patients. It highlights the value of rectal temperature in detecting early signs of infection. This early detection of infections allows for the early treatment of these BTU patients and results in the avoidance of interruption of therapies as well as avoidance of transfer of these patients to the Acute Care Hospital. In addition, the patients with fever were more likely to have associated metabolic abnormalities, which carries a more severe prognoses, a finding supported by medical and surgical literature; thus opening the door to further research on these markers in the BTU setting. Rectal temperature is a cost effective screening tool that can potentially impact acute inpatient care on a grand scale.
Safety and Efficacy of Increasing Doses of IncobotulinumtoxinA (400U-800U) for Upper and Lower Limb Spasticity: Results of the Phase III TOWER Study
Jörg Wissel, MD, FRCP; John R. McGuire, MD; Olivier Simon, MD, PhD; David Simpson, MD
Objectives: Patients with severe multifocal spasticity may benefit from botulinum toxin treatment at higher doses. This study evaluated the safety and efficacy of increasing incobotulinumtoxinA (Xeomin®) doses (400U-800U) for patients with spasticity.
Design: This prospective, single-arm, dose-titration study (NCT01603459) enrolled adult patients (18–80 years of age) with spastic hemiparesis due to cerebral causes, who were expected to require a total body dose of 800U incobotulinumtoxinA. Patients received 3 consecutive injection cycles (ICs) with 400U, 600U, and 600-800U incobotulinumtoxinA, respectively, each followed by 12–16 weeks of observation. Outcome measures included: adverse events (AEs), Resistance to Passive Movement Scale (REPAS, based on the Ashworth Scale), Goal Attainment Scale (GAS), and EuroQoL 5-dimensions (EQ-5D) questionnaire.
Results: In total, 155 patients were enrolled. IncobotulinumtoxinA dose escalation did not lead to an increased incidence of AEs (IC1:36.1%; IC2:37.5%; IC3:25.7%). The most frequent AEs were falls (7.7%), nasopharyngitis, arthralgia, and diarrhea (6.5% each). No treatment-related serious AEs occurred; 5 patients (3.2%) discontinued due to AEs.
The mean (standard deviation [SD]) change in REPAS score from each injection to 4 weeks post-injection increased throughout the study (IC1:-4.6[3.9]; IC2:-5.9[4.2]; IC3:-7.1[4.8]; p < 0.0001 for all). The proportion of patients achieving at least 3 out of 4 treatment goals increased from 25.2% for IC1, to 50.7% for IC2, and 68.6% for IC3. Mean (SD) EQ-5D QoL scores improved from 59.9 (18.9) at baseline to 69.7 (17.6) at the end of study visit (p < 0.0001).
Conclusions: Increasing incobotulinumtoxinA doses (400U up to 800U) enabled treatment in a greater number of muscles, leading to increased treatment efficacy resulting in improved muscle tone, individual goal attainment, and quality of life, without compromising patients’ safety or tolerability.
Saftey of Use of Botulinum Toxin Injections in Children under One
Supreet Deshpande, MD; Nikhil Deshpande; Mark Gormley, MD
Objectives: Children with cerebral palsy can have hypertonia and infants with brachial plexus injuries can have contractures from muscle strength imbalances that can interfere with cares, comfort, and development. Treating these muscles with botulinum toxin before the age of 1 year may improve function and minimize the adverse impact on development and care. However, in children under the age of 1 because of their small size, there is concern that botulinum toxin injections may lead to adverse effects from the toxin spreading to untargeted muscles, potentially impacting breathing, swallowing, and overall strength. This study seeks to demonstrate that treatment with botulinum toxin in children less than 1 year old can be safe.
Design: Retrospective medical chart review
Results: 23 patients (11 male, 12 female) received botulinum toxin injections before the age of 1 (3 to 12 months) at an average dose of 6 units/kg, with a range of 3 to 15 units/kg . One patient received Botulinum toxin at a concentration of 50units/cc, the rest received a concentration of 100units/cc. Ten patients were treated in the lower extremities, 7 in the upper extremities, 11 in the pectorals, 11 in the subscapularis muscles, 2 in the sternocleidomastoid, 1 in the trapezius, 3 in the sub occipital. Five out of 23 patients had only one muscle treated at the time of treatment, the rest of the patients received treatment to a combinations of muscles, and 6 received multiple rounds of injections before one year.
Conclusions: 22 patients had no reported complications. 1 patient experienced fever, vomiting and diarrhea for 1 week following the injections, but at a later injection had no adverse effects. Patients receiving injections close to the throat and chest had no complications. One child treated with a more diluted dose in the neck reported no complications. Botulinum toxin injections in children under the age of 1 appear to be safe, although further studies with a larger sample of patients should be done.
The Effect of Traumatic Brain Injury on Circulating Female Reproductive Hormones: Are Hormone Levels Prognostic Markers for Outcomes?
Mary E. McClanahan, MD; Benjamin Brusch, MD; Justin J. Gilbert, MD; Janet P. Niemeier, PhD; Jonathan Silverman, MD
Objectives: 1) To determine levels of expression of reproductive hormones (progesterone, estradiol, luteinizing hormone, follicular stimulating hormone, and cortisol in serum of 21 women ages 18 to 35 with mild to severe TBI and 21 age-matched healthy controls. 2) Obtain evidence of neuroprotective role of progesterone for women following TBI
Design: prospective case controlled design with repeated measures of serum (within 24 hours of injury and at 72 hours after injury) cognitive, functional and community participation scores (baseline and 3 month follow-up) Follow-up was done by phone. Measures: Minimental State Exam (baseline), Menstrual History questionnaire (baseline and Follow-up)), Functional Independence Measure (FIM) [baseline and Follow-up], Community Integration Questionnaire (CIQ) [Follow-up]
Results: Progesterone did not significantly affect outcomes for women after TBI. Controls had significantly higher estradiol levels than patients. Higher Glasgow Coma Scores were significantly related to high levels of FSH and LH at injury. Progesterone had a substantial, but not significant, positive correlation with social integration. Cortisol was significantly (p=.0001) higher for women with TBI than for healthy controls.
Conclusions: Findings mirror the mixed results in the brain injury literature related to gender differences in outcomes after TBI. Findings also are similar to those of Wunderle et al. (2013) in that Progesterone did not affect recovery from TBI for women in this current sample. Disruptions in menstrual cycles of women who sustain TBIs may be due to a body stress response as reflected in the high cortisol levels of our participants with TBI. More research is needed, with a larger sample to clarity the complex underlying factors in the effects of TBI on reproductive hormones and the ovulatory cycle for women.
The Hip-Spine Connection: Physical Examination Findings in Adolescent and Young Adults with Low Back Pain
Laura M. Pilgram, BA; Linda Van Dillen, PT, PhD; Heidi Prather, DO
Objectives: The objective is to describe hip physical examination findings in adolescents and young adults presenting for evaluation of low back pain (LBP) and compare pain and function in those with findings of both a hip and spine disorder to those with findings of a spine disorder alone.
Design: This is a prospective observational cohort study of consecutive patients (ages 10–23) presenting for evaluation to a physiatrist for evaluation of LBP. Validated patient reported pain, hip and lumbar spine functional questionnaires were obtained including: pain diagram, numeric pain rating (NPR), modified Oswestry Index (mODI), Rolland-Morris (RMQ), UCLA activity score, modified Harris Hip Score (mHHS), STarT Back Screening Tool, and HOOS Hip Survey. A musculoskeletal and neurological examination was performed by a single examiner and results were recorded. Specific hip tests including goniometer measurement of hip range of motion and hip provocative tests were performed. Patient characteristics, pain and function were compared between those with and without positive hip findings.
Results: 24 consecutive patients (18 women, 6 men) with a mean age of 18.9 years (SD±3 years) and mean BMI of 23.7 kg/m2 (SD±5 kg/m2 ) were enrolled. On physical examination 1) 3 (12.5%) displayed an antalgic gait, 2) 13 (54%) had < 20° of hip internal rotation and 3) 5 (20%) had 1, 6 (24%) had 2 and 10 (40%) had 3 positive provocative hip tests. Those with < 20° of hip internal rotation were found to have worse (p=.02) hip functional scores as measured by mHSS.
Conclusions: This is the first data to describe connections between hip and spine in adolescent and young adult populations presenting with LBP. Further study is needed to define how hip disorders impact and contributes to LBP. Acknowledgements: This study was funded by the Rehabilitation Research Experience for Medical Students (RREMS) Program.
The Visual Performance of Non-Native vs Native English Speakers on a Sideline Concussion Screen: An Objective Look at Eye Movement Recordings
Joel Birkemeier, MD, MBA; Janet Rucker; Todd Hudson, PhD; Weiwei Dai, MS; John Ross Rizzo, MD; Katie Dempsey; Jan Verstraete, MA
Objectives: This study investigates the differential ocular motor performance of native English speakers, as compared to non-native English speakers, on a sideline concussion screen called the King-Devick (K-D) test under objective eye movement recordings. More specifically, we tested the temporal, spatial and kinematic oculometrics of native English speakers and those who spoke English as a second language on the K-D test.
Design: A total of 54 individuals were evaluated in this study. 27 were native English speaking and 27 for whom English was a second language (ESL). A computer generated King-Devick Test was administered to all participants under infrared-based videooculographic (VOG) recordings. The individuals also completed a Bilingual Dominance Scale survey, which measures quantitatively how dominant one is in their primary versus secondary language.
Results: Test times showed significantly slower times for participants who spoke ESL, as compared to native English speakers (54.40 +/− 15.37 vs. 42.79 +/− 8.56 P=0.0014) The KD Inter-saccadic Interval, defined as the time between two task specific saccades was significantly slower for ESL2 (353.16 +/− 97.18 vs. 285.18 +/− 44.56 P=0.0021) Additionally, the total number of saccades for ESL was significantly higher (154.59 +/− 31.44 vs. 139.04 +/− 16.39 P=0.0282). Peak saccade velocity in both groups was very similar and there was no significant differences (345.14 +/− 50.66 vs. 354.87 +/− 45.78). Lastly, there were modest correlations between BDS scores and the aforementioned oculometrics. The correlation coefficient between BDS score and total test time and KDI are −0.1 and −0.3 respectively, which means if the subject has a higher BDS score (less dominant in primary language) total test time and KDI are smaller.
Conclusions: These findings highlight the performance disparities that linguistics may impose on the King-Devick Test, a rapid number naming task, often used in sideline concussion screening. While these screens are best implemented pre-season to establish intra-title baselines, potentially accounting for the performance changes of non-native English speakers, we are often not provided this clinical opportunity, and, if so, language should be considered and factored into to the interpretation
Ultrasound Determined Knee and Hip Muscle Parameters Predict Formalized Strength Measurements in Adults with Knee Osteoarthritis
Jordan Stumph, BS; Carly A. Creelman, MA; Alfred Gellhorn, MD
Objectives: Knee osteoarthritis (OA) is a highly prevalent and disabling disease, and interventions aimed at slowing its progression are urgently needed. Research has shown lower quadriceps strength in knee OA patients than matched controls and that higher knee extensor strength predicts lower pain and better physical function. Less is known regarding the role of hip muscle strength in symptomatic knee OA. However, there is a strong theoretical basis for its importance since hip musculature determines knee joint position.
We hypothesize that measuring muscle size and fat infiltration of hip abductors, hip adductors, and knee extensors with ultrasound on adults with knee OA will be feasible and correlate with formal strength measurements.
Design: We enrolled nine subjects (18 knees) with unilateral knee OA in this cross-sectional study. Muscle thickness and echo intensity of the quadriceps, hip abductors, and hip adductors were measured with ultrasound. Strength measurements were obtained with a handheld dynamometer. Pearson correlation coefficients were determined relating muscle thickness and echogenicity to strength. Parameters for the symptomatic and asymptomatic sides were compared.
Results: Ultrasound-measured quadriceps muscle thickness correlates with knee extension torque (r=.70, p=.001). Hip abductor muscle thickness correlates with hip abduction torque (r=.70, p=.001). Hip adductor muscle thickness correlates with hip adductor torque (r=.43, p=.07). Ultrasound-measured echogenicity negatively correlated with torque for hip adductors (r=−.62, p=.006) but was not significant for other muscle groups. No significant difference in muscle thickness or force was found between symptomatic and asymptomatic sides.
Conclusions: This is the first report of the correlation between ultrasound muscle measures and strength in adults with knee OA. Ultrasound-measured muscle thickness strongly correlated to formalized torque measurements of knee extensors, hip abductors, and hip adductors. Obtaining these measures in a clinical setting is feasible and may help guide exercise therapy prescription, as well as provide a longitudinal biomarker.
Upper Urinary Tract Imaging and Assessment in a Cohort of Veterans with Spinal Cord Injuries or Disorders
Sophia Miryam Schüssler-Fiorenza Rose, MD, PhD; John P. Lavelle, MD
Objectives: 35% of SCI/D veterans are estimated to have renal insufficiency, a complication of neurogenic bladder. The VA Handbook on the Continuum of Care for SCI/D veterans recommends annual upper urinary tract (UUT) and creatinine evaluations. This study examines compliance with these recommendations.
Design: A retrospective cohort study of VISN21 veterans with SCI/D (n = 1954) using the VA National Patient Care Databases (FY2000-to FY2012) was performed. Outcomes are percent SCI/D veterans receiving yearly upper UUT assessment and creatinine measurement. Manual chart review verified participant SCI/D status. UUT or renal function assessment was determined by the presence of appropriate ICD-9 codes. Exclusion criteria were death in first study year or new injury in last study year (n=143). The cross-sectional percentage of veterans with UUT evaluation on a per year basis and the longitudinal percentage (number of years a veteran received required assessment over total years eligible) were calculated.
Results: Upper urinary tract assessment was performed annually for only 2.3% of this veteran cohort during the 12 year study period. 14.6% had an UUT assessment in 50% or more of eligible years whereas 37.4% had none. On average, 22.8% (range 7.9% – 31.9%) received UUT each year. UUT imaging (average 20.8% per year) was more frequent than advanced renal function assessment (8.8%). 41.6% of the cohort had an annual creatinine measurement. 41.5% had a measurement in at least half of eligible years. 3.4% had no creatinine measurement.
Conclusions: 1) Few veterans with SCI/D received annual upper urinary tract assessments. 2) Annual Creatinine measurements were performed in < 50% of the cohort. Neurogenic bladder can lead to renal insufficiency and failure, which may be prevented or alleviated by prospective monitoring of the UUT for anatomical changes and function. The identification of barriers to the recommended follow-up should be a high priority.
Use of an Artificial Spinal Cord in the Treatment of Spinal Cord Injury
Radhika Sharma, BS; Asad Mazhari, MD; Taania Girgla; Tonya J. Whitehead, BS, MS; Richard R. Honablue, MS, MD; Harini G. Sundararaghavan, PhD; Jay M. Meythaler, MD, JD; Jean Peduzzi, PhD
Objectives: The goal of this study is to combine a number of strategies for spinal cord repair and arrange them to mimic the normal organization of the spinal cord to create an ‘artificial spinal cord’. We have attempted to replace damaged elements (neurons, support cells) and encourage the growth of ascending and descending axons while also addressing injury-induced changes. We hypothesize that the artificial spinal cord will cause functional improvement and morphological changes in the spinal cord after producing a spinal cord injury through spinal cord segment removal.
Design: Twelve male Lewis rats were used in this study and were randomly assigned to one of three groups. The first group acted as controls and underwent a sham surgery consisting of a laminectomy from T9-T11. The second group underwent a spinal cord segment removal and a blank hydrogel was implanted. The third group underwent a spinal cord segment removal and the hydrogel implanted contained stem cells, neurotrophic growth factors, an enzyme to prevent scar formation around the injury site, and a scaffold base of aligned electrospun fibers. Outcome measures are being assessed by BBB score, beam test, Hargraves test, and the inclined plane test. Data will be analyzed via a two-way ANVOA with a Scheffe post hoc comparison. Statistical significance is considered to be present at P < 0.05.
Results: The spinal cord injured rats have undergone environmental enrichment, exercise, and behavioral testing in the weeks since their injury. Performance in Group 3 (artificial spinal cord) has improved and is better than Group 2 (blank hydrogel) but significance has not yet been reached. Testing is continuing in these rats.
Conclusions: This study is still in progress. The combination of several treatment approaches, that have each previously demonstrated functional improvement, could lead to results which would greatly benefit the development of effective treatment for individuals with spinal cord injuries.
Using Outreach as an Opportunity to Expand Diversity in the PM&R Residency
Julia L. Iafrate, DO; Ryan C. C. Kruse, MD; Stephen J. Wisniewski, MD
Objectives: The purpose of this outreach project is to break down barriers to diversification in the Physical Medicine and Rehabilitation (PM&R) program at Mayo Clinic. Funding new initiatives is always challenging, especially in the era of the Affordable Care Act. In a historically non-diverse hospital system, the PM&R department has attempted to create opportunities for integration of individuals from different backgrounds. Recently, a unified effort has been undertaken to increase exposure to special programs for underrepresented minorities and individuals with disabilities at the Mayo Clinic. The PM&R Diversity and Inclusion Committee has a goal to include core faculty and residents in performing outreach in underrepresented medical communities when traveling for national meetings.
Design: In collaboration with the Mayo Office for Diversity, and in an effort to be cost-effective, faculty members were encouraged to visit nearby medical schools during conference travel to answer questions about the residency program. Schools that were identified as high-yield based on the enrollment of underrepresented individuals were strategically targeted. Key support from the executive committee in allotting extra time for travel, facilitating networking efforts, and assisting in website development was essential to this project’s success. Engaging Mayo staff or alumni who were graduates of the schools visited added another layer of connection to the interactions.
Results: Since starting this initiative, the number of underrepresented medical students that have applied to the PM&R residency program or come for visiting student rotations has increased. This recent success speaks to the great potential of this new approach.
Conclusions: This effort is cost-effective and has helped expose underrepresented students to the Mayo PM&R residency program. We have established this process as a routine component of our academic and educational travel within the department. In the future, as PM&R alumni of these underrepresented schools grow, it will further enhance the authenticity of the outreach program.
Utilization of Physical Therapy to Treat Degenerative Lumbar Spondylolisthesis from 2000-2011
Joseph A. Sclafani, MD; Alexandra Constantin, PhD; Pei-Shu Ho, PhD; Venu Akuthota, MD; Leighton Chan, MD
Objectives: Degenerative lumbar spondylolisthesis is a deformity often identified in symptomatic low back pain. Physical therapy is frequently used as a first line treatment in newly diagnosed spondylolisthesis to develop trunk muscle balance, improve functionality and decrease overall pain. This study is an analysis of physical therapy utilization to manage degenerative spondylolisthesis in Medicare beneficiaries from 2000 through 2011.
Design: This study used an initial cohort comprised of 5% of all patients with ICD-9 codes for back pain recorded in the Centers for Medicare and Medicaid Services Carrier file, Outpatient file, or Inpatient file, from 2000 to 2011. A cohort of beneficiaries with a new ICD-9 diagnosis code for degenerative lumbar spondylolisthesis was isolated. Beneficiaries with a concurrent diagnosis of lumbar trauma, infection or malignancy were excluded. Current billing codes for several modalities of physical therapy from 2000-2011 were used to identify the number of procedures performed each year on this cohort, using the CMS Carrier file. Numbers are reported as 15 minute billing units unless otherwise stated.
Results: A total of 95,647 individuals with a new diagnosis of degenerative spondylolisthesis were included in the analysis. There were 104,373 initial evaluations for physical therapy performed within this cohort. Range of motion and flexibility exercises accounted for 1,148,328 billing units. Active modalities of strengthening accounted for 554,274 units (47,122 units gait training and stair climbing; 251,511 units dynamic functional performance; 255,641 units neuromuscular re-education). There were 1,274,420 units of passive modalities (89,241 units massage therapy; 150,046 units electrical stimulation; 343,826 units of ultrasound; 691,307 units of manual traction) and 47,146 total billing units of water therapy.
Conclusions: Physical therapy is a commonly prescribed treatment modality for degenerative spondylolisthesis. Within this cohort, a greater proportion of therapy time was spent performing passive modalities compared to active modalities of truncal strength and stabilization exercises.
Variations in Rehabilitation Regimens and their Impact on Treatment Outcomes for Rotator Cuff Tears
Cristina Page; Emily N. Peterson, MS; Gregory D. Ayers, MS; Nitin Jain, MD, MSPH
Objectives: Patients with rotator cuff tears are commonly referred for non-operative treatment. There is a lack of data on use of physical therapy techniques, compliance with programs, and home-based therapies. Our objective was to assess variations in rehabilitation programs and their impact on outcomes for degenerative rotator cuff tears.
Design: Subjects: Patients with rotator cuff tears confirmed on clinical examination and imaging. Methods: Our ongoing longitudinal cohort study includes data from 108 patients undergoing non-operative treatment for rotator cuff tears. All patients were prescribed physical therapy and were considered compliant if they reported performing exercises by six-month follow-up. Each participant completed questionnaires at enrollment, and 3, 6, and 12 months of follow-up. The Shoulder Pain and Disability Index (SPADI) was our primary outcome measure.
Results: Mean SPADI scores showed significant improvement by final follow-up (45.6 +/−24.4 to 25.3 +/−22.8), with pain subscores decreasing at a higher rate than disability scores. The compliance rate with physical therapy was 88.6%. There were similar patterns of decrease in SPADI for patients doing physical therapy with a therapist versus those performing exercises at home only. The most commonly used techniques were stretching (46%), strengthening (45%), bands (32%), and weights (33%). Patients performing strengthening or stretching exercises had better outcomes by 6 months than those not performing strengthening or stretching.
Conclusions: Physical therapy can result in significant clinical improvement for patients with degenerative rotator cuff tears. Patients undergoing rehabilitation with a physical therapist had similar outcomes as compared with those performing exercises only at home. Patients who incorporated stretching or strengthening into their rehabilitation program had better pain and function as compared with patients who were not stretching or strengthening. This data can be used to design a standardized evidence-based rehabilitation program for non-operative treatment of rotator cuff tears.
Vitamin D Deficiency in Elderly South-East Asian Patients Admitted to a Rehabilitation Unit in Sunny Singapore
Keng Kong, MD
Objectives: The objectives of this study were to investigate the prevalence of vitamin D deficiency in a cohort of elderly South East Asian patients admitted to a rehabilitation centre in sunny Singapore and to establish factors associated with vitamin D deficiency.
Design: This was a prospective study of 134 patients aged 65 years and older admitted to a tertiary rehabilitation unit over a 15-month period. Data collected included patient demographics (age, gender, ethnicity, body mass index), pre-morbid ambulatory status using the Functional Ambulation Category, frequency of falls over the past 2 years prior to current hospitalisation, rehabilitation diagnosis for admission, medical co-morbidities, calcium and vitamin D supplementation (defined as taking supplementation for at least 5 days a week for the past one month as reported by the patient) and functional status on admission to and discharge from rehabilitation as measured on the Functional Independence Measure.
Bloods for 25-hydroxyvitamin D3 (25OHD3) level was taken within 7 days of rehabilitation admission. Serum calcium, phosphate, albumin, magnesium and parathyroid hormone (PTH) levels were also measured. We defined vitamin D deficiency using Holick classification as follows: vitamin D deficiency is considered when vitamin D level A vitamin D level ≥30 ng/mL is considered normal/
We analyzed the data using SPSS version 16. We used univariate logistic regression analysis to ascertain factors associated with Vitamin D deficiency. The factors studied were age, gender, ethnicity, body mass index, calcium and/or vitamin D supplementation, premorbid ambulatory as measured on the FAC, recurrent fallers (history of ≥ 2 falls in the previous 2 years before admission) and FIM score on admission to rehabilitation. We considered a P value of < .05 to be statistically significant.
Results: The mean age was 72.0±5.7 years, and there was a slight preponderance of male patients (58.2%). Ethnically, the majority of patients were Chinese (88.1%). Stroke was the commonest rehabilitation diagnosis (49.3%) 59 patients (44%) had Vitamin D deficiency and 56 (41.8%) had Vitamin D insufficiency. On univariate analysis, age, gender, calcium and/or Vitamin D supplementation, premorbid ambulatory status and mean admission FIM score were not significantly associated with Vitamin D deficiency. Only race and recurrent fallers were significantly associated with Vitamin D deficiency. Malays/Indians and recurrent fallers were more likely to be at risk of Vitamin D deficiency. Among the recurrent fallers, those who had ≥ 3 falls had significantly lower mean 25OHD3 levels than those with 2 falls (15.9±7.4 ng/ml compared with 20.8±1.7ng/ml, p=0.006). On multivariate logistic analysis, race and recurrent fallers remained significant independent factors associated with Vitamin D deficiency.
Conclusions: There is a high prevalence of Vitamin D deficiency and insufficiency in this study. Routine screening of Vitamin D levels should be considered given the significant impact of Vitamin D on musculoskeletal function.
Determinants of Recovery from a 161-km Ultramarathon
Joseph Chin, BS; Natalie Badowski, MD; Kristin Stuempfle, PhD; Carol Parise, PhD; Martin D. Hoffman, MD
Objectives: This study examined short-term recovery from a 161-km ultramarathon through functional and subjective measures, and explored which factors determined the rate of recovery.
Design: Participants of the 2015 161-km Western States Endurance Run completed two 400 m runs at maximum speed during the 21 days before the race and on days 3 and 5 after the race, underwent a blood draw for plasma creatine kinase (CK) concentration post-race, and provided lower body muscle pain and soreness ratings (10-point scale) and overall muscular fatigue scores before the race, immediately after the race and for the subsequent 7 days.
Results: Among the 72 race finishers completing the study, 400 m run times were 26.3% slower (p=0.001) at day 3 and 12.4% slower (p=0.01) at day 5 compared with pre-race times. Muscle pain and soreness ratings and muscular fatigue scores had statistically returned to pre-race levels by 5 days post-race. Lower body muscle pain and soreness across the recovery period was modeled by time (decreased by 1.1 points each day), post-race plasma CK concentration (0.8 and 1.5 points higher for CK value of 10,001-27,999 and ≥28,000 U/L compared with ≤10,000 U/L, respectively), and age (0.4 points lower for each decade of aging).
Conclusions: Post-race plasma CK and age are the main determinants of resolution of lower body muscle pain and soreness following an ultramarathon. Appropriate training would be recommended to attenuate muscle damage and optimize ultramarathon recovery.
Melanoma in Lower Limb Deformity- M. I.L. D. Physiatry Assessment and Treatment
David Berbrayer, MD
Objectives: To develop a multidisciplinary clinic involving treatment of lower limb melanoma and evaluate outcome
Design: The largest academic melanoma group- oncology and plastic surgery in acute care- approached Physiatry in acute care to develop a team to manage complications following chemotherapy and lower extremity limb slavage procedure to restore function and quality of life in patients treated with melanoma.A team was formed consisting of Physiatrist, Physiotherapist, occupational therapist, pedorthotist, podiatrist, nurse, prosthetist and orthotist to evaluate each patient within 4–6 weeks of surgery and develop a treatment plan.Complications of treatment included: wound care managment, foot drop, peripheral neuropathy, partial foor amputation, managment of pain, and enhancing physical activity and improving quality of life. This clinic has now been operating for 6 months. The first challenge was the acuity of the referral in acute care and organizing the team for best outcomes.Further diagnostics included a detailed physiatric history and examination, EMG and Nerve conduction study, imaging studies of affected parts. Treatment included: wound healing, pain management, orthopedic footware and orthotics, ankle foot orthosis, prosthesis and an active physiotherapy program. Family members and education was conducted throughout the rehabilitation managment and the clinic included physiatry residents and undergraduate medical students.The Physiatrist met regulary with the oncologist and palstic surgeons and educated the surgeons about levels of amputation and best outcomes.This new intervention resulted in a change of praxctice for the plastic surgeons with not only performing life saving surgery but also considering function and quality of life.
Results: In 6 months:
6 males, 4 females
age range: 25–50
2 high school educated, 8 university
all married or partners
2 peripheral neuropathies successful pain mangement control and iagnosed and monitored with EMG / nerve conduction
1 foot drop treated with AFO
4 partial foot treated with extradepth footwear and orthotics
3 transtibial amputations with prosthesis.
1. This is an example of partnership between surgery and oncology in acute care large academic facilities and role of Physiatry
2. All patients involved in exercise program which improved physical and cognitive outome.
3. Diagnostics assisted in care delivery of all patients who reported satisfaction
4. Education of surgeons and oncology creates ongoing dialogue discussing best evidence based care
5.This unique clinic is now applying for funding to sustain activity and grants to explore future research opportunities
Poster Presentations Thursday, February 18, 2016
Atypically Presenting Spontaneous Lumbar Spondylodiscitis: A Case Report
Rodion Erenburg, MD; Jameel Khan, MD; Margarita M. Nunez, DO; Sanjeev Agarwal, MD
Case Diagnosis: Atypically presenting spontaneous lumbar spondylodiscitis.
Case Description: A previously healthy 41 year old male presented to physiatry clinic with complaints of severe, non-traumatic lower back pain radiating to his right flank which began insidiously over 1 week. Pain was rated as 10/10, exacerbated by valsalva, alleviated by rest. He initially presented to the ED 4 days prior where a CT of abdomen and pelvis was unremarkable and he was discharged home with pain medication without relief. By the time of his clinic visit, the patient’s pain had worsened progressively to the point where he was no longer able to ambulate independently. He denied having fever, chills, weakness, urinary or bowel incontinence. On exam, the patient was distressed but had no neurological deficits. MRI of L-spine revealed a broad based central L5-S1 disc herniation with extensive inflammatory changes and adjacent vertebral body marrow edema. Patient was admitted for inpatient workup. Tissue biopsy was negative for gram stain and pan cultures grew no organisms. Neurosurgery recommended no intervention. Patient remained afebrile and was managed conservatively with oral steroids and pain medications. Patient was discharged home on the seventh hospital day with no neurological deficits, minimal low back pain and outpatient physical therapy program.
Discussions: Spontaneous spondylodiscitis is quite uncommon in the general population. Diabetes or recent invasive spinal procedures carry an increased risk. Classic signs include constitutional symptoms, focal neurologic deficits and positive blood cultures which were all absent in this case. Prompt diagnosis and early neurosurgical evaluation can greatly reduce morbidity from potential neurological sequelae.
Conclusions: Clinicians need to maintain a high level of suspicion for inflammatory spondylodiscitis as this condition may present atypically and carries significant morbidity if not promptly diagnosed.
A Case of Anterior Interosseous Nerve Syndrome with a Martin-Gruber Anastamosis
Steven Chan, MD
Case Diagnosis: Martin-Gruber anastamosis is a pattern of anomalous innervation, where nerve fibers typically travel along the anterior interosseous nerve to innervate many of the intrinsic hand muscles. This innervation pattern does not produce any clinical symptoms, but with an anterior interosseous neuropathy, the clinical presentation can be difficult to diagnose. This is a case report of an anterior interosseous neuropathy occurring in the setting of a Martin-Gruber anastamosis.
Case Description: A 55 year old woman presented to the electrodiagnostic lab with right arm weakness for 2.5 months, without antecedent trauma. She initially noticed difficulty twisting a key in the car ignition, and that progressed to weakness with gripping and twisting objects. She also described numbness in her right hand and all of her fingers, especially apparent when waking in the morning. Physical examination revealed weakness with finger abduction, thumb interphalangeal joint flexion, index and long finger distal interphalangeal joint flexion, and pronation. She also had difficulty opposing the tips of her right thumb and index finger in an attempt to make an “OK” sign. Needle electromyography (EMG) revealed acute denervation and reduced recruitment in the right flexor digitorum profundus (slips to the index and long fingers) and first dorsal interosseous muscles, and reduced recruitment in the flexor pollicis longus muscle. Needle EMG was normal in the right deltoid, biceps, triceps, pronator teres, flexor digitorum superficilais, flexor digitorum profundus (slips to the ring and small fingers), and opponens pollicis muscles. Nerve conduction studies were negative for an ulnar neuropathy at the wrist and elbow, but did reveal a mild sensory median neuropathy at the right wrist (Combined Sensory Index was greater than 1.2 milliseconds). Further nerve testing also demonstrated a Martin-Gruber anastamosis in her right upper extremity. Given the denervation in the anterior interosseous nerve (AIN) -supplied muscles, along with the normal needle EMG of other median-innervated muscles, she was diagnosed with an anterior interosseous neuropathy. In the setting of a Martin-Gruber anastamosis, this resulted in denervation in the distally-supplied ulnar-innervated muscles, which explained her finger abduction weakness and the denervation seen in the first dorsal interosseous muscle (in the absence of an ulnar neuropathy on nerve conduction studies). The conclusion was that the patient had a Martin-Gruber anastamosis, with a superimposed anterior interosseous neuropathy. The patient was managed conservatively, with relative rest, therapy exercises for the right upper extremity, and a steroid injection into the carpal tunnel (for her hand paresthesias). Her symptoms improved, and on a follow-up visit with the orthopedist, she regained strength in her thumb and finger flexors and finger abductors.
Discussions: The AIN is a branch of the median nerve, with purely motor function. Compression of this nerve result in weakness in thumb interphalangeal joint flexion, index and long finger distal interphalangeal joint flexion, and pronation. AIN syndrome is rare, accounting for less than 1% of all upper extremity compression syndromes, and electrodiagnosticians must have a high awareness of this condition to aid in diagnosis. Martin-Gruber anastamosis is an anomalous innervation seen in 7.7 to 34% of the population. This neural communication usually involves nerve fibers traveling along the median nerve and branching off the AIN, to innervate the adductor pollicis, first dorsal interosseous, and abductor digiti minimi muscles. This condition does not cause any clinical symptoms, but in the setting of an AIN syndrome, the distal muscles are affected. This patient presented with signs of weakness that were consistent with an AIN syndrome, but that did not explain her finger abduction weakness. Further electrodiagnostic testing revealed the patient’s Martin-Gruber anastamosis. With this underlying anomalous innervation, the AIN syndrome produced weakness with her finger abductors, as well as the denervation seen on EMG of the first dorsal interosseous muscle. Like many people with AIN syndrome, she recovered spontaneously over 6–8 weeks.
Conclusions: This case report presents a patient with anomalous innervation combined with a rare neuropathy. Anteriour interosseous neuropathy accounts for less than 1% of all upper extremity compression syndromes. Electrodiagnosticians must have a high clinical suspicion of this condition to diagnose it, especially in the setting of anomalous innervation such as a Martin-Gruber anastamosis.
A Case of Bilateral Femoral Head Avascular Necrosis in a Young Healthy Female
Usman Choudhry, DO; Kevin Jiang, MD; Sonia Shetty, MD
Case Diagnosis: Bilateral Femoral Head Avascular Necrosis in a Young Healthy Female
Case Description: The patient is a 54-year-old female with progressive atraumatic bilateral groin and hip pain for the last six months. She had a prior history of pelvic fracture 30 years ago but was otherwise healthy with no significant medical history or prior functional deficits. In the last 3 months, the pain became severe to the point that she required a cane to ambulate and could not sit for prolonged periods of time. She had been to five separate hospitals and underwent magnetic resonance imaging (MRI) of her hips and pelvis, which did not reveal any abnormalities. She presented to our emergency department to seek another opinion. The patient reported smoking one cigarette per day and had one to two beers per week. She had no prior history of steroid use, denied heavy alcohol use, and denied a history of diabetes or thyroid disease. Her family history was positive osteoarthritis.
On physical examination, the patient was 5’5”, 150 pounds, and a BMI of 55. She had a notable antalgic gait with a positive trendelendberg bilaterally. Her lower extremity motor strength was 5/5. Her sensation was intact and her pulses were normal. Both hips flexed to about 90 degrees, externally rotated to 5 degrees, with internal rotation to neutral, abduction at 5 degrees, and adduction at 5 degrees.
Pelvic x-rays revealed bilateral femoral head avascular necrosis with femoral head collapse. The patient decided to have bilateral anterior approach total hip replacements. Surgery was successful and without complication. Patient was admitted to the PM&R service after postoperative day 3. She made excellent progress and by discharge was transferring independently, walking up to 500 feet and was able to navigate 6 stairs.
Discussions: Avascular necrosis (AVN) of the femoral head is a pathologic process that results from interruption of blood supply to the bone. This ischemia usually results in the death of marrow and osteocytes subsequently collapsing of the necrotic segment. AVN is a poorly understood condition that can be traumatic or nontraumatic. An increased frequency of idiopathic cases are being observed. This was an unusual case where no etiologic factor was identified and yet the patient presented with bilateral nontraumatic avascular necrosis. Many associated risk factors for avascular necrosis have been identified including glucocorticoid use, heavy alcohol usage, thyroid disease, thrombophilic disease, none of which this patient possessed. Furthermore, the diagnosis took over 6 months despite having seen several providers along with an MRI evaluation. It has been shown that early diagnosis of the disease will most likely avoid late damage of joint destruction. Chemotherapy and kidney transplants are frequently associated with the disease. Whereas previously the temporary operational joint preservation and subsequent joint replacement were often the only option of treatment, conservative and joint-preserving measures today play an increasing role. Rehabilitation can assist the patient with decreased pain and improvement in function.
Conclusions: Despite no identifiable risk factors, this case of prolonged bilateral hip pain and gait dysfunction in a young, previously healthy person highlights the importance of appropriate early testing. Atraumatic bilateral femoral head avascular necrosis should continue to remain in the differential with close followup. If left untreated, it can lead to a subchondral fracture then subsequent collapse.
A Case of Leptomeningeal Neurosarcoidosis
Justin Louis Weppner, DO; Austin Albright, MD; Geoffrey R. Smith, MD; Nina Baker, MD, MPH
Case Diagnosis: Complete T7 paraplegia secondary to leptomeningeal neurosarcoidosis.
Case Description: A 57-year old female patient presented to a tertiary academic acute care hospital with a headache, generalized weakness, inability to ambulate, lumbar back pain, generalized paresthesia, and urinary incontinence. Magnetic resonance images (MRI) of the cervical, thoracic, and lumbar spine where obtained and revealed innumerable areas of nodular enhancements throughout the cervical, thoracic, and lumbar spine concerning for tumor. MRI of the brain without contrast revealed diffuse nodular leptomeningeal enhancement most prominently at the basal cisterns. The patient was admitted to the hospital with a diagnosis of cauda equina syndrome secondary to nodular tumor. Her condition continued to decline progressing to complete T7 paraplegia with mixed upper and lower motor neuron findings. Over the course of treatment the patient began to develop intermittent bowel incontinence and dysfunction with intact lower sacral reflexes. Chest computed tomography revealed multiple enlarged supraclavicular, mediastinal, and hilar lymph nodes concerning for malignancy versus sarcoidosis. Lymph node biopsy revealed prominent inflammatory infiltrate characterized by abundant non-necrotizing granulomas suspicious for sarcoidosis versus inflammatory process. An extensive work-up was conducted for infectious etiology including bacterial, fungal, and viral process that was negative. Laboratory evaluation was significant for an elevated serum C-reactive protein and lactate dehydrogenase. Serum angiotensin-converting enzyme level was normal. The patient was started on methylprednisolone 1 gram daily for three days resulting in minimal improved sensation to her lower extremity. She was transitioned to oral prednisone 80 mg daily with a plan for a slow taper over the next two months and was started on mycophenolate mofetil 500 mg twice a day. The patient was admitted for comprehensive rehabilitation. On discharge from inpatient rehabilitation she had an overall positive Functional Independence Measure score change of 6 points. The patient’s rehabilitative course was complicated by poor cognition and insight into her medical condition thought to be secondary to sarcoid infiltration into the brain. The patient was discharged home in the care of her husband with home health physical therapy and a plan for Physical Medicine and Rehabilitation follow-up. The patient is currently being treated for neurosarcoidosis as an outpatient.
Discussions: Sarcoidosis involving the spinal cord is extremely rare, affecting less than 1% of patients with sarcoidosis. The cervical and thoracic cords are most frequently involved, and there is often patchy involvement. Imaging will often suggest a spinal cord tumor. Patients with spinal cord involvement often have elevated C-reactive protein and lactate dehydrogenase. Serum angiotensin-converting enzyme level is usually not elevated. Examination of the cerebral spinal fluid may reveal elevated protein, leukocytosis, and oligoclonal bands. Treatment is achieved most frequently using corticosteroids and immunosuppressant medications. Patients are usually steroid dependent and tapering can result in clinic worsening of the patient’s condition. Laminectomy and subsequent biopsy is often performed to confirm the diagnosis. More extensive surgery, when used to decompress the spinal cord, has been associated with a decline in neurologic function postoperatively in the neurosarcoid population because of the unpredictable nature of the disease course and inflammation. Spinal cord sarcoidosis can be monophasic, relapsing-remitting, or progressive in nature resulting in moderate to severe disability.
Conclusions: Neurosarcoidosis is a rare and often a diagnostic challenge because it can be the first presentation of the disease. The diagnosis is dependent on exclusion of neoplasm, infection, and demyelinating diseases and is supported by demonstrating systemic sarcoidosis. The diagnosis may require laminectomy and biopsy of the spinal cord if other systemic areas are not available for biopsy, however, the disease is not treated with spinal cord decompression even when there are arthritic changes. Mainstay of treatment includes corticosteroids and immunosuppressant medications. Neurosarcoidosis patients have similar neurologic deficits to nontraumatic spinal cord injury but may have fluctuations in neurologic status, require management of steroid and immunosuppressive medications, and respond unpredictably to surgical decompression. The physiatrist should be aware of the clinical presentation, diagnosis, treatment, and prognosis in order to guide the rehabilitation course.
A Case of Post-Surgical Gouty Arthritis Presenting Like Sepsis after Knee Joint Replacement: A Case Report
Hana F. Azizi, MD PGY-4; Antonio Howard, MD; Gary Inwald, DO
Case Diagnosis: A 64-year-old woman with a history of obesity and osteoarthritis was admitted to the acute inpatient rehabilitation three days after elective left total knee replacement.
Case Description: On admission she reported pain in the right knee out of proportion to her exam. She had chills without fever, severe limited range of motion with no erythema, swelling or right knee joint tenderness. Two days later, she developed high-grade fever. Initial labs including CBC and cultures were negative for signs of infection. Subsequent labs showed elevated erythrocyte sedimentation rate (ESR 139), C-reactive protein (CRP 18), and Uric acid (11.6). X rays of the right knee and ankle joints were unremarkable. She was started on colchicine for clinical suspicion of gout attack and she underwent intra-articular steroid injection to the right knee. The patient responded quickly to these measures and showed decreased pain and improved range of motion in the right lower extremity after 2–3 days and was able to participate in therapy. Repeat labs on day 10 of admission showed CRP of 0.4, ESR of 100.0 and uric acid of 10.0 – all trending downwards.
Discussions: Most cases of gout attack present with excruciating pain, tenderness, erythema, warmth and swelling in one joint. Our patient underwent different diagnostic tests and consultative evaluations due to an unusual presentation of gout. The severely limited range of motion and pain in her right lower extremity affected early ambulation and prolonged her hospital stay. A study on post-surgical patients with gout showed similarly extensive workup due to febrile episodes in these patients.
Conclusions: Gout attacks are extremely painful and can be precipitated by trauma and surgery. Uric acid of 9 or higher is a risk factor for postsurgical gout attack. Atypical presentation of gout should be considered in patients with fever, limb pain and elevated uric acid. Early and accurate diagnosis facilitates early appropriate intervention that reduces the impact on post-surgical recovery.
A Case of Profound Generalized Weakness Due to Nonsystemic Vasculitic Neuropathy Misdiagnosed as Acute Motor and Sensory Axonal Neuropathy
George Marzloff, MD; Ajax Yang, MD, MPT; Anne Felicia. Ambrose, MD, MS
Case Diagnosis: nonsystemic vasculitic neuropathy
Case Description: A 68-year-old female with hypertension, diabetes, and hepatitis C presented with bilateral upper and lower extremity distal weakness, distal lower limb sensory loss, hyporeflexia, intermittent low-grade fevers and weight loss. Electromyography (EMG) revealed sensorimotor axonal polyneuropathy with denervation in arm and leg, which was consistent with acute motor and sensory axonal neuropathy (AMSAN), a Guillain-Barre Syndrome (GBS) variant. However, the patient did not respond to a five-day course of intravenous immunoglobulin (IVIG).
Differentials included vasculitic neuropathy (VN), nutritional deficits, toxins, and paraneoplastic syndromes. Further investigations revealed elevated C-reactive protein (155.8 mg/L) and ESR (123 mm/hr). ANA, ANCA, cryoglobulins, creatine kinase, and ganglioside antibodies were negative. Gastrocnemius biopsy showed transmural inflammation of vessels. Sural nerve biopsy demonstrated loss of large- and small-caliber myelinated fibers with ongoing axonal degeneration. These findings were consistent with peripheral medium-vessel vasculitic neuropathy. The patient was then started on systemic glucocorticoids and cyclophosphamide after which the patient made rapid improvements in her functional status.
Discussions: GBS presents as rapid-onset muscle weakness due to autoimmune-induced peripheral axonal demyelination. VN weakness results from peripheral nerve inflammatory ischemia. VN is typically associated with systemic vasculitides (e.g. Wegener’s syndrome, Churg-Strauss syndrome, polyarteritis nodosa or cryoglobulinemia) but may present in isolation as in our patient. Diagnosis requires EMG, nerve conduction studies, and neuromuscular biopsy. First-line treatment of GBS is IVIG or plasmapheresis, whereas VN requires glucocorticoids, plus immunosuppressive therapy for severe cases.
Conclusions: Rehabilitation physicians should consider re-evaluating patients who were diagnosed with GBS who do not respond in an appropriate fashion. Our patient was initially treated for AMSAN but only showed functional improvement after VN was correctly diagnosed and treated with glucocorticoids.
A Case Report of Epidural Lipomatosis Complicating Treatment of a Patient on Chronic Prednisone for Transverse Myelitis
Samuel T. Clanton, MD, PhD; Leslie Rydberg, MD
Case Diagnosis: A 43 year old man with past medical history including neurosarcoidosis and C4-7 transverse myelitis diagnosed in 2010 and chronically on varying doses of prednisone presented to an acute care facility with worsening upper and lower extremity weakness. MRI revealed active demyelination at C6 and abnormal signal and edema from C2-T2, as well as the presence of thoracic lipomatosis. He was admitted and given 1 g methylprednisolone x5 days and an infusion of Remicade. He was discharged on 60 mg daily prednisone.
Case Description: The patient was then admitted to acute inpatient rehabilitation (AIR). Neurologic exam on transfer showed 2/5 lower extremity flexor and 3/5 extensor and ankle strength, and at least 4/5 strength in his upper extremities. After three weeks of progressive improvement in rehabilitation, the patient noticed subtle deterioration in his lower extremity strength. His neurologic exam was variable during this period, but within 4–5 days, the patient was unable to activate his hip or knee flexors. MRI revealed improvement in his prior inflammatory lesions but dramatic worsening of the previously noted lipomatosis, causing compression of his spinal cord from T6-T8. He then underwent T4-T10 right hemilaminectomy and decompression and later transferred back to AIR to complete rehabilitation.
Discussions: Spinal epidural lipomatosis (SEL) is a rare condition in which fat tissue proliferates in the extradural space and can cause spinal cord compression. It is most commonly associated with exogenous steroid exposure and most commonly effects the thoracic or lumbosacral spine. SEL is important to recognize as it can mimic primary neurologic diagnoses such as transverse myelitis but can be caused by the steroids used to treat them.
Conclusions: Spinal epidural lipomatosis is a condition which can cause spinal cord compression that mimics impairments seen in patients with conditions treated with steroids such as transverse myelitis or multiple sclerosis.
A Case Report: Improvement in Chronic AC Joint Pain after PRP Injection
Jovauna M. Currey, MD; Ronald Takemoto, MD
Case Diagnosis: Grade 1 AC joint injury
Case Description: 38 year-old male presented to the clinic with a 6 month history of non-radiating, 6/10, superior left shoulder pain after being thrown down and landing on his outstretched left arm. Examination was significant for tenderness at AC joint, scarf test positive without visible deformity. Crepitus was noted at the AC joint with overhead movements. No instability was present. X-ray showed osteoarthritis in the AC joint. Ultrasound showed positive geyser sign over AC joint. He was initially treated with intra-articular ultrasound guided prolotherapy injection along with home exercise program x2. Prolotherapy helped only for 5 days, and brought the pain down to 5/10. At 6 month follow-up, patient was still having 5/10 pain. An ultrasound guided intra-articular PRP injection of the left AC joint was performed with continuation of his home exercises. After two months, the pain decreased to 1/10, however, he states there is still a non-pain producing “clunking” sensation with overhead movement. Patient was given the SPADI shoulder survey at each appointment, scores were: 37.6% at initial visit, 37.6% after prolotherapy and 6.9% after PRP.
Discussions: Conservative treatment is recommended after Grade 1 AC shoulder injuries, but there is no specific treatment for patients who develop chronic pain in the AC joint. There have been multiple publications regarding the use of PRP in different shoulder injuries, however, there has yet to be any case reports of its use in chronic Grade 1 AC injuries.
Conclusions: We believe this is the first case report regarding the use of PRP in painful chronic Grade 1 AC joint injuries. As demonstrated by the decrease in this patient’s SPADI scores after the intra-articular PRP injection, PRP appears to have been beneficial in this regard.
A Case Series Describing the Efficacy of Oral and Injected Steroids for the Treatment of Symptomatic Perineural Cysts
Jason S. Frederick, MD; Mohsen Tahani, MD
Case Diagnosis: Perineural cysts
Case Description: Three patients, one male and 2 female, were evaluated for chronic pain with radicular symptoms including extremity weakness and sensory changes. Each obtained MRI imaging studies of the spine showing perineural cysts, 2 at cervical levels and 1 in the sacral region. In all of the cases, the perineural cyst(s) were located along spinal roots that correlated with the distribution of the patient’s symptoms. Two of the patients were prescribed a short, tapered dose of oral steroids. The third patient received a caudal epidural steroid injection. The effects of the treatments were measured at 1 and 2 month follow up clinic appointments and phone evaluations. Alleviation of pain was recorded in all three patients with 60%-80% improvement in average VAS scales. Two of the 3 patients also reported increased extremity strength and sensation in the distribution of the affected nerve roots.
Discussions: Perineural cysts, also known as Tarlov cysts, occur most often in the sacral region at the junction of the dorsal ganglion and the posterior nerve root. With a reported prevalence of 1.5% - 4.6% in the general population, perineural cysts are mostly asymptomatic. Approximately 1%, however, cause symptoms due to nerve compression including pain, weakness, and sensory deficits. While there have been many case reports exemplifying successful management of perineural cysts with surgery, there have been few demonstrating successful symptomatic management with conservative treatments. A previous case series by Mitra et al in 2008 demonstrated the efficacy of such conservative therapies, specifically treatment with oral and injected steroids.
Conclusions: Based on the treatment courses and outcomes of this case series and previous studies, oral and injectable steroid therapy may provide an alternative to surgery in the management of symptomatic perineural cysts.
A Quality Improvement Project: Improving Sleep Documentation on TIRR Unit 6
Erika L. Moody, MD; Cole Linville, DO, MBA
Objectives: The objective of this quality improvement project is to identify the most common reason for sleep disruption in patients at TIRR Memorial Herman Hospital admitted on unit 6 (brain injured patients) by implementing a sleep/wake cycle documentation protocol. Sleep disorders are very common after brain injury. Insomnia, fatigue, and sleepiness are the most frequent sleep-associated complaints after traumatic brain injury (TBI). 1 Narcolepsy (with or without cataplexy), sleep apnea (obstructive or central), periodic limb movement disorder, and parasomnias occur less commonly. 1 Depression, anxiety, and pain are common TBI-associated comorbidities with substantial influence on sleep quality.1 Disrupted sleep can worsen neuropsychiatric, behavioral, and physical symptoms of TBI. 2 Additionally, sleep disruption impairs recovery and can lead to cognitive decline. 2 Persistent sleep disturbances independently predict poorer functional and social outcomes one year after mild TBI. 3 Post-stroke patients with insomnia have shown a reduced overall health-related quality of life and impairments in energy and thinking domains. 4 On brain MRI, an association between poor sleep quality and severity of white matter hyperintensities have been demonstrated. 5 Both short ( <5 hours) and long sleep (>9 hours) durations are associated with increased risk of stroke mortality.6 The aim of this study will be accomplished through multidisciplinary staff education and having a sleep log posted in each patient’s room. This will be evidenced by at least a 50% improvement in documentation of the reason for a patient to be awake during the two week study period in February 2015.
Design: The Plan-Do-Study-Act (PDSA) Cycle for quality improvement was implemented for this study. Our team consisted of Physicians, the Nursing Clinical Manager, the Operations Administrator, the Pharmacy staff, Nurses and Nursing Assistants at TIRR Memorial Hermann Hospital. This study was carried out at TIRR Memorial Hermann Hospital Unit 6. The design and intervention of this study included multidisciplinary staff education on the accuracy of bedtime sleep/wake cycles recording on the patient’s sleep log, which included the reason for sleep disruption. Pre-intervention data from August 1 – 31, 2014 was reviewed and analyzed. Post-intervention data from February 2 – 15, 2015 was reviewed and analyzed. Data collected included room number and bed location (bed A vs. bed B), gender, age, primary diagnosis, admit and discharge date, length of stay, admit time and day of week admitted, hours of sleep recorded (from 9 pm to 6 am), sleep medication ordered, and reasons documented for sleep interruption.
Results: Pre-intervention data from August 1 – 31, 2014 was reviewed. Reasons for sleep disruption were not routinely being documented in electronic medical record (EMR) sleep log. Staff was documenting a full hour of sleep when known sleep disruptors were occurring, such as during medication administrations, midnight vital signs, scheduled catheterizations or recordings of toileting, ect. During staff meeting with Nursing Clinical Manager and Operations Administrator, we discovered that there is no standardized process for staff to record patient sleep. Nurses and Nursing Assistants are mostly charting at the end of their shift at early morning hours “by memory,” thus it is questionable if EMR sleep logs are accurate. Multiple sleep disruptors were identified by staff – either physician ordered or by hospital policy. After implementing sleep/wake cycle documentation protocol, the goal of at least 50% improvement in documentation of the reason for sleep disruption was met.
Conclusions: The recorded reasons for sleep disruption increased from 32 to 94 (194% increase). Hours unaccounted for decreased from 39 to 4 (90% decrease). The mean number of sleep hours recorded per patient decreased from 7.1 hours/night to 5.4 hours/night. Toileting, medication, and midnight vital signs were the 3 most common reasons for sleep disruption in the brain injured population on TIRR unit 6. Patients on TIRR unit 6 are being frequently interrupted during sleep hours and such sleep disturbance has many potential negative secondary health effects and poorer functional recovery in this population. Staff is likely over-reporting sleep hours on the EMR sleep log. The improvement in the accuracy of the sleep logs can likely be attributed to the intervention of instructing and educating nursing staff although this is unlikely to be sustainable over the long-term.
A Rare Case of Acute Longitudinal Transverse Myelitis with C4-T6 Involvement
Grace Maloney, MD; Padma Srigiriraju, MD
Case Diagnosis: A rare case of acute longitudinal transverse myelitis with C4-T6 involvement
Case Description: A 57 year old man was admitted to acute care following development of bilateral lower extremity weakness and numbness. MRI revealed an intramedullary cord lesion with cord edema. Neurologic workup was initiated including: lumbar puncture with CSF studies and further imaging. No causative factor was identified. Patient received 5 days of methylprednisolone, IVIG and Rituxin; however neurologic symptoms progressed to upper extremity weakness and respiratory failure necessitating intubation. Tracheostomy was performed following failure to wean off ventilator and patient transferred to long-term acute care. Following medical stabilization, he was transferred to acute inpatient rehabilitation. Initially, he was total assist for transfers. This improved to max assist. He was initially total assist for mobility but progressed to use of a wheelchair with supervision for a distance of 500 feet.
Discussions: Transverse myelitis is a rare disorder that has multiple presentations and etiologies including infectious, inflammatory, autoimmune, traumatic, radiation induced, and idiopathic type. Cord involvement may be classified as acute partial, acute complete, and longitudinally extensive. Recovery and prognosis differs dramatically between patients. A wide range of issues require attention during rehabilitation including: spasticity, pain, sensory abnormalities, sexual dysfunction, bladder/bowel dysfunction, lifestyle, and psychological impact.
The challenges and subtleties in diagnosis and treatment are essential for the rehab clinician to understand. A thorough understanding of the disease enables provision of effective management and patient education.
Conclusions: Given the rarity of longitudinal transverse myelitis, variation in etiology, and extensive time over which treatment occurs, no large studies exist to provide conclusive evidence on predicting prognosis and rehabilitation outcomes. The presented case provides an in depth look at the challenges faced in treating an idiopathic case of longitudinally extensive transverse myelitis. The case highlights the complexity and importance of both the diagnostic and rehabilitation process.
A Rare Case of Akinetic Mutism and its Rehabilitation Outcome
Andrew Patton; Esther Yoon; Mohammad S. Islam, MD; Carlos Arias, MD; Yamilette Burgos-Quinones, MD
Case Diagnosis: A 57-year-old female with akinetic mutism in the setting of paraneoplastic encephalitis secondary to multiple myeloma.
Case Description: After presenting to the hospital for confusion, dizziness, and anarthria, a 57-year-old female is diagnosed with paraneoplastic encephalitis secondary to multiple myeloma. A predominant symptom of her syndrome is akinetic mutism, a neuropsychiatric syndrome characterized by lack of spontaneous speech and movement with relatively preserved attention in an awake, alert patient. After almost 5 months of acute medical care, patient was admitted to inpatient rehabilitation.
Discussions: At 5 weeks, the patient continued to demonstrate a variable pattern in her rehabilitative course with a general positive trend in her progress. Despite this oscillation, days when she is more participatory in her therapy have increased in frequency and have yielded progress in mobility and ADLs. Initial PT/OT and SLP evaluations found the patient requiring maximum to total assistance in most functional measures. With ADL, gait, and transfer training, as well as therapeutic exercise, the patient not only increased her function, improving to mostly supervision, but also decreased the amount of time and effort needed to complete these tasks. In the last days of her rehabilitation stay the patient began speaking coherently and in full sentences, began participating in her discharge planning, and a trial of food by mouth.
Conclusions: To our knowledge, this is the first reported case of akinetic mutism following paraneoplastic encephalitis secondary to multiple myeloma and its rehabilitative course. We suggest that intensive rehabilitation, along with involvement of familiar relationships, has a positive effect on functionality in a patient with akinetic mutism. Possible correlation with steroid administration leads to a hypothesis of its benefit in the rehabilitation process.
A Rare Case of Severe Hemophilia and Moyamoya (SHAM) Syndrome Diagnosed on the Inpatient Rehabilitation Unit
Isaac P. Syrop, MD; Jesuel Padro-Guzman, MD
Case Diagnosis: Severe hemophilia and moyamoya (SHAM) syndrome
Case Description: A 21 year old male, with a history of hemophilia A, presented to the ED after a syncopal event in the shower. In the ED, he became acutely altered with a CT head showing acute right subdural hemorrhage with a right-to-left midline shift and bilateral uncal herniation. The patient was taken directly to the OR for a hemi-craniectomy and hematoma evacuation. After a prolonged 17 day Neuro ICU course, including a right frontal infarct, rehabilitation was consulted for management and disposition. The rehabilitation team, along with neurology, found this patient’s presentation very unique, with both hemorrhagic and ischemic strokes. Cerebral angiogram was ordered and confirmed the diagnosis of moyamoya. As described in a couple of case studies, the rehabilitation team was interested in a relationship between hemophilia A and moyamoya. Further clinical workup revealed mild facial dysmorphia and developmental delays. Genetics was consulted and molecular cytogenic studies identified a large deletion in the long arm of chromosome X containing 3 OMIM genes (F8, MTCP1 and BRCC3). Deletions of this region are associated with severe hemophilia A and moyamoya (SHAM) syndrome (Blood. 2014;123(25):4002–4). Based on genetic testing, the diagnosis of SHAM syndrome was confirmed. When physical therapy first evaluated the patient, he was performing bed mobility with 2 person maximum assist and transfers with 2 person moderate assist. Over the next 3 weeks, the patient progressed well and was ambulating 35 feet with 2 person minimum assist using a rolling walker. Unfortunately, beyond 3 weeks after admission, the patent had multiple neurologic and medical setbacks and regressed functionally.
Discussions: Throughout this patient’s complex hospital course, the rehabilitation team played a crucial role in workup, management and rehabilitation of an extremely rare syndrome. A review of the literature yields only 4 likely individuals with this novel SHAM syndrome (Blood. 2014;123(25):4002–4. Pediatr Neurosurg. 2002;36(3):157–160. J Thromb Haemost. 2012;10(10):2099–2107. Hum Mol Genet. 1992;1(3):179–186.). This abstract marks the fifth case ever presented. In addition to aiding in the prognosis of this individual patient, the diagnosis of SHAM syndrome may be of consequence to his family and genetic counseling is recommended.
Conclusions: An inpatient rehabilitation unit in a tertiary referral hospital admits patients with diverse diagnoses and coordinates care amongst many specialties. When working on an interdisciplinary team, as exemplified in this case, a physiatrist is in a distinct position to combine multiple clinical findings into one unique diagnosis, such as SHAM syndrome.
A Rare Case of Symptomatic Os Vesalianum
Mohammad S. Islam, MD; Nicole E. Levy, BS; Mahmood Syed, MD
Case Diagnosis: A Rare Case of Symptomatic Os Vesalianum
Case Description: This is the case of a 35 year old man who presented with severe left foot pain for three months. It was initially thought to be an old fracture of the fifth metatarsal bone based on X ray imaging. He was managed conservatively with placement of a CAM boot, use of NSAIDs for pain control, and physical therapy. These methods of treatment were not successful in relieving the patient’s symptoms. MRI imaging showed os vesalianum as opposed to the previously suspected avulsion fracture. After several months of conservative management, the patient elected to schedule surgical treatment for excision of the os vesalianum.
Discussions: Os vesalianum pedis is a rare accessory ossicle of the foot, located proximal to the base of the fifth metatarsal within the peroneus brevis tendon. When symptomatic, it can cause lateral foot pain. Because of the infrequent incidence of this condition, it is often misdiagnosed as in this case. Imaging is therefore a very important tool in diagnosing this condition. In this case, MRI was imperative in providing the diagnosis of os vesalianum and ruling out an avulsion fracture of the fifth metatarsal as the source of this patient’s foot pain.
Conclusions: Because it is such a rare diagnosis, os vesalianum can be misdiagnosed and therefore not managed properly. Imaging methods such as X ray and MRI are vital tools in discerning the correct diagnosis here. This condition can be managed either conservatively or surgically with good result. While this condition is fairly uncommon, it is essential to diagnose this properly using the available imaging modalities in order to optimize the best treatment for each patient.
A Rare Case of Upper Trunk Brachial Plexopathy Following a Urological Procedure: A Case Report
Stanley Poole, DO; Kenneth Rodrigues, MD
Case Diagnosis: This presentation is to increase awareness of the potential for brachial plexus injury during a prolonged urological procedure. A case of brachial plexopathy in a 43 year old male following an ileal conduit urinary diversion urological procedure was encountered. Nerve palsy due to positioning on the operating table is commonly seen over the elbow and popliteal fossa. Brachial plexus injury is a less recognized complication of prolonged urological procedures.
Case Description: A 43 year old right handed T9 ASIA A SCI male with history of bilateral upper extremity ulnar neuropathy presented with new onset right upper extremity weakness of 0-1/5 shoulder abduction and elbow flexion strength on manual muscle test (MMT) scale with decreased sensation to light touch in the right C5 and C6 dermatomes immediately following an ileal conduit urinary diversion urological procedure. NCS/EMG was performed and found electrophysiologic evidence of an acute right upper trunk brachial plexopathy with ongoing axonal denervation. Due to the patient’s weakness, motor units were unable to be analyzed for reinnervation.
Discussions: A lesion of the brachial plexus can result in motor, sensory, and sympathetic disturbances. Trauma accounts for a large proportion of brachial plexopathies. The upper trunk is formed from the C5-6 roots. Thus, upper trunk lesions result in weakness of nearly all muscles with C5-6 innervation and sensory loss involving the lateral arm, lateral forearm, lateral hand, and thumb. This case is possibly a result of a positional traction injury from prolonged surgery. It should be noted, this case could be consistent with Turner-Parsonage upper brachial plexus post-anesthesia idiopathic neuritis affecting the C5 and C6 nerve roots.
Conclusions: Upper trunk brachial plexopathy following an ileal conduit urinary diversion urological procedure is uncommon; recognition of this possible adverse outcome should be considered and may warrant further studies.
A Rare Cause of Quadraparesis; Lead Poisoning from Retained Bullet Shrapnel
Emma Nally, MD; Emily Kivlehan, MS; Robert Bunning, MD
Case Diagnosis: Severe Quadraparesis from lead toxicity caused by retained bullet fragments.
Case Description: A 31 year old soldier with gunshot wound (GSW) in 2006 with retained shrapnel in the left femur was admitted to acute care on three occasions in 2015 complaining of abdominal pain, vomiting, constipation, progressive severe weakness, numbness, fatigue, and weight loss. Laboratory evaluation revealed anemia and unexplained elevated liver function tests, with positive heme-occult stool. Esophagogastroduodenoscopy, percutaneous liver biopsy, and PET-CT were inconclusive. On the third admission, lead level was 129 ug/dL (normal less than 10ug/dL). Intravenous, then oral chelation therapy was initiated. Retained shrapnel fragments in the cystic thigh swelling were removed. Lead levels decreased and patient was admitted to acute rehabilitation. Initially he was quadraparetic due to polyneuropathy and severe muscle weakness. Lead levels decreased and after 7 weeks of acute rehabilitation his function gradually improved and he was able to ambulate 1000 feet with a rolling walker at a supervision level.
Discussions: Lead toxicity is a relatively rare, yet catastrophic multi system disorder that is often characterized by constipation, myalgia, decreased mentation, polyneuropathy, and abdominal pain. This patient had retained bullets for 17 years with no toxicity. The formation of a cystic structure may have caused absorption of lead and progressive symptoms over 4 months. The vague presentation and decreased exposure to patients with lead toxicity may delay treatment, but early diagnosis may prevent severe functional impairments.
Conclusions: Progressive neuropathy should trigger a heavy metal screen before symptoms are severe. Bullet fragments that have not caused toxicity for many years may still become toxic, especially when in fluids of a pseudocyst or joint. For unexplained neuropathy, a history of GSW may be relevant.
A Retrospective Chart Review of Infection and Complications of Electrodiagnostic Nerve Conduction and Electromyography Studies in an Adult Ambulatory Care Setting
Lisa Marie Williams, MD; Ninad Karandikar, MD; Min Kim, DO
Objectives: The rate of infection of electrodiagnostic studies is thought to be rare. There have been several isolated outbreaks of electromyography (EMG) related infections however to our knowledge, the infection rate attributed to EMG is unknown. Additionally, complications such as pace maker malfunction, compartment syndrome and hemorrhage have also been reported but the frequency is unknown. The purpose of this study is to estimate the risk of infection and complications of pace maker malfunction, compartment syndrome and hemorrhage from electrodiagnostic studies in an ambulatory care setting.
Design: This is a retrospective observational chart review study.
The population included allcomers to an adult ambulatory physical medicine and rehabilitation (PM&R) and neurology electrodiagnostic lab in a closed healthcare system from December 2005 to December 2014.
Using the electronic health record we performed a retrospective chart review of 3993 patients who had EMG/NCS performed and had associated infection International Classification of Diseases (ICD) 9 codes linked to their chart within 90 days after the EMG/NCS encounter. Current Procedural Terminology (CPT) code for electrodiagnostic procedures were 95905, 95860 to 95864 and 95907 to 95913. An exhaustive list of over 100 ICD-9 codes linked to infection as well as ICD-9 codes linked to pacemaker complications, hemorrhage and compartment syndrome were used. Detailed chart review was performed if there was an infection, hemorrhage or compartment syndrome ICD-9 code documented within 90 days of EMG/NCS
Results: There were 12 ICD-9 codes associated within 90 days of the electrodiagnostic studies reviewed from December 2014 to December 2015. All 12 codes associated were related to infection. There were no codes related to pacemaker malfunction, hemorrhage or compartment syndrome found. There were 68 total cases of infection found out of 3993 electrodiagnostic procedures over a consecutive nine year period. Further detailed chart review revealed these infections were not associated with EMG/NCS. Further, there were no related complications of pacemakers, findings of campartment syndrome or hemmorrhage related to the electrodiagnostic studies performed during the period from December 2014 to December 2015.
Conclusions: Reasurance that there is a low risk of complications from electrodiagnostic studies has been the mainstay in advising patients prior to undergoing this procedure. Infection, hemorrhage, compartment syndrome and pace maker malfunction are all theoretical risks. This is the first large scale retrospective chart review study looking at complications of EMG/NCS studies. Our retrospective chart review study revealed no associated infections, hemorrhage, compartment syndrome or pacemaker malfunctions related to EMG/NCS.
A Unique Presentation of Seronegative Spondyloarthritis Presenting as Chronic Neck Pain
Samuel T. Dona, MD; Amir El Shami, MD; Lauren Kremm, DO
Case Diagnosis: A 40-year-old male with history of colorectal cancer and schizoaffective disorder presented for initial evaluation of chronic neck pain. Nine months prior, patient reported a neck injury sustained while being restrained after an altercation. Upon presentation, patient endorsed constant neck discomfort exacerbated by motion and alleviated by NSAIDS. Furthermore, history complicated by acute psychosis with the patient endorsing symptoms related to recent alien abduction and surviving zombie attacks.
Case Description: Physical exam notable for decreased range of motion of the cervical, thoracic and lumbar spine in all planes. Hypertrophy was observed to the cervical paraspinals and bilateral trapezius. X-rays of the cervical spine revealed arthodesis of the facet joints bilaterally at all levels suggestive of ankylosing spondylitis (AS). Patient then underwent formal evaluation for AS. Laboratory results positive for elevated ESR and CRP; negative for Rheumatoid factor, ANA and HLA-B27. X-rays of thoracolumbar spine demonstrated multilevel vertebral body squaring and syndesmophytes consistent with AS. Patient referred to Rheumatology for comprehensive evaluation. Rehabilitative efforts included pain management with NSAIDS and opoids in addition to TENS unit with physical therapy.
Discussions: Recognition of seronegative spondyloarthropathy, a potentially debilitating condition involving the axial skeleton, is necessary when assessing young individuals who present with chronic neck pain. In this unique case, diagnosis was difficult given complaints of generalized cervical pain with concomitant history of psychiatric illness. There is a need to implement guidelines regarding the rehabilitation of seronegative spodyloarthropathy with recent literature advocating for medical optimization in addition to early initiation of physiotherapy.
Conclusions: It is important for the clinician to include seronegative spondyloarthropathy in the differential among the potential causes of musculoskeletal pain involving the axial skeleton. Consolidating clinical findings with objective data will lead to an accurate diagnosis, guide early treatment, and alter progression of disease with improvement in functional outcome.
A Young Woman with Klippel Feil Syndrome and Periscapular Pain: A Case Report
Brian Snitily, MD; Leah G. Concannon, MD
Case Diagnosis: Sprengel Deformity in a patient with Klippel Feil syndrome
Case Description: A 23 year old woman with thoracic scoliosis and Klippel Feil syndrome with prior C4/5 discectomy and anterior fusion, was referred for evaluation of bilateral periscapular pain. She noted difficulty lifting her arms above her head all her life, but the pain began one year ago. Examination was notable for scapular elevation at rest. Shoulder abduction was limited to 90 degrees both actively and passively, with decreased scapular rotation. Additionally there was slight inferior medial scapular winging bilaterally at rest that worsened with movement at the shoulder. Neurologic exam was normal. Review of a prior MRI of the cervical spine confirmed the diagnosis of Sprengel deformity with the presence of an osseous connection between the upper scapular and C5 vertebral body (omovertebral bone). Of note, the patient had not been told of her diagnosis of Sprengel deformity in spite having seen several specialists regarding her Klippel Feil syndrome.
Given the lack of neurologic abnormalities, the patient was referred for physical therapy to focus on optimizing overhead activities and strengthening periscapular musculature. After six weeks of physical therapy, she noted improvement in her periscapular pain and reported greater ease in performing household activities and caring for her young children.
Discussions: Sprengel deformity is a result of failure of the scapula to descend during fetal development and is usually identified at a young age. It is commonly accompanied by various other anomalies, especially in the cervicothoracic vertebrae or the thoracic rib cage. The most common anomaly is Klippel Feil syndrome (present in 7-42% of individuals with Sprengel deformity), as well as absent or fused ribs, chest wall asymmetry, cervical ribs, congenital scoliosis, and cervical spina bifida. Due to the scapula being in an elevated position, there is a limited ability for upward rotation of the scapula due to abutment against the posterior ribcage, restricting shoulder range of motion. This restriction in range of motion can be magnified with the presence of an omovertebral bone or fibrous connection between scapula and mid cervical vertebrae, which is seen in 35% of individuals with Sprengel deformity. This restriction in range of motion can lead to disuse atrophy of periscapular muscles, impingement at the shoulder and functional limitations to overhead activities.
Conclusions: For adults presenting with uncorrected Sprengel deformity, physical therapy focusing on periscapular muscle conditioning is a reasonable initial approach to reduce pain and improve functional activities.
Acute Onset Upper Lumbar Radiculopathy in a Rare Case of Burkitt Lymphoma
Salvador Portugal, DO; Gregory Burkard, DO; Charles Kim, MD
Case Diagnosis: Acute Onset Upper Lumbar Radiculopathy in a rare case of Burkitt Lymphoma
Case Description: This patient is a 33 year-old female who presented to an outpatient spine clinic for initial evaluation of gradual onset non-radicular mild low back pain that began 2 weeks prior without inciting event. At time of initial visit, the patient denied “red flags”, and the physical exam was sigificant for right lumbar paraspinal muscle tenderness with a normal neurological exam. The patient was treated for a lumbar strain with conservative management including NSAIDs and a muscle relaxant.
Over the course of 2 days her symptoms progressively became more severe, prompting her to follow-up with a new complaint of right anterior thigh numbness. Patient was found to have right hip flexor weakness with sensory deficits of the the anterior thigh. Patient’s symptoms were recalcitrant to a Medrol dose pack. Lumbar MRI with contrast revealed a large 14 x 7 x 6 cm psoas mass infiltrating the right L1-L2 and L2-L3 neural foramina with mass effect on exiting right L1 and L2 nerve roots. Biopsy and further work up revealed the mass to be Burkitt Lymphoma-sporadic subtype. The patient was admitted and chemotherapy treatment was initiated.
Discussions: Burkitt lymphoma is a rare cancer considered to be the most highly aggressive of all cancers. In the United States, the sporadic subtype is estimated to have an incidence of 3 cases per 1 million people which predominantly effects males. Our patient lacked any red flags and risk factors associated with Burkitt’s Lymphoma (HIV or immunodeficiency). Although it is standard practice to ask all the “red flag” questions, they do not alwas provide the clinician with a suspician of cancer as evidence in a rapidly aggressive cancer.
Conclusions: This rare case is clear evidence of the aggressive nature of Burkitt lymphoma with a rapidly progressing upper lumbar radiculopathy. Given the atypical response to oral steroid medication and rapid progression of this patient’s neurological symptoms, the necessity for early diagnostic imaging (MRI) allowed for a speedy diagnosis and immediate treatment to improve this patient’s chances of survivial.
Acute Sensory Ataxic Neuropathy in a Patient with Underlying Vitamin B1 and E Deficiencies
Victoria G. Treadway, MD; Julie Lanphere, DO
Case Diagnosis: Acute sensory ataxic neuropathy
Case Description: A 38 year old male with chronic polyneuropathy of unknown etiology presented with 1 week history of progressive gait instability and ascending paresthesias, preceded by a gastrointestinal illness. Initial work-up was notable for CSF albuminocytologic dissociation, vitamin B1 and E deficiencies, and NCS demonstrating an axonal sensory neuropathy.
A presumptive diagnosis of GBS was made and the patient received a 5-day course of IVIG as well as vitamin repletion. He was then discharged to inpatient rehabilitation with ongoing functional impairments. Examination was notable for areflexia and mild weakness (4/5) in bilateral hip flexors, knee flexors, and ankle dorsiflexors. Proprioception, light touch, and pin-prick sensation were abnormal in both upper and lower extremities. Based on this presentation, suspicion for a Miller Fisher variant (specifically acute sensory ataxic neuropathy) was raised.
During his rehabilitation course, the patient demonstrated improvements in gait and balance while his weakness remained stable. He was discharged to home where he participated in outpatient PT.
Discussions: Guillain-Barre syndrome is a broad term encompassing a spectrum of autoimmune neuropathies. This patient presented with several features shared by the various clinical subtypes of GBS including antecedent infection, monophasic course, areflexia, distal paresthesias, CSF albuminocytological dissociation, and NCS abnormalities. However the presence of sensory ataxia and axonal sensory neuropathy in this case are most consistent with the acute sensory ataxic neuropathy subtype. The presence of an underlying polyneuropathy and vitamin deficiencies adds a layer of complexity to this case as these may also have contributed to his symptoms.
Conclusions: Acute sensory ataxic neuropathy is a subtype of GBS associated with sensory ataxia and an axonal sensory neuropathy on NCS. Based on our experience, these patients may benefit from IVIG and acute inpatient rehabilitation with emphasis on gait training, balance, and proprioceptive techniques.
Alien Hand Syndrome after Metronidazole Use
Rachel Welbel, MD; Diane A. Thompson, MD
Case Diagnosis: Alien hand syndrome after metronidazole encephalopathy
Case Description: A 52 year old male was admitted to the acute rehabilitation unit after resection of a right cerebellar metastatic melanoma. On admission he exhibited left sided dysmetria and mildly decreased bilateral hip flexor strength. He had leukocytosis, found to have c.difficle infection, and was started on metronidazole 500mg TID. Altered mental status and left sided hemiplegia developed over the next 24 hours. MRI brain revealed restricted diffusion in the splenium and posterior body of the corpus callosum and hyperintense FLAIR signal throughout the bilateral parietal and occipital lobes. Physical exam was notable for repetitive unconscious grabbing of his right arm with his left arm along with accusing others of the act. This finding is consistent with alien limb. Metronidazole was switched to vancomycin for continued treatment of c.difficile. His symptoms started to improve within 12 hours. His neurologic exam returned to normal within 2 weeks and he was later discharged home.
Discussions: Other differential diagnoses for the patient’s presentation included leptomeningial disease, acute infarct, active malignancy and meningitis. However, symptom onset and resolution corresponded with metronidazole use and since no other etiology was discovered, metronidazole encephalopathy was the leading diagnosis. FLAIR hyperintense lesions in the corpus callosum have been documented in metronidazole encephalopathy. Further, alien hand syndrome is a rare entity seen in cortical disconnection often found in lesions of the parietal lobes and corpus callosum. This is the first known case of alien hand syndrome occurring with metronidazole use.
Conclusions: Metronidazole is a medication commonly used to treat c.difficle and toxicity has been associated with encephalopathy. This case indicates that upon presentation of alien hand syndrome, drug toxicity should be excluded as a cause. Metronidazole, in this case, was identified and discontinued quickly allowing the patient to have a full recovery.
An Integrated Rehabilitation Treatment Plan for a Patient with Ollier Disease
Timothy D. Flesher, MS, MD; Steven Farrell, MD; Cathy Hites, PT; Christine Robinson, OT
Case Diagnosis: Ollier Disease
Design: Case Description: A 30-year-old male with a history of Ollier Disease had multiple recent falls and left hip pain. Imaging and needle biopsy revealed left femoral chondrosarcoma necessitating a left-sided hemipelvectomy. A comprehensive inpatient rehabilitation stay resulted in a discharge to home.
Discussions: Ollier Disease is a rare, sporadic disorder where benign, intraosseous cartilaginous tumors, called enchondromas, develop near bone growth plates causing a bowed and shortened deformity. Treatment is surgical correction of deformity. The incidence of secondary chondrosarcoma in Ollier Disease is approximately 25%, with the pelvic and shoulder girdles most affected.
Therapy challenges: Because of enchondromas on his hands, the patient had difficulty with ADLs. He could not hold toilet tongs. He became adept at shifting the enchondromas when dressing. He also used his arms and right lower extremity to propel his wheelchair, his prior primary mode of locomotion. A tumor in the left proximal humerus made his left arm 3 inches shorter than his right arm so a left-sided platform was added to his walker. The patient was discharged ambulating up to 150 feet using a platform rolling walker.
PM&R challenges: The hemipelvectomy resulted in significant pain control issues. Medication management was successful in allowing greater participation in therapy. The enchondromas of the hands had open areas that were monitored for infection. Eventual surgical excision of the lesions was discussed to enhance functional outcomes.
Conclusions: Using an integrated approach from all rehabilitation disciplines allowed this unique patient with Ollier Disease to maximize pain control and improve function via comprehensive therapies despite the challenges of a hemipelvectomy and significant hand lesions. The program resulted in a successful discharge to home.
An Unusual Case of Intractable Seizures in Ciguatera Poisoning
Armen Derian, MD; Katherine Lin, MD; Joshua Rothenberg, DO; Seema Khurana, DO
Case Diagnosis: New onset intractable seizures in a pediatric patient with ciguatera poisoning
Case Description: Ciguatera fish poisoning is the most frequently reported seafood toxin illness associated with the ingestion of contaminated tropical fish (barracuda, snapper, grouper, eel, sea bass). Larger predatory fish (>70cm) pose a greater risk for carrying the toxin as it accumulates up the food chain. The toxin has known physical and functional manifestations, which can vary based on the type and amount of fish consumed. A self-limited time course with symptomatic control and supportive care remain the hallmark of management. This is a case of a previously healthy teen fisherman who presented with an unusual case of prolonged intractable generalized tonic-clonic seizures refractory to standard anti-seizure medications. These seizures developed after he consumed his catches for the day, a pogie fish and a mutton snapper. They measured >75 cm, and the patient ate twice the amount as his relatives, none of whom developed the severe neurologic sequelae. They merely had nausea and vomiting but none of them developed seizures. Additionally, he had weakness, paresthesias, neuropathic pain and functional decline that responded to rigorous inpatient rehabilitation not previously described in the literature. Electroencephalogram upon admission confirmed seizure activity, showing generalized slowing, frequent rhythmic clonic movements with superimposed polyspikes, diffuse cortical hyperexcitability consistent with encephalopathy and diffuse cerebral dysfunction. His seizure activity was controlled with a strong cocktail of anti-seizure medications: levetiracetem 1500 mg BID, divalproex sodium 200 mg BID, and oxacarbazepine 450 mg BID. The patient displayed severe functional deficits requiring maximum assistance with mobility, transfers, gait, standing and balance. He also exhibited severe upper body tremors which limited his ability to perform activities of daily living. After one week of intense inpatient rehabilitation consisting of three hours per day of physical and occupational therapy, the patient ambulated 300 feet over level surfaces and demonstrated improved coordination with heel-to-shin, rapid-alternating movements, and finger-to-nose testing. He had full motor strength on manual muscle testing in all extremities, improved since admission to inpatient rehabilitation. The patient was discharged with oral levetiracetam 1500 mg twice daily, which was tapered down slowly. Six months post discharge, the patient remained on levetiracetam 375mg twice per day, and was unable to discontinue the medication completely due to persistent seizure-like activity and paresthesias.
Discussions: It is estimated that 10,000-50,000 people per year suffer from ciguatera fish poisoning. Gastrointestinal symptoms such as nausea, vomiting, diarrhea, and abdominal pain present within a few hours and often resolve in one to four days. Neurological symptoms often follow gastrointestinal symptoms, and presentations may consist of paresthesias, dysesthesias, generalized pruritus, myalgias, hot and cold temperature disturbance, mental fatigue, muscle weakness, ataxia, and memory loss. In severe cases, seizures, altered mental status, and coma can result. However, the current literature does not include any definitive reports of status epilepticus associated with ciguatera fish poisoning. Although neurological manifestations can become chronic, in the majority of cases symptoms resolve within weeks but can last up to six months. This is the first case of prolonged intractable seizures beyond the expected six month window previously cited for resolution of symptoms after confirmed ciguatera poisoning. Thus, monitoring for epileptic activity after six months should be considered in all patients displaying neurological sequelae post ciguatera toxin poisoning. Additionally, our patient suffered from residual functional decline, which responded remarkably to physical and occupational therapy that objectively showed a doubling in his functional independence measures (FIMs).
Conclusions: Despite being the most commonly reported seafood toxin illness, the diagnosis of ciguatera fish poisoning is a clinical one with no human biomarkers to confirm its presence. The diagnosis must be considered in patients who develop gastrointestinal and neurological symptoms post large tropical fish ingestion. After initial stabilation with intravenous mannitol, anti-seizure medications, and symptomatic control, patients should be referred to inpatient rehabilitation as they will benefit from three hours of daily physical and occupational therapy in order to improve their functional independence. Within nine days of starting rehabilitation, our patient’s FIM scores doubled. This supports the notion that it remains critically important that rehabilitation is employed early in the hospital course for better functional outcomes. As such, although rehabilitation has not been linked to ciguatera fish poisoning recovery within literature, it should play a large role in the management of select cases.
An Unusual Case of Pigmented Villonodular Synovitis
Mohammad H. Zaidi, DO; Hamad Saleemi, DO; Bilal Khan, DO; Yu-Jen Lai, MD
Case Diagnosis: Pigmented Villonodular Synovitis
Case Description: A 66 year old female with a history of thyroid cancer presented with right hip pain. Imaging studies revealed a large mass emanating from the right hip abutting the sciatic nerve posteriorly, associated with erosions of the femoral head. Tissue biopsy was consistent with Pigmented Villonodular Synovitis (PVNS.) Surgical excision, sciatic neurolysis, and total hip arthroplasty were performed and the patient was transferred to acute inpatient rehabilitation, where a FIM gain of 46 points was achieved within 7 days.
Discussions: PVNS is an inflammatory condition of the joint capsule which causes damage to the adjacent structures. It typically affects males in their third decade of life with an incidence of 1 per 500,000. 80% of cases involve the knee joint whereas only 15% involve the hip. MRI typically demonstrates nodular masses within the joint capsule. Arthroscopy reveals villous outgrowths and nodular densities emerging from the synovium. Histopathology exhibits synovial infiltrates with hemosiderin-laden macrophages, and large synovial outgrowths as a result of a chronic inflammatory process. Definitive diagnosis requires biopsy. Hemarthrosis has been established as the cause of the distinctive histological findings. There remains no consensus as to the definitive etiology of this disease process. Treatment options include radiation therapy and synovectomy. Recurrence rates of up to 45% have been reported following radiation or synovectomy. Definitive management is through joint replacement.
Conclusions: This case highlights an atypical presentation of PVNS of the hip, in which the symptoms and demographics are markedly different from the expected clinical presentation. Excision and arthroplasty followed by acute rehabilitation may provide an excellent clinical outcome.
An Unusual Case of Spontaneous Non Communicating Cervical and Lumbar Vertebral Osteomyelitis Masquerading as Upper Extremity and Low Back Pain: A Case Report
Stephen Erosa, DO; Francis Lopez, MD, MPH
Case Diagnosis: Cervical and Lumbar discitis/osteitis with associated bilateral paravertebral and prevertebral phlegmon, severe canal stenosis, and thecal compression at L3-L4 of unknown source of infection.
Case Description: The patient is a 73 year old male who, 4 weeks prior admission, experienced left wrist pain and swelling, and low back pains after using a sledge hammer. His wrist pain radiated to his neck and was initially treated with physical therapy after negative imaging of his arm as an outpatient. His back pain which radiated to both legs, progressively worsened. The pain was intermittent, sharp, and rated 10/10 on VAS; it was alleviated with rest and exacerbated by movement. He also noted a ten pound weight loss and occasional chills. At baseline he was independent. On admission to medicine floors he was unable to ambulate without assistance. An MRI demonstrated a cervical and lumbar vertebral osteomyelitis. The work up including cardiac imaging and biopsy were negative for malignancy as well as bacterial, or fungal infection. ESR and CRP were markedly elevated. He was started empirically on IV antibiotics and bedside PT/OT. After 1 month of treatment the patient improved and was ambulating 200 feet with straight cane at Supervision to Moderate assistance.
Discussions: Spontaneous bacterial vertebral osteomyelitis has been documented in the literature and attributed to advanced age. To our knowledge this is the first case to present in two isolated vertebral regions. Our patient did not have a history of IV drug use, systemic infection, malignancy, surgical/interventional manipulation, or immunosuppression but was advanced in age.
Conclusions: This case demonstrates the importance of considering spontaneous vertebral osteomyelitis as a differential diagnosis in our aging population.
An Unusual Presentation of an Ape-Hand
Sarabjeet Arneja, MD
Case Diagnosis: 38 year old female comes in to rehabilitation clinic with a left sided ape hand. The left hand shows evidence of hypothenar, thenar and first dorsal interossei atrophy. The left 4th and 5th digits are flexed in benediction sign. She is not able to make a full fist on the left hand or do thumb opposition; left Froment’s sign is positive. There is worsening weakness of the left hand along with numbness/paresthesias. Along with weak handgrip, there is also decreased left hand digit abduction stength, and decreased wrist extension. She is incidentally found to have left nystagmus. Sensory deficits are noted in the entire left upper and lower extremities compared to the right, and in the back on the entire left side. There is hyporeflexia on the left side compared to the right. She has difficulty with toe and heel ambulation, although no gross loss of balance noted.
Case Description: The patient was started on Neurontin for a working differential diagnosis of brachial plexitis vs cervical cord lesion. Electrodiagnostic evaluation showed mild right ulnar neuropathy at the elbow, bilateral median neuropathy at the wrists, and a left C8/T1 cervical nerve root lesion. Cervical MRI was done, and showed an expansile intramedullary cervical and thoracic mass going to T12, as well as Cerebellar tonsils below foramen magnum with kinking of cervicomedullary junction. She was sent to neurosurgery and underwent a decompression of occiput for Arnold Chiari malformation and cervical syrinx. Unfortunately, the patient continued to experience worsening symptoms of weakness, paresthesias and pain in left upper and lower extremities. The patient started a course of rehabilitation, including physical and occupational therapies to work on ranging and strengthening hand intrinsic musculature as well as strengthening the hip flexors and ankle dorsi-plantar flexors, as well as gait and balance training. Additional further surgical intervention was also being planned by neurosurgery.
Discussions: Arnold Chiari malformation type 1 is characterized by abnormally shaped cerebellar tonsils that are displaced below the level of the foramen magnum. The prevalence is 0.1 to 0.5 percent. They are congenital and thought to occur due to defects in hindbrain growth vs traction by a tethered cord or a defect in closure of the neural tube in early fetal development resulting in leakage of cerebrospinal fluid.
A syrinx is thought to occur from craniospinal pressure due to the blockage of cerebrospinal fluid flow in the subarachnoid space at the level of the foramen magnum, leading to pressure backup into the venous system and dissipating into the spinal cord parenchyma and central canal, leading to syrinx formation.
Posterior foramen magnum decompression is done at the craniocervical junction to restore the normal flow of CSF in the area of the foramen magnum. A duroplasty is avoided due to concern for CSF leak and pseudomeningocele. The rates of reoperation is significantly higher without duroplasy (13 vs 2 percent). A Syrinx shunt placement is used mainly for patients with Chiari malformation who fail posterior decompression due to progressive symptoms or syrinx enlargement.
This patient is now a candidate for a syrinx shunt placement procedure.
Conclusions: Arnold Chiari malformation is a source of morbidity in patients. Early detection is important in the prevention of worsening symptomatology. As in this case, the patient may present in an unusual way and require extensive clinical, radiological and electrodiagnostic examination in order to diagnose the condition. Appropriate and timely management is important in these patients, including a course of rehabilitation, along with neurosurgical evaluation for surgical intervention.
An Unusual Presentation of Generalized Chronic Pain diagnosed as Relapsing Polychondritis
Aashish Deshpande, MD
Case Diagnosis: This is a case of a 51 year old female treated for many years with worsening pain issues, beginning in her back and subequently involving multiple regions of her body. After numerous diagnostic evaluations provided no answers, a clinical diagnosis of Relapsing Polychondritis was given providing the patient with an answer to her pain issues. Evaluyation, workup and treatment are discussed.
Case Description: A 51 year old female presented to the general Physiatry outpatient clinic with low back pain with radiation to the bilateral lower extremities. With failure of conservative treatments and care, workup showed osteoarthritic changes and disc protrusions in the lumbar spine consistent with the initial presentation. Subsequently the patient went on to develop severe, unremitting pain issues in the head and neck, arms and legs, chest, abdomen and lower extremities. The patient also presented with waxing and waning painful joint arthralgias. No trauma, infection, or other etiology for the widespread pain issues could be found. Treatment involved high doses of long and short acting narcotics with often deleterious and limiting side effects. After initial referral to Rheumatology with no diagnosis, she was recently referred back in follow up. She saw the chairman of the department of Rheumatology at a University tertiary care center, and was given the clinical diagnosis or Relapsing Polychondritis (RP) by meeting 3 of McAdam’s criteria including bilateral auricular chondritis, Nasal Chondritis, and ocular inflammation. She was subsequently placed on Methotrexate and high dose Steroids, with not only improvement of her pain issues but also an actual lowering of the high dose narcotics that were used. She continues to follow up in the clinic with 6 months of sustained improvement.
Discussions: Relapsing Polychondritis is a rare condition, with approximately 600 cases reported worldwide. Many cases, due to the rarity of the disease, go unreported. The etiology of RP is unknown, but seems to be an immunologic reaction to Type II collagen. Clinical manifestations include Auricular Chondritis, Vestibular Dysfunction, Laryngotracheal disease, arthritis/ joint pain, Nonspecific dermatologic disorders, Neuropathies and headache, and ocular manifestations. Upon careful review of the patient’s 4-7 year course of pain issues and symptoms, she in fact may have suffered at different times headache, radiculopathy, rashes, nausea/dizziness, arthralgias and nonspecific ocular dysfunction. Indeed, her initial presentation of back pain and radiculopathy may have been caused by Type II collagen dysfunction in the discs. Diagnosis is clinical, with the McAdam criteria generally accepted. Laboratory tests are usually nonspecific, including anti-collagen type II antibodies. Initial workup for immune-mediated diseases had been done with negative results. Treatment is to target clinical manifestations, such as NSAIDS for joint issues, immunosuppressive agents or cytotoxic agents for more severe inflammatory issues. The prognosis for RP is mixed with fluctuating, slowly progressive inflammatory manifestations throughout the body. The disease is potentially lethal with pulmonary complications being most notable. The patient is improving slowly with treatment.
Conclusions: In a patient presenting to the general Physiatry outpatient service, protracted and severe chronic pain presents a difficult and challenging issue. We present a case of chronic pain in multiple regions of the body with the diagnosis of Relapsing Polychondritis. The audience is asked to be aware of this rare entity and consider the diagnosis in similar cases when the pain issues are undiagnosed or require high levels of narcotic medication.
An Unusual Presentation of Lateral Hip Pain in a Runner
Anish A. Mirchandani, DO; Jaspal Singh, MD
Case Diagnosis: A 35 year old female athlete with lateral hip pain, found to have a proximal iliotibial band tear.
Case Description: A 35-year-old healthy female athlete presented for the evaluation of left lateral hip pain. The patient had a history of discogenic low back pain, which had been successfully treated one-year prior to presentation. The patient is an avid marathon runner and reported that her pain started gradually and was exacerbated with running. She described the pain as dull and sore over the area. On physical exam the patient had tenderness to palpation over the left lateral hip below the iliac crest. She also had weakness noted with hip abduction and internal rotation, which also reproduced her pain. An MRI of the left hip was obtained which revealed a proximal iliotibial band (ITB) tear at the level of the iliac wing. The patient was advised to begin a 4-week therapy program, which focused on a hip abductor program, eccentric exercises, and active release therapy. Upon reassessment after completing a 4-week therapy course the patient had complete resolution of her symptoms. On exam, she no longer had noticeable weakness in her left lower extremity and no tenderness to palpation over the left lateral hip. She was able to steadily resume a running program. Eventually upon follow up, the patient reported that she successfully completed two marathons without return of symptoms.
Discussions: This is the first reported case, to our knowledge, of a significant tear in the proximal portion of the ITB in an athlete that presents with lateral hip pain. This case also highlights the importance of considering proximal ITB pathology in the athletic population, particularly females, and having a confirmatory diagnosis to offer the patient an appropriate physical therapy program for the affected area.
Conclusions: The source of lateral hip pain in the athletic population can be variable. This case illustrates the significance of considering proximal ITB pathology as a source of lateral hip pain in athletes, particularly females.
Analysis of Factors Contributing to Functional Improvement of Liver Transplant Recipients during Inpatient Rehabilitation
Hejun Yuan, MD, PhD; Kim Barker, MD; Samuel M. Bierner, MD; William M. Lee, MD
Objectives: Liver transplant (LT) recipients have significant functional impairments, and some have to be admitted to inpatient rehabilitation (IPR). We aim to analyze factors that contributed to improvement in FIM score changes for LT who completed IPR.
Design: Retrospective chart review was performed of 18 LT recipients admitted for IPR. Demographic data, length of stay (LOS) in intensive care or acute care or IPR, discharge destination, lab data (pre and post) and Functional Independence Measure Score (FIM at admission and discharge) were collected for each patient.
Results: Descriptive Statistics: The normally distributed variables included delta scores (change score: discharge – admit) for the following FIM variables: bowel and bladder management, LE dressing, toileting, commode and shower transfers, mobility-walking. From our sample delta scores were not normally distributed: for all cognitive FIM scales, bowel/bladder accidents, eating, grooming, UE dressing, and bed and wheelchair mobility.
Mean (S.D.) (Range): age at admission 55.6 (11.6) (32, 69) years. Days post-transplant: 29 (13.4) (14, 60); hospital LOS before transplant: 14.8 (10.6) (1, 41); IRF LOS: 12.9 (7.4) (3, 32). Change scores (discharge minus admission) for FIM Cognitive: 3.1 (3.9) (-1, 13); FIM Motor: 20.5 (13.4) (1, 45).
Linear regression analysis of the dependent variable (change in FIM-Motor score) gave F = 4.06 (D.F. = 16), which was significant, p =.031.The R-squared was 0.804 (adjusted R-squared 0.61). Root MSE = 9.14. The significant independent predictors were: heart rate at discharge, LOS on IRF, hospital days before liver transplant, and number of days status post-transplant. Using standardized “beta” coefficients, these coefficients were: HR -0.582; LOS 0.466; Hospital Days pre-LT 0.672; and Days post-transplant -0.6. Age, gender and MELD score, among other variables, pre-LT were not significantly related.
Conclusions: Some LT recipients are significantly debilitated post-transplant and can benefit from rehabilitation. Length of time in hospital prior to transplant is a strong predictor of this need. Length of IRF stay is strongly related to improvement in FIM Motor score. 20 point FIM motor gains can be expected. Cognitive FIM score change was not significant in our sample.
Anatomical Landmarks for Localization of the Tendon of the Long Head of Biceps Brachii with Ultrasonographic Validation
Saiyun Hou, MD, PhD; Sheng Li, MD, PhD; John Harrell, MD
Objectives: The purpose of the study was to establish anatomical landmarks for biceps tendon groove localization based on intrinsic anatomical relations and to validate the localization with ultrasonographic measurement.
Design: 25 young and healthy volunteers were recruited for the prospective study. We established two anatomical landmarks, the medial epicondyle vertical line related landmark, and the coracoid process landmark. The biceps long head groove was visualized under ultrasonography and was marked on the skin. The distance from the groove skin mark to the medial epicondyle vertical line and the coracoid process was measured horizontally was measured at 0° and 45° of shoulder external rotation respectively. Mean, 95% confidence interval (CI) of the distance were calculated and its correlation with height, weight and body mass index (BMI) was analyzed.
Results: Medial epicondyle vertical lines were medial to the groove at both 0° and 45° of shoulder external rotation. The distance between the groove and the medial epicondyle vertical line was 9.3mm (95% CI, 6.8 to 11.8) and 21.5mm (95%CI, 18.9 to 24.1) in 0° and 45° of shoulder external rotation, respectively. Correlation coefficients were 0.04/0.10, 0.32/0.42, and 0.26/0.37 for weight, height and BMI in 0°/45° of shoulder external rotation, respectively. The distance between the coracoid process and the groove was 44.0mm (95% CI, 41.5 to 46.5) and 62.2mm (95%CI, 59.2 to 65.2) in 0° and 45° of shoulder external rotation respectively. Correlation coefficients were 0.36/0.41, 0.36/0.54, and 0.18/0.12 for weight, height and BMI in 0°/45° of shoulder external rotation, respectively.
Conclusions: The medial epicondyle vertical line and the coracoid process landmark are both useful anatomical landmarks to localize the biceps groove. The anatomical landmark based localization is essentially not correlated with title’s weight, height or BMI.
Anterior Humeral Circumflex Artery: Making the Case for Musculoskeletal Ultrasound-Guided Bicipital Tendon Sheath Injections
Arben Brahaj, MD, RMSK; Peter (I-Kung) Wu, MD, PhD; Sampada Acharya, MD; Minna J. Kohler, MD; Shweta Kishore, MBBS, MD
Objectives: Local corticosteroid injections are commonly used to treat anterior shoulder pain attributed to tendinopathy of the long head of biceps tendon (LHBT). Injections near the bicipital groove, especially when performed by palpation of anatomic landmarks, involve the risk for not only LHBT rupture or atrophy, but also vascular injury or injection into the anterior humeral circumflex artery (AHCA), whose anterolateral ascending branch (AAB) runs parallel to the lateral aspect of the LHBT. Injury to the AHCA, a branch of the axillary artery that provides the main blood supply to the majority of the humeral head and LHBT, has been associated with humeral head avascular necrosis. Because of the inherent inaccuracy and risks associated with palpation-guided LHBT steroid injections, this study sought to increase awareness of AHCA anatomy and its relevance to complications of LHBT sheath injections. Using musculoskeletal ultrasound (MUS) to visualize the AHCA in relationship to the LHBT, we further demonstrate the utility of MUS-guidance, which has been shown to increase the accuracy of steroid injections compared to palpation-guidance, to avoid complications.
Design: Grey scale and color flow Doppler MUS examinations were performed on the anterior shoulders of 12 subjects with LHBT tendinosis to localize the AHCA and its AAB in relationship to the LHBT. MUS findings were correlated with medical literature on AHCA anatomy.
Results: Grey scale ultrasound enhanced by color flow Doppler examinations accurately localized the AAB lying lateral to the LHBT in the bicipital groove, within a mean distance of 19.2±11.9 mm, allowing successful MUS-guided steroid injection to the LHBT while avoiding vascular injury.
Conclusions: The proximity and course of the AHCA along the LHBT introduces the high risk of vascular injury or intravascular injection that can occur during palpation-guided LHBT sheath injections. Using MUS to visualize local anatomy when performing injections can improve patient safety and avoid complications.
Anterior Interosseous to Ulnar Nerve Transfer for Treatment of Traumatic Ulnar Nerve Palsy
Roderick G. Geer, MS4; Faren Williams, MD, MS; David Mazin, MD; Marci Jones, MD; David Magit, MD
Case Diagnosis: Traumatic Ulnar Nerve Palsy
Case Description: A 24-year-old right-hand-dominant female sustained a left distal humerus fracture secondary to motor vehicle accident. She had surgical fixation with exam 4 weeks later positive for left ulnar claw hand with 0/5 strength of intrinsic muscles, abductor digiti minimi, and flexor digitorum profundus (FDP), ulnar head. Electrodiagnostic study three months post-injury revealed no ulnar motor or sensory responses. Needle study revealed axonal loss in ulnar-innervated muscles, but not muscles innervated by other peripheral nerves. An EDX study five months post-injury demonstrated no ulnar motor or sensory responses, but showed reinnervation in the FDP, ulnar head. At that time, hand intrinsic muscles and hypothenar eminence were significantly atrophied. The patient had a noticeable claw hand and lacked light touch sensation in an ulnar distribution. Due to lack of distal reinnervation, the patient underwent an anterior interosseous to ulnar nerve transfer at the wrist and humerus fracture revision due to non-union. After one week, the patient showed increased sensation on the ulnar side of the ring finger with persistent numbness in the small finger.
Discussions: Functional recovery after traumatic peripheral nerve injury depends on the time to motor endplate reinnervation and number of regenerated axons that reach their target. After nerve transfer, axonal regeneration allows nerve coaptation and recovery of distal motor and sensory function. This patient had positive prognostic factors for functional recovery. She was young, healthy, and injured her non-dominant extremity. The second EMG suggested some proximal ulnar nerve regeneration. Serial EMG’s performed at routine increments will help quantify the extent of reinnervation.
Conclusions: The physiatry electromyographer, working closely with surgeons, can help define the nerve injury, prognosis, and optimal timing for surgery if deficits persist. This report illustrates the importance of collaboration between physiatry and hand surgery, in this case, to achieve the highest functional outcome.
Aphasia in a Right Hand Dominant Patient Secondary to Right Cortical Stroke
Jared Levin, MD; Thuy D. Vu, MD
Case Diagnosis: Transcortical Motor Aphasia Secondary to Stroke, in a Right Handed Patient
Case Description: 71 y/o right handed male was transferred to Rehabilitation for stroke, which initially presented with left sided hemiparesis and dysarthria. In the ED he was found to have left facial droop, aphasia and left hemi-neglect. There was no reported right sided weakness. CT head showed loss of gray-white matter differentiation in the right frontal-parietal lobes. Follow up MRI/MRA confirmed absence of left cortical injury. The patient showed expressive aphasia, with intact comprehension and repetition. He was diagnosed with Transcortical Motor Aphasia. The patient underwent intensive training with Speech Therapy, and showed persistent improvement in his production of language.
Discussions: It is well recognized that over 90% of the population is right handed, and that this is related to the Left Hemisphere containing the Primary Motor Cortex. Conversely, it is believed that left handed individuals most often have their Primary Motor Cortex in their Right Hemisphere. Similarly, it is believed that in over 95% of individuals, specific areas of the Left Hemisphere are responsible for speech and language, with the Right Hemisphere controlling attention, visual cognition and communication skills. It has been shown that hand and language dominance usually occurs in the same hemisphere. Our patient presents a unique case, as he is right hand dominant, with what appears to be a right dominant language center. According to a study by Knecht et al, in which transcranial Doppler Sonography was used to assess hand and language dominance, of all Right handed individuals, about 4% have a Right cortical language center. This would place our patient in about 0.16% of the population.
Conclusions: Our patient presented with aphasia secondary to a right cortical stroke, identifying a neuro-anatomic anomaly made more unique by the lack of association between his dominant motor and language centers.
Apical Mass in Lung Presenting as Brachial Plexopathy: A Case Report of Electrodiagnostic Findings
Bindu Sundar, DO; Nida Gleveckas-Martens, DO
Case Diagnosis: Apical mass in lung presenting as brachial plexopathy: A case report of electrodiagnostic findings
Case Description: 66 year old male with history of hypertension, hyperlipidemia, chronic smoker was referred for electrodiagnostics for right arm weakness and pain. Patient reported that he had symptoms of a stroke few weeks ago which caused transient left sided weakness that resolved. Soon after his discharge from hospital he noted weakness and numbness especially in right 5th digit and medial forearm. He noted symptoms initially started with pain in the neck which radiated down his arm in addition to intermittent sharp pain in his shoulder and medial forearm. Patient was referred to EMG clinic for work up for possible right sided ulnar neuropathy. Exam was significant for decrease in motor strength of wrist extensor at 4-/5, finger flexors and extensors at 3+/5 and severe weakness in all finger intrinsics and thenar muscles. Reflexes were decreased in right triceps and brachioradialis at 1+/4. EMG demonstrated a normal median sensory response but an abnormal ulnar sensory, median and ulnar motor responses. Right median antebrachical cutaneous nerve was also asymmetrical in comparison to left side. There was no focal slowing or conduction block across the right elbow.
Discussions: Patient presented with typical ulnar neuropathy symptoms but elctrodiagnostics pointed to proximal pathology. In this case it was localized to the level of lower trunk medial cord due to abnormality in medial antebrachial cutaneous nerve responses. Patient underwent subsequent imaging which showed an apical lung mass on the right.
Conclusions: Upper extremity brachial plexopathy can sometimes present as a peripheral mononeuropathy, in this case ulnar neuropathy. However, electromyographers must consider including brachial plexopathy in their differential, if there are physical exam findings of more extensive involvement. Brachial plexopathy with unclear etiology must be worked up for other causes of nerve compression. In this case it turned out to be an apical mass compressing on the plexus.
Arachnoiditis Presenting as Chronic Ankle Pain: A Case Report
Michael Auriemma, MD; Simon Willis, MD; Eric Wisotzky, MD
Case Diagnosis: Arachnoiditis
Case Description: A 62 year old man, with past medical history significant for type two diabetes and C3-C4 anterior cervical discectomy and fusion, presented with 8 month history of severe aching and throbbing left greater than right ankle pain of insidious onset, concentrated just superior to the lateral malleolus. He denied any relief from gabapentin or a previous steroid injection of the left tibiotalar joint. Magnetic resonance imaging (MRI) of the left ankle was unrevealing while lumbar MRI indicated mild to moderate neural foraminal stenosis at L5-S1 bilaterally. Physical therapy and bilateral L5 transforaminal epidural steroid injections offered no relief. Electromyography was performed and demonstrated evidence of a motor more than sensory predominantly axonal polyneuropathy. Closer review of the lumbar MRI indicated the presence of lumbar arachnoiditis. Pregabalin, tramadol, a lumbar interlaminar epidural, electrical stimulation, and acupuncture were all tried without benefit. Given the lack of response to all treatments, it was felt that the arachnoiditis was the primary pain generator. The patient was referred for a spinal cord stimulator (SCS) trial and experienced immediate relief upon completion of the trial. Secondary to a successful trial the patient is currently awaiting treatment with permanent surgical placement of a SCS.
Discussions: Arachnoiditis is a disorder that consists of chronic, intractable pain caused by inflammation of the arachnoid. Causes include infection, previous injury, chemical irritation, and prior history of spinal surgery. Typical symptoms include numbness, paresthesias, and burning pain in the lower back and legs. Isolated ankle pain is an unusual presentation of arachnoiditis. Currently there is no definitive cure and treatment is aimed at controlling pain and other symptoms.
Conclusions: It is important to keep arachnoiditis in the differential diagnosis for difficult to manage pain, particularly in patients with a prior history of spinal surgery.
Assessing the Utility of Objective Pelvic Motion Tracking for the Clinical Evaluation of Lower Limb Amputee Walking Performance
Gerasimos Bastas, MD, PhD
Objectives: Early and reliable detection of deteriorating walking performance, by objective assessment tools, would go a long way toward safeguarding the health and livelihood of over 1 million Americans living with lower limb loss. Non-optimized prosthetics make physical activity more tiring, can cause direct or indirect injury, predispose to secondary degenerative disorders like osteoarthritis and low back pain and are a principal cause of dissatisfaction by users. Insidious changes in people’s abilities and needs affect the “performance-coupling” between user and device, typically manifesting belatedly in clinically significant gait deviations. Clinical evaluation in the ambulatory setting relies exclusively on subjective observational gait analysis (OGA), a non-standardized practice fraught with known challenges surrounding reliability, irrespective of observer training level even with checklist-based tools, and its poor correlation to instrumented gait analysis measurements. Absent validated methodologies for the evaluation of walking performance in lower limb amputees (LLAs), we currently lack standardized assessment measures to identify gait deviations timely, in a manner also permitting quantification and monitoring of intervention response. Prior work has shown differences in the motion of the pelvis between able-bodied individuals and LLAs. The pelvis, as a connecting node between the lower limbs and the rest of the body, can reflect deviations in a multitude of gait pathologies. This is because during walking, the orientation and motion of the pelvis are directly affected by the biomechanical performance of each lower limb. Objective Pelvic Motion Tracking (OPMT) can therefore serve as a good indicator for prosthetic walking performance. Our study is the first to attempt a clinical correlation of walking ability to objective metrics of gait parameters in LLAs, that could be used in real time in the outpatient setting to help guide care. We demonstrate that OPMT can help practitioners distinguish clinically concerning walking patterns in their LLA patients.
Design: Using a single inertial measurement unit (IMU) containing accelerometers, gyroscopes and magnetometers, we recorded patterns of pelvic motion from 4 able-bodied controls, 7 transfemoral (TFA) and 5 transtibial amputees (TTA), during walking. The device is lightweight, wireless, does affect interfere with walking function and is worn across the waist with placement atop of the 5th lumbar vertebra (L5). It reports ranges of pelvic motion in the coronal, sagittal and transverse planes, side-to-side symmetry, acceleration/deceleration phases, walking speed and time spent with one and/or both lower limbs on the ground. The subjects were evaluated at typical ambulatory settings (outpatient clinic). Clinicians (a physiatrist, a prosthetist and a physical therapist) with expertise in amputee care, observed subjects’ walking trials, qualifying their walking ability as “adequate” (-A), or as “requiring intervention” (-RI) by concensus, per the standard of care. Multidimensional scaling was employed for visualization of symmetries for the pelvic acceleration waveform in the direction of progression, the lateral pelvic tilt and transverse rotation.
Results: We report here on preliminary walking trial data from 4 able-bodied controls, 5 TTA and 7 TFA LLA subjects. We noted differences in speed/cadence, stance/swing times and the ranges of pelvic motion for TTA and TFA levels (more pronounced at the higher level), in keeping with previously reported findings. We were able to demonstrate significant differences in the symmetries for the pelvic acceleration waveform in the direction of progression, the lateral pelvic tilt and transverse rotation (symmetries refer to the percent agreement of the temporal variance of the stated parameters normalized to the gait cycle): able-bodied controls (>99-100% for all parameters), TTA-A (90-99.5%), TTA-RI (77.4-95.9%), TFA-A (65.9-96.9%) and TFA-RI (31.1-93.5%) subjects, permitting a multivariate pathognomonic clustering capable of distinguishing “adequate” walking ability from that “requiring intervention.”
Conclusions: Our data analysis indicates that tracking objective kinetic and kinematic parameters of pelvic motion can serve as a good indicator of LLA walking ability. OPMT can reliably indicate when a prosthetic device warrants adjustments or revision in people with lower limb amputations. The numerous objective metrics captured can characterize ensemble states of localized functional optima, for the different levels of amputation, as well as clinically significant deviations. Based on this preliminary data, further studies are warranted to validate the utility of OPMT in the clinical evaluation of LLA walking. Introduction of objective means to the evaluation of LLA walking performance would have a highly significant clinical impact. Standardization of the assessment will allow clinicians to conserve time, reliably document and communicate objective findings, monitor performance, qualify prescribed interventions and quantify their efficacy. Tools such as OPMT may permit the creation of evidence-based practice guidelines in the provision of amputee care.
Avascular Necrosis Masking as Radiculopathy: A Case of Premature Closure
Vince Si, MD
Case Diagnosis: Idiopathic avascular necrosis of the bilateral femoral heads
Case Description: This is a 67 year old female with no significant medical history who presented to clinic for evaluation of low back and left leg pain x 2 years. The pain is described as dull and radiates down the lateral left leg past the knees sparing the foot. The pain is worst upon standing but is also present when supine and seated. Functionally, she ambulates 5 blocks with a straight cane and with great difficulty negotiating stairs. She was evaluated by her primary care physician who felt the pain was radicular in nature and ordered an MRI of the lumbar spine which showed degenerative joint disease (DJD) with compression of right L5 nerve root. She was subsequently referred by her PCP for management of radiculopathy.
Upon examination, the patient had minimal pain on flexion and extension of the back. Examination of her legs was revealing for atrophy of the left quadriceps, decreased range of motion at the left hip in flexion, external, and internal rotation. She was also unable to flex her hip and flex/extend her knee against gravity. She had an antalgic gait with circumduction on the left. Her exam was concerning for intrinsic hip pathology vs radiculopathy vs peripheral neuropathy. EMG was negative for radiculopathy or peripheral neuropathy, and hip XR showed bilateral avascular necrosis (AVN) of the femoral head, left worse than right. She was diagnosed with idiopathic AVN of bilateral femoral heads and referred to orthopedics for surgical evaluation. She began a course of physical therapy for strengthening of core and hip-girdle complex with goals to stabilize the hip joints and reduce pain.
Discussions: AVN of the femoral head is seen in patients with certain risk factors, such as corticosteroid use or alcohol abuse. This case is an unusual presentation, as the patient had bilateral AVN of the hip without a history of steroid use, alcohol abuse, trauma, osteoporosis, or coagulopathy. Moreover, this case highlights the difficulty of accurate diagnosis since the symptoms can be wide-ranging and non-specific and can be easily confused with more common clinical diagnoses, such as radiculopathy, iliotibial band syndrome, or intrinsic knee pathologies.
Conclusions: Idiopathic AVN can be a diagnostic dilemma due to its rarity and often non-specific symptoms. It is, therefore, important to perform a detailed hip examination in patients with complaints of back, leg, or knee pain and to keep hip pathologies within the differential.
Baclofen Withdrawal Secondary to Gastrointestinal Malabsorption in a Patient with Colitis
Ali Valimahomed, MD; Jesuel Padro-Guzman, MD
Case Diagnosis: Baclofen Withdrawal
Case Description: This is a case of a 76 year-old woman with a past medical history of multiple sclerosis (MS) admitted to the hospital with bright-red-blood-per-rectum and diarrhea. Colonoscopy revealed pseudomembranes colitis and biopsy was positive for ischemic colitis. Infectious work-up, including clostridium difficile testing, was negative. During the hospitalization the patient experienced progressive urinary retention, altered mental status, spasticity, tachycardia, and respiratory failure requiring intubation. She received methylprednisolone intravenously for suspected MS flare without improvement in symptoms. Electroencephalogram was negative for seizures. Head computed tomography without contrast was negative for an acute process. It was finally concluded that the symptoms were due to withdrawal from baclofen secondary to poor gastrointestinal absorption as a result of colitis. The patient was transitioned from oral baclofen to intravenous diazepam, with gradual resolution of symptoms. Colitis was medically managed with intravenous fluids and Lomotil as needed. The patient was successfully extubated and transitioned back to home medications.
Discussions: Although medication non-compliance if often suspected in baclofen withdrawal, this case illustrates that acute gastrointestinal dysfunction, such as colitis (ischemic, inflammatory, or infectious), may result in poor absorption of oral baclofen with subsequent withdrawal symptoms. In cases of suspected baclofen malabsorption secondary to gastrointestinal dysfunction it is prudent to transition to intravenous antispasmodics.
Conclusions: It is important to recognize the symptoms of baclofen withdrawal. Clinicians should monitor for signs and symptoms of withdrawal in patients with acute gastrointestinal processes due to the possibility of impaired absorption.
Barriers to Procurement of Personal Wheelchairs at a Multidisciplinary Center for Assistive Technology: A Quality Improvement Project
Mark Fisher, BS, MD; Brad Dicianno, BS, BA, MS, MD
Objectives: To evaluate the impact of various barriers on the procurement of manual and power wheelchairs obtained through a university affiliated center for assistive technology.
Design: Approval was obtained from the Quality Improvement Subcommittee. A retrospective chart review was conducted using a random sample (n=82) of individuals with an initial evaluation in 2014. Insurance carrier, equipment received, equipment upgrade (difference between equipment possessed at presentation and equipment prescribed), vendor (independent variables), and days from initial evaluation to fitting (dependent variable) were collected. Equipment was coded using an ordinal scheme based upon the amount of function the equipment provides. A linear regression analysis with dummy variables and using Insurance A as constant was performed to detect an association of independent variables with time to procurement.
Results: R square of the regression model was 0.279 (p < 0.001). When compared to Insurance A, higher equipment codes slowed delivery for Insurance D (Beta -0.386, p=0.017). Equipment upgrades slowed delivery for Insurance A to a greater extent than Insurance B (Beta -0.263, p=0.021) or Insurance D (Beta -0.289, p=0.015). Average delivery time was higher for Insurance C (Beta 0.306, p=0.007) and Insurance D (Beta 0.255, p=0.019) when compared to Insurance A. Vendor used did not significantly impact delivery time (p=0.069). The compared means for procurement time for insurance carrier and equipment group were calculated.
Conclusions: Insurance C and D (both public insurances) delayed the overall time to procurement. The greater the disparity in equipment between the clients’ prior equipment and new equipment the greater the delay of Insurance A’s (private insurance) approval when compared to Insurance B (private insurance) and Insurance D. The compared means data that was calculated gives an estimated time until delivery based upon the equipment prescribed and the client’s insurance carrier.
Battlefield Acupuncture Training in Residency: A Course that Gets to the Point
Gregory L. Condie, DO; Ajit Pai, MD; David Drake, MD
Objectives: Battlefield Acupuncture (BFA) is an emerging tool as a way to fight pain without the use of narcotics. This modality is not generally taught in physical medicine and rehabilitation (PM&R) residency programs; but, is gaining interest due to it use by the military and VA health care systems. Presently, there is no standard curriculum for residents to learn BFA techniques. A pubmed search produced few research articles on implementing acupuncture or integrative medicine in residency training, but none specific to BFA. Understanding resident attitudes and assessing their level of proficiency after BFA training will allow us to better implement a novel certification process for residents and improve their skills in treating pain as resident physicians while in residency.
Design: Post-graduate year 2, 3 and 4 resident-physicians at a single residency training program were participated in a 3 hour didactic lecture and demonstration. Hands on training was completed by a certified BFA instructor with ASP acupuncture studs. A post-training survey using a 5 point Likert scale was administered to assess resident’s perception of competency with BFA techniques and whether the training enhanced their education.
Results: Resident-physicians (n =18 participated; n=12 responded to the survey) 50 % generally felt one session was adequate and that it enhanced their education. 58% have used the training techniques since the training was given. 58 % felt the training wouldn’t affect their choice of residency. 46 % said they would recommend other’s start similar training, with another 48 % unsure about it. While 33% would agree that they would use this in their future practice, 41 % were undecided while 24 % disagreed or strongly disagreed with the idea.
Conclusions: In our sample, Residency-Physician training in BFA techniques is effective and generally well received. This training can be seamlessly incorporated into the curriculum on an annual or biannual basis. This may then be used as a template for other programs to emulate.
Best Placement of Temperature Probe during an Electrodiagnostic (EDX) Evaluation of Carpal Tunnel Syndrome (CTS)
Jennifer Soo Hoo, MD; Leilei Wang, MD, PhD
Objectives: It has been well established that temperature influences nerve and muscle function and must be taken into consideration when analyzing findings on EMG to avoid misdiagnosis. Our study’s goal was to determine where the best placement of the temperature probe was during a CTS study.
Design: We obtained infrared temperature readings using a Slim-Line INR 462 Infrared Thermometer with Laser Sighting probe, which can measure real time temperature changes, of both hands of 7 asymptomatic individuals at both the proximal and distal phalanx of each finger, thenar, hypothenar, and wrist on both dorsal and palmar side. Temperature differences were then compared and analyzed. We used a hair dryer and infrared heating lamp to warm up the hand of 2 subjects and then followed temperature of the hand every minute after until temperature returned to baseline.
Results: We discovered there is noticeable variability in temperature between individuals and in the same individual in different parts of the hand. We also found that there are variable side to side temperature differences in the same individual. After warming a patient using a hair dryer for 45 seconds, we found temperatures cooled rapidly and the distal phalanx temperatures returned < 30°C after 1–2 minutes, and the proximal phalanx temperatures returned < 30°C after 4–5 minutes.
Conclusions: We found that the temperature reading on the dorsum of the hand doesn’t predict digit temperature. The side-to-side temperature variation argues against placing the temperature probe on the contralateral limb at the corresponding location. We also found that that cutaneous temperature drops quickly after warming with common warming techniques and would return to pre-warming temperature in a few minutes. Given the large temperature gradient in a specific digit, further studies are needed to determine which site should be used for temperature correction. These questions are currently under investigation.
Beyond the Muscle: A Case of Bronchiolitis Obliterans with Organizing Pneumonia as a Preceding Manifestation of Anti-Jo-1 Antibody Positive Polymyositis
Craig Van Dien, MD; Laurent Delavaux, MD; Iqbal Jafri, MD; Sara Cuccurrullo, MD
Case Diagnosis: Polymyositis
Case Description: A 54 year old gentleman with a history of hypertension and bronchiolitis obliterans with organizing pneumonia (BOOP) previously on long term steroids is admitted to acute inpatient rehabilitation for functional deficits related to proximal muscle weakness. The patient was initially diagnosed with BOOP in Sept 2014 and was managed with a long-term steroid taper with completion in April 2015. In March 2015 the patient reported the onset of proximal upper and lower extremity weakness that resulted in a declining functional status. Electromyography in May 2015 demonstrated diffuse subacute or chronic myopathy of the bilateral lower extremities. Prior to admission to rehabilitation, the patient was reevaluated at an acute medical center with workup demonstrating elevated creatinine kinase, myoglobin (both serum and urine), aldolase and serum anti-Jo-1 antibodies. Scleroderma, ACH blocking/binding antibodies, and antinuclear antibodies were negative. He underwent muscle biopsy with pathology later demonstrating inflammatory myopathy with moderate myofiber atrophy including perifascicular atrophy consistent with polymyositis. The patient was started on oral steroids and transferred to acute inpatient rehabilitation. During his rehabilitation stay, he was continued on oral steroids with improvement in his functional status from a moderate assist with transfers and activities of daily living (ADLs) and contact guard assist with ambulation to independent with most ADLs, and supervision with ambulation.
Discussions: Polymyositis is an idiopathic inflammatory myopathy generally characterized clinically by proximal muscle weakness. Commonly reported is the association between interstitial lung disease and polymyositis, with fewer reports of BOOP as the preceding manifestation of polymyositis.
Conclusions: This is an interesting and rare case of BOOP as a preceding manifestation of anti-Jo-1 antibody positive polymyositis with clinically significant proximal muscle weakness manifesting with reduction in steroid dosing.
Bilateral Carpal Tunnel Syndrome in the presence of Transthyreitin (TTR) Amyloidosis: A Case Report
Alcinto Steven Guirand, MD; Sean A. Lacey, BSC
Case Diagnosis: Bilateral Carpal Tunnel Syndrome in the presence of Transthyreitin (TTR) Amyloidosis
Case Description: A 78 year old male with recently diagnosed wild type TTR cardiac amyloidosis and moderate-severe bilateral carpal tunnel syndrome presented to a tertiary center outpatient clinic with bilateral hand numbness and decrease in manual dexterity. He was approximately thirteen years status post carpal tunnel release of both wrists with good relief of symptoms. Electrodiagnostic studies were requested to evaluate for the presence of bilateral carpal tunnel syndrome or cervical radiculopathy.
Sensory and motor conduction studies of the right and left upper extremity were performed. This was followed by needle EMG of selected proximal and distal muscles of the right upper extremity. There was electrical evidence to suggest the presence of severe, bilateral median neuropathies at the wrists, such as can be seen in the carpal tunnel syndrome. There was additional evidence to suggest bilateral nonlocalizing ulnar sensory neuropathies. There was no evidence of cervical radiculopathy.
Discussions: Both variant and wild type TTR deposition within tenosynovial tissues at the wrist have been shown to be a cause of idiopathic carpal tunnel syndrome. Variant deposition at the wrist often occurs early in the course of the type II amyloid neuropathy phenotype of familial TTR amyloidosis. Carpal tunnel syndrome in the setting of wild type deposition can be the preliminary finding in patients with senile systemic amyloidosis which predominantly involves the cardiovascular system.
Conclusions: In patients with TTR amyloidosis, idiopathic carpal tunnel syndrome may be the initial manifestation of disease. The presence of bilateral symptoms may be further suggestive of familial or wild type TTR amyloidosis.
Bilateral Femoral Fractures in a Patient Taking a Bisphosphonate: A Case Report
Jahnna Levy, DO; Nayeema Chowdhury, DO; Wayne Stokes, MD
Case Diagnosis: A 62 year old female with a two year history of bilateral hip pain found to have bilateral subtrochanteric femur stress fractures while on a daily dose of a bisphosphonate for five years.
Case Description: A 62 year old female line-dancer presented to an outpatient office with complaint of two years of right greater than left hip pain extending distally to her knees with occasional right knee swelling. She denied any accidents, falls or trauma. Pain was described as sharp, with occasional radiation to the groin. Her pain was exacerbated with weightbearing, ambulation, negotiating stairs and dancing. She had complete resolution of her pain with rest. She has been a professional line-dancer for over 30 years, practices approximately 4 hours per week without any recent changes in her technique. Past medical history was significant for osteoporosis. Current medications were notable for beta blockers and recent discontinuation of a bisphosphonate taken 5 days a week for 5 years. Physical exam was notable for 15 degree limitation in external rotation on the right with pain, otherwise exam was unremarkable. Bilateral Hip Xrays were ordered which revealed bilateral subtrochanteric stress fractures with lateral cortical breaks right greater than left and mild right hip osteoarthritis. Patient was placed on bilateral lower extremity non-weightbearing precautions for a minimum of three months due to risk of progression of fractures to complete displacement and was referred to orthopedics for consideration of surgical intervention.
Discussions: Bisphosphonates are a class of drugs that are used to treat and prevent several bony pathologies including osteoporosis, paget’s disease, osteogenesis imperfect, multiple myeloma, and primary hyperparathyroidism. Specifically, bisphosphonates have been shown to prevent clinical fractures in women younger than 80 years of age with documented osteoporosis. Bisphosphonates target osteoclasts, reducing their degradation of bone to restore balance between osteoblasts and osteoclasts. Potential common adverse effects include esophageal and stomach erosion, osteonecrosis of the jaw and cardiac arrhythmias. Potential uncommon adverse effects include atypical subtrochanteric or femoral shaft fractures.
Conclusions: Three large randomized studies including the Fracture Intervention Trial + Long Term Extension Trial, the HORIZON Trial and the Pivotal Fracture Trial analyzed different bisphosphonates have reviewed the relative risk of atypical low impact hip fractures on post-menopausal women taking bisphosphonates. While rare, patients treated for 5 years of greater have a .13-.22% relative risk for atypical subtrochanteric or femoral shaft fracture, however, the prevention of fracture outweighs the risk.
Bilateral Subtle Cavus Foot: Under-Recognized Biomechanical Culprit of Foot Pain
Milagros Llull-Vera, MD; Mooyeon Oh-Park, MD; Nahyun Kim, MD
Case Diagnosis: Bilateral subtle cavus foot: under-recognized biomechanical culprit of foot pain.
Case Description: A 57-year-old woman presented with insidious onset of lateral ankle instability and pain for 10 years. She felt her feet were ‘turning in’ during weight bearing, which interfered with walking. She denied any feet trauma, paresthesia, or weakness. She had a pair of custom-made orthosis with partial relief. There was no family history of neuromuscular disease and prior electrodiagnostic testing was normal. Clinical evaluation revealed bilateral high-arched feet, callus on 5thmetatarsal, and positive peek-a-boo heel sign. Biomechanical evaluation showed hindfoot varus and forefoot valgus in subtalar neutral position with gastrocnemius tightness bilaterally. Neurological examination was normal. Lateral Coleman block test revealed correction of bilateral calcaneovarus. After application of 1/8” lateral forefoot posting, patient reported immediate reduction of pain and instability. Modification to her current insoles was prescribed including lateral forefoot/hindfoot posting and heel elevation. The patient was also educated on daily gastrocnemius stretching and footwear with rigid lateral counter without antipronation reinforcement.
Discussions: Pes cavus, characterized by increased medial arch height, is often associated with pain and/or instability of the foot and ankle. Cavus foot may show biomechanical deficits including forefoot valgus and limited ankle range of motion from tight gastrocnemius muscle. Plantarflexed 1st ray relative to the lateral forefoot drives the hindfoot into inversion leading to instability of the ankle and hindfoot. Correction of hindfoot varus with Coleman block test indicates flexibility of the subtalar joint and supports orthotic intervention. Key principles of orthotic prescription include lateral forefoot posting (if forefoot valgus), lateral hindfoot posting (if correctable hindfoot deformity), and heel elevation to accommodate tight heel cord. Furthermore, appropriate footwear education and gastrocnemius stretching should be included in treatment plan.
Conclusions: Addressing underlying biomechanical deficits in cavus by systematic orthotic management is essential for successful treatment of foot pain and instability.
Bone Complications after Pelvic Radiation: An Unusual Case of Hip Pain
Sonal Oza, MD; Monica Rho, MD
Case Diagnosis: Bone Complications after Pelvic Radiation: An Unusual Case of Hip Pain
Case Description: A 65 year old female with Stage III Vaginal Cancer developed left lateral thigh pain three weeks into radiation therapy. She had whole pelvic, inguinal, and vaginal radiation; brachytherapy and Cisplatin chemotherapy in 2010. In 2011, symptoms progressed into left lumbar paraspinal and gluteal pain; leg weakness, cramps and burning with ambulation. Patient required a cane and was unable to climb steps. Upon presentation to our clinic in 2012, she was post-5 injections (low back, left buttock, right thigh, 2 hip bursa) without relief. Exam elicited pain with hip flexion, internal and external rotation. Left hip flexion was limited to 20 degrees. She had pain with laying supine and bearing weight. Gait was severely antalgic. Hip x-ray revealed left hip avascular necrosis (AVN). MRI of pelvis demonstrated bilateral sacral insufficiency and right pubic body fractures. DEXA scan indicated bilateral hip osteopenia. Bisphosphonate therapy was initiated. Patient participated in water therapy and core-strengthening exercises in PT. She underwent a left total hip arthroplasty in 2015. Hip pain has nearly resolved and gait has improved.
Discussions: Radiation is associated with bone cell death. It induces an acellular matrix and causes fibrosis, endothelial proliferation resulting in microvascular occlusion. These processes increase susceptibility to fractures and to AVN. Radiation is associated with an 8.6 to 17% pelvic insufficiency fracture incidence rate, with 5 year cumulative incidence rates of 5.1 to 63%. The sacrum is most commonly affected as it transfers weight from the spinal column. Conservative management is indicated. AVN is rare with incidence rates of 0.4 to 1.2%. Risk factors include steroid use, older age. Evidence is unclear whether steroids with chemotherapy increases occurrence.
Conclusions: Hip pain in patients with gynecologic malignancies post-radiation should be evaluated for avascular necrosis and insufficiency fractures.
Botulinum Toxin as an Optional Treatment for Failed Back Syndrome: A Case Report
Robert Kinne, MD; Tallat Rizk, MD
Case Diagnosis: Failed Back Syndrome
Case Description: A 62 year-old male presented to PM&R clinic with back pain and significant debility due to failed back syndrome with associated paraspinal muscle spasms. The patient had a history significant for L4-L5 lumbar disc herniation for which he previously underwent L4-L5 laminectomy approximately two years prior to presentation, followed by L4-L5 vertebral fusion after experiencing refractory low back pain. Despite these two surgeries, in addition to multiple epidural steroid injections, the patient continued to require daily narcotic pain medication to and suffered from limited mobility. He was subsequently treated with botulinum neurotoxin (botox) injection to his bilateral lumbar paraspinal muscles. The patient reported 80–90 percent pain relief, was more physically active and was able to stop taking all narcotic pain medications while experiencing no complications.
Discussions: As demonstrated in animal studies, botulinum neurotoxin has a number of proposed mechanisms beyond its muscle paralysis effect by which it may provide pain relief in humans. Using this information, there has been a recent increase in attempts to use botox as treatment for generalized chronic back pain, with encouraging initial results. To date, however, there has been very limited analysis of Botox injection as a treatment modality in the specific population of Failed Back Syndrome patients. This is a relatively prevalent condition often complicated by paraspinal muscle spasm which can leave the patient with a high degree of morbidity and subsequently incurs a large amount of healthcare expenses.
Conclusions: Failed back syndrome is a condition commonly seen within PM&R and can be difficult to treat. This condition is frequently associated with and may be complicated by paraspinal muscle spasms. While many treatment options exist for this patient population, most have significant side effects and limited efficacy. Botulinum neurotoxin injection is a potential treatment modality that should be considered and warrants further study.
Brachial Neuritis: A Case of Delayed Diagnosis
David Haustein, MD; Jennifer M. Thomas, MD
Case Diagnosis: Brachial Neuritis affecting the anterior interosseous nerve
Case Description: A 53 year old gentleman developed sudden and severe left upper back pain. Worried about a heart attack, he presented to an emergency department where he was diagnosed with pleurisy and discharged. His pain persisted despite oral analgesics and he then developed left small finger paresthesias and weakness in the hand. Receiving a revised diagnosis of cervical radiculopathy, he presented for an EMG seven months after symptom onset. He had weakness of left index finger flexion and thumb interphalangeal joint flexion but otherwise normal strength. Median and ulnar sensory and motor conduction studies were normal but the needle EMG found spontaneous activity and decreased recruitment in a left anterior interosseous nerve distribution. He was diagnosed with brachial neuritis affecting the left anterior interosseous nerve.
Discussions: Brachial neuritis, also known as Parsonage Turner syndrome or neuralgic amyotrophy, is an uncommon neurologic syndrome that can cause significant impairment. Most patients complain of sudden onset of extreme neuropathic pain followed by multifocal weakness and atrophy in the upper limbs; these initial symptoms are often mistakenly attributed to cervical spine or shoulder pathology. Electrodiagnostics frequently confirm spontaneous activity and decreased recruitment in a single peripheral nerve or plexus distribution. Treatment is conservative with oral analgesics, therapy and modalities as needed.
Conclusions: The presentation of brachial neuritis is varied but frequently presents with severe shoulder pain, paresthesias and weakness. For many patients, diagnosis is delayed until the patient is evaluated by a musculoskeletal or neurological specialist. Given the severity of pain and weakness impacting function and quality of life, a timely diagnosis and evidence-based treatment will help prevent morbidity with this rare condition.
Breaking the Cycle: A Case Study of Cannabinoid Hyperemesis Syndrome
Logan McCool, DO; Olga Epstein, MD
Case Diagnosis: Cannabinoid Hyperemesis Syndrome with Peptic Ulcer Disease
Case Description: 24-year-old male with past medical history of episodic abdominal pain presents with cyclical vomiting and two types of abdominal pain–one that is vague and another that is “hollow”. The patient reports significant relief of his vague abdominal pain with hot showers. The patient was evaluated by ID and GI and underwent an extensive work-up with abdominal imaging along with colonoscopy and esophagogastroduodenoscopy. Results revealed no abnormalities other than gastritis on endoscopy. After initially denying, the patient later admitted to smoking at least 3–4 joints of marijuana per day in the week prior to hospital admission for self-management of the hollow abdominal pain. The patient’s nausea and vague abdominal pain subsided, but he continued to complain of hollow abdominal pain at discharge. After discharge, pathology report, from upper endoscopy, yielded infection with h. pylori. The patient reported improvement of all symptoms after appropriate treatment and follow-up.
Discussions: Cannabinoid Hyperemesis Syndrome (CHS) has become increasingly recognized in the literature after being initially described in 20041. CHS is classically characterized by a triad of chronic cannabis use, cyclic episodes of nausea and vomiting, and frequent hot bathing1–9. The patient’s abdominal pain is multifactorial due to h. pylori infection and cannabinoid hyperemesis syndrome. To the authors’ knowledge, this is the first known case where marijuana use was reported to be limited to one week prior to presentation of cyclical nausea and vomiting 1–9. This patient represents a growing demographic 6,10 who seek to self-manage pain with marijuana, and the case study highlights the importance for recognizing cannabinoid hyperemesis syndrome and for counseling patients on more effective therapies.
Conclusions: Physiatrists must recognize the growing practice of pain self-management with marijuana10, and the resulting uncommon and seemingly paradoxical presentation of cannabinoid hyperemesis syndrome.
Brush Your Teeth! Herpes Encephalitis after Dental Procedure: A Case Report
Dena Abdelshahed, MD; Neil Jasey, MD
Case Diagnosis: Herpes encephalitis after molar extraction
Case Description: A 75 year-old male underwent extraction of two molars and placement of a cadaveric bone graft. Shortly after, he developed facial edema and fevers and was started on Amoxicillin. After completing the antibiotic, he developed diarrhea and dehydration, and therefore presented to the ER ten days after the initial extraction.
He was admitted with dehydration and developed altered mental status, decreased responsiveness and tonic clonic seizures with right arm and right facial twitching. He was treated with antiepileptics while a CT of the brain was performed. CT revealed a possible subacute infarct in the right cortex and loss of gray/white matter differentiation in the medial and anterior pole of the right temporal lobe within the insular cortex. MRI showed increased T2 and decreased T1 signal in the same distribution consistent with herpetic encephalitis.
Lumbar puncture yielded 12,000 WBC with 90% lymphocytes. He was started on empiric antibiotics; gram stain, anaerobic and aerobic cultures and Lyme titers were negative. However, PCR for herpes simplex virus 1 was positive in CSF and serum. He completed 21 days of Acyclovir. At rehabilitation admission, he was NPO requiring PEG tube feeding, was aphasic and minimally interactive. He was started on neuro-protective medications including vitamin B and coenzyme Q10 as well as amantadine to promote arousal; he was eventually discharged to home with family on a PO diet, verbal, answering questions and following commands with moderate consistency.
Discussions: There are no published reports of HSV encephalitis after dental procedure. Herpes encephalitis is thought to occur after direct transmission of the HSV virus via a cranial nerve which may have occurred in this case. Providers should be aware of this potential occurrence, especially in patients with prior herpetic infections.
Conclusions: Herpes encephalitis is a newly reported possible complication after dental procedure.
Central Pain Syndrome after Acute Spinal Subdural Hematoma (SDH) - A Case Report
Kristina Quirolgico, MD; Heidi Schambra, MD
Case Diagnosis: A 42 year-old female with scoliosis underwent posterior spinal fusion revision. Intra-operative neuromonitoring changes prompted an emergent MRI which showed a T7-8 SDH with mass effect. The procedure was aborted. Afterward she had lower extremity weakness and pain.
Case Description: After 7 days of conservative treatment, the patient was transferred to the acute inpatient rehabilitation unit. The patient had numbness to light touch at T7-8 dermatomes, a painful band-like pulling sensation in the T8-T12 distribution, and severe burning pain to light touch in left L1-S1 dermatomes. She was also unable to move her left lower extremity against gravity. Repeat MRI showed resolution of SDH and minimally increased cord edema at T7-8 involving the dorsal columns and right ventrolateral cord. She was started on gabapentin and uptitrated by 300mg a day to 1200mg TID, with subsequent addition of amitriptyline 40mg daily. With each dosage increase, the patient’s pain improved and she recovered functionally so that by discharge she was ambulating with a cane and the pain was limited to her left foot.
Discussions: Central pain can occur after injury to the central nervous system. Common symptoms are allodynia, dysesthesia, and muscle pain described as cramping or constricting. The patient’s complaints of left-sided allodynia, “band-like” pain, and at-level numbness are consistent with involvement of the dorsal columns and right spinothalamic tract. Gabapentin has been shown to alleviate diabethic neuropathy and post-herpetic neuralgia in clinical trials. Both gabapentin and amitriptyline have been shown to relieve allodynia in animal models, but there are few randomized controlled studies supporting their use for central pain due to acute spinal cord injury in humans. Both medications have been proven beneficial in the pain management of this patient.
Conclusions: For central pain from acute cord compression and edema from subdural hematoma, gabapentin and amitriptyline can be used effectively for pain control.
Central Pontine Myelinolysis after Treatment of Severe Hyponatremia Due to Diuretic Use in Management of Hypertension
Ondrea McKay, MD; Radhika Bapineedu, MD
Case Diagnosis: central pontine myelinolysis due to rapid correction of sympotmatic hyponatremia following diuretic use
Case Description: 65 year old woman admitted for inpatient rehabilitation after a prolonged hospital course secondary to central pontine myelinolysis. She has a PMH of hypertension and diabetes, which had been treated with metformin and lisinopril but she had been noncompliant for some time. Her problems began in March of 2015 when she was visiting family in Asia and complained of severe headache. After she was examined by a local physician, it was presumed her headaches were due to elevated blood pressure and she was subsequently started on a thiazide diuretic. Despite treatment of her hypertension and improvement of her blood pressure readings on a subsequent visit, her headaches and nausea persisted. Approximately 6 days after starting the diuretic it was stopped and an MRI was done which was normal. Her symptoms were treated symptomatically until approximately 4 days after her MRI when her symptoms worsened and she also complained of dizziness. She was emergently taken to the hospital and initial blood work revealed severe hyponatremia with a sodium of 95 and hypokalemia with a potassium of 2.9. She was admitted to the hospital for correction and treated with IV fluids of hypertonic saline, after which she became initially more responsive and alert. One week after initiation of treatment she developed sudden onset dysphagia, aphasia and decreased level of consciousness. Initial MRI was negative following this episode, repeat MRI showed involvement of the pons and basal ganglia, indicating pontine and extrapontine myelinolysis.
After diagnosis her sodium was managed with free water restriction with eventual normalization. During her stay in rehab she progressed very well. She did have significant spasticity which responded well to oral baclofen as well as issues with mood lability and dysphagia. She initially required PEG tube feedings but was upgraded prior to discharge and her mood stabilized after titration of her medications. She left rehab feeling like her independence had been restored despite her difficult medical course.
Discussions: Thiazide diuretics are often a first line treatment of hypertension and the side effect of severe hyponatremia may be overlooked. This case is a reminder that caution should always be taken when prescribing medications especially in medically complex patients. This case also reminds physicians that when treating patients with hyponatremia, which is prevalent in many rehab patients that it should be done carefully and with close monitoring. Central pontine myelinolysis is not a common occurrence and may be forgotten in the management of hyponatremic patients.
Conclusions: Careful correction of sodium should occur in the treatment of hyponatremia, which is common in our TBI and stroke populations.
Managing medications in the rehab setting can be very difficult, especially with patients with multiple comorbidities, careful attention should be placed to avoid any iatrogenic injury.
Cervical Medial Branch Blocks in the Sitting Position: A Novel Technique
Rajat Mathur, MD
Case Diagnosis: To describe a sitting approach for cervical facet interventions in patients who are unable to tolerate either prone or recumbent positions.
Case Description: Case 1: A 75-year-old female presented with axial mid-cervical spine pain without radiation into the upper extremities referred to the Pain Clinic for diagnostic cervical medial branch block (MBB). Several failed attempts in performing medial branch blocks in prone, supine or lateral decubitus positions secondary to tremors, and muscle cramps. Patient was then placed in a sitting position and fluoroscopic unit was adjusted to allow the injection to be performed using the lateral approach. Patient underwent a successful radiofrequency ablation in the sitting position. Case 2: A 47-year-old male with past medical history of reflux disease presents with cervical facet arthropathy for diagnostic left medial branch blocks. Due to the severity of his reflux disease, we elected to approach the MBB by placing the patient in a sitting position. The facet joints were identified using a lateral approach and the needle was advanced from the posterior and inferior aspect under direct vision and placed parallel to the medial branches.
Discussions: Patients in the above cases reported significant improvement greater than 50% improvement of axial cervical spine pain following MBB and radiofrequency thermal coagulation of the medial branch sensory nerves affecting facet joints with successful results.
Conclusions: During MBB, it is critical to avoid accidental entry into vessels, a nerve root sheath, or subarachnoid space. It is critical to be cautious to ensure that the needle tip is placed directly over the posterior elements on the lateral projection while the patient is sitting up. Upright approach may be very beneficial in patients who are obese, have movement disorders, pulmonary disorders. Other advantages include allowing patient comfort with easy positioning and breathing.
Cervical Radiculopathy Pain Resolves with Shoulder Injection
Suleiman Lapalme, MD; Pamela Hansen, MD; Frank Jackson, DO
Case Diagnosis: Cervical radiculopathy
Case Description: An 81 year old male presented to his physician with non-traumatic acute onset of severe left shoulder pain and weakness. Ultrasound and xray identified calcific tendinosis and rotator cuff (RC) tear. His left shoulder was injected with 2mL Lidocaine 1%, 2mL Bupivacaine 0.25%, and 80mg Kenalog 40mg/mL, with marked improvement of pain. However, at his four-week follow-up visit, the weakness persisted. The weakness was attributed to his RC tear. He was not a candidate for MRI due to an implanted pacemaker. He was referred to an orthopedic surgeon for consideration of repair. The astute surgeon felt the severity of the weakness was unusual and consulted our team. We performed an EMG, which revealed a severe C5 radiculopathy with 3+ denervation in C5 innervated muscles with minimal recruitment. A CT myelogram identified severe C4-5 left foraminal stenosis.
Discussions: Timely decompression is an important prognostic factor in a severe radiculopathy, and unfortunately, this unusual series of events led to a delay in diagnosis. It is important to be aware that “diagnostic” injections are not always truly diagnostic. Steroid in the vicinity of a pain generator can lead to improvement in symptoms. There is some systemic absorption which can lead to pain relief and obscure the true pain generator. Also important is the placebo effect, which is reported to be around 30%.
Conclusions: In patients with shoulder pain and weakness, caution should be exercised when making a diagnosis. Although in this case the patient’s symptoms and response to his injections were suggestive of shoulder pathology, it missed the radiculopathy, and may have led to a worse outcome. This may have been avoided with a higher index of suspicion for alternate diagnoses, closer follow up, and watching for specific patterns of weakness which may be suggestive of a radiculopathy.
Chronic Low Back Pain Evaulation and Workup Leading to an unusual Diagnosis of Marfan’s Syndrome
Aashish Deshpande, MD
Case Diagnosis: A patient presented to the outpatient clinic with axial low back pain with no lower extremity symptoms. Further workup revealed Dural Ectasia seen in the Lumbar Spine MRI. Upon review and further discussion, a working diagnosis of Marfan’s Syndrome was entertained and the patient was counseled on further evaluation and workup.
Case Description: The patient presented to Outpatient MSK clinic with a history of pain in multiple areas of the body including the neck, wrists, knees and low back. Most issues were felt by the patient to be minor at the time of the office visit except for the low back pain. In particular, the low back pain had significantly worsened in the last year. There was a remote (5+ yr) history of auto accident, with no specific injury or pain issues at the time to the low back. She reported over 8–10 months increasing low back pain without inciting event, and without radiation of pain/numbness/tingling into the lower extremities. No incontinence, no paraparesis or other associated symptoms. Examination showed no neurologic signs or symptoms, no pain across the low back with any active movement, reduced range of motion due to pain with all active or passive back movements. Straight leg raise showed back pain without radiation. Palpation across the midline low back as well as paraspinal tissues reporduced tenderness most notably at L5-S1. Pelvic and hip examination were negative for pain reproduction. Palpation across the joints of the knees, wrists, and 1st and 2nd digits produced tenderness without deformity, laxity, or swelling. Remainder of the clinical examination was non-contributory. The patient was given antiinflammatory medications, limited use muscle relaxers, and sent to physical therapy. The patient stopped PT after 6 sessions indicating not only increased low back pain with massage as well as exercise therapies, but increased pain in the hips, knees, and wrists with the activities. An MRI of the LS spine was ordered to further evaluate the patient’s symptoms. The MRI report indicated multiple areas of attenuated T2 signal in the lumbar spine, particularly in the lower segments. These were interpreted as dural ectasia. Upon further questioning, the patient indicated a personal history (not previously discussed with any physicians) of Joint hypermobility and in her youth the ability to dislocate her hips and knees. She thought nothing of this as multiple members of her family had similar issues. A differential diagnosis of Marfans syndrome was discussed the patient, with counseling and education of joint preservation and pain management The patient refused genetic testing at the time of diagnosis, but plans to have it done along with multiple other family members after discussion of ocular and cardiac manifestations that may occur. At present the follow up data is not available.
Discussions: Marfan’s Syndrome is a multisystem connective tissue disorder usually associated with mutation in fibrillin, and occasionally with mutation in transforming growth factor beta receptor 1 or 2. Aorta and mitral valve issues, lens dislocation, myopia, and joint laxity (often chronic) are often presenting features. The Ghent criteria are often used for definitive diagnosis. The common presentation in a patient with Marfan’s syndrome and dural ectasia is low back pain, headache, proximal leg pain, weakness and numbness above and below the knee, and genital rectal pain. Symptoms are often present daily, exacerbated by upright posture, and not improved by recumbency. In review, the patients mild hip pain may have been a manifestation of the dural ectasia of proximal leg pain. She did not present with any of the other common symptoms, and discussed no personal or familial history of the diagnosis.
Conclusions: The case presented shows that a thorough review of a patients history (often not fully elucidated for several visits) and evaluation can elicit an unusual diagnosis and therefore a completely different treatment paradigm. In this case, low back pain as an initial presentation led to the presumptive diagnosis of Marfans Syndrome not only for this patient but possibly for multiple family members.
Clinical and Electrophysiological Features of Non-Traumatic Bilateral Anterior Compartment Syndrome in a Patient with Sickle Cell Trait
Dana Sutton, MD; Omar Baez, MD
Case Diagnosis: Bilateral Deep Peroneal Neuropathy Secondary to Non-traumatic Anterior Compartment Syndrome
Case Description: A 17 year old male with sickle cell trait developed acute bilateral lower leg pain while running to catch the bus and roller skating. As the pain persisted despite over-the-counter analgesics, he sought medical attention in the emergency room later that night. Workup showed a serum creatinine kinase (CK) of 8563 U/L. The patient was given IV fluids, but CK eventually reached 29420 U/L and he developed weakness in his feet. MRI showed severe myositis in the anterior compartment of the lower legs bilaterally and compartment pressures measured over 60 mmHg. He underwent bilateral fasciotomy and was subsequently discharged to an acute rehabilitation facility.
Nerve conduction study and electromyography (NCS/EMG) was performed four months later. The study revealed bilateral deep peroneal neuropathies with atrophy of the innervated muscles and no sensory deficits. Activation produced only distant motor units in the left tibialis anterior muscle.
Discussions: The patient suffered from bilateral lower leg anterior compartment syndrome, the most common location of the condition. Since the deep peroneal nerve traverses this compartment, it can be compressed by the excess pressure. Our case represents electrophysiologic proof of such an injury. Exertional compartment syndrome is a rare form of compartment syndrome caused by excessive exercise. The patient’s sickle cell trait may have been a predisposing factor to this condition as sickling of the red blood cells at low oxygen levels can cause further ischemic injury in the setting of elevated compartment pressure. Previously, the literature has not proven a direct correlation between the two conditions.
Conclusions: We present a case of exertional lower leg compartment syndrome with subsequent bilateral deep peroneal neuropathy. The patient’s sickle cell trait may have predisposed him to the rare condition.
Clinical Course of Hemophagocytic Lymphohistiocytosis from Diagnosis to Rehabilitation: A Case Report
Daniel Reid, MD; Marina Ma, MD; Robert Bunning, MD
Case Diagnosis: Hemophagocytic Lymphohistiocytosis (HLH), Critical Illness Polyneuropathy, Critical Illness Myopathy.
Case Description: Fifty-nine year old female with a past medical history of hypertension, psoriasis, osteoarthritis, and gastroesophageal reflux disease presented initially complaining of flu-like symptoms. Despite antibiotic treatment, she continued to worsen and developed altered mental status. Initial work up showed fevers, hepatosplenomegaly pancytopenia with severe thrombocytopenia of 12,000, elevated lactate of 7 and elevated ferritin. She then developed a seizure prompting intubation and admission to the intensive care unit. Peripheral smear and bone marrow biopsy confirmed the diagnosis of HLH.Treatment was initiated with an abbreviated HLD-2004 protocol consisting of etoposide and dexamethasone. Following treatment, she was weaned off vasopressors and her pancytopenia resolved. Her neurological exam improved from complete paralysis to 1/5 in proximal muscles and 3/5 in distal muscles. She was transferred to acute inpatient rehabilitation (AIR) for debility and critical illness polyneuropathy versus critical illness myopathy.
Discussions: HLH occurs after strong immunologic activation, oftentimes coupled with systemic infection, immunodeficiency, or underlying malignancy. It is characterized by the excessive activation of normal T lymphocytes and macrophages. Diagnosis can be made via molecular or five of the following eight criteria: fever above 38.4 degree Celsius, splenomegaly, at least 2 lineage cytopenia, hypertriglyceridemia and/or hypofibrinogemia, hemophagocytosis, low or absent NK-cell activity, ferritin above 500ng/mL, and elevated sCD25. Our patient made remarkable improvement following initiation of treatment protocol, resulting in termination of etoposide after the fourth dose and dexamethasone weaned off. She improved in AIR and was discharged ambulating 150 feet with a rolling walker and was modified independent to supervision for activities of daily living.
Conclusions: Prompt diagnosis and treatment of HLH is paramount to ensure survival. As HLH patients are critically ill in their initial course, many develop critical illness polyneuropathy versus myopathy which necessitates transfer to AIR following their acute care.
Colon Cancer with Metastasis to the Spine: A Case Report
Ginece J. Jackson, MD; Sara Cuccurullo, MD; Krishna Urs, MD
Case Diagnosis: Colon cancer with metastasis to the spine
Case Description: A 54-year-old female with a history of stage IV colon cancer was admitted with headache and syncope. Imaging revealed a left frontal cortical lesion, two left cerebellar lesions and mass effect on the fourth ventricle. She was treated with Keppra and IV steroids. She underwent a suboccipital craniotomy and a partial C1 laminectomy with resection of the cerebellar masses. She also had an external ventricular drain placed. She had back pain with no neurologic deficit. Imaging revealed metastasis to her cervical, thoracic and lumbar spine without spinal cord compression. She was previously seen by radiation oncology and was given a course of radiation to the spine. Despite the metastasis to her spine, she was able to participate in physical therapy and remained ambulatory. She was discharged home with plans for palliative whole brain radiation and chemotherapy.
Discussions: Colon cancer usually metastasizes to the liver, lungs and peritoneum. Metastatic colon cancer to the spine is a rare occurrence. The reported incidence of metastasis to bone is 5-10%1. If a patient lives long enough, it is possible for colon cancer to metastasize to the bone.
Conclusions: Patients are living longer with colon cancer due to improvements in cancer treatment. Patients with long-term colon cancer have a risk of developing metastatic lesions to the spine. Physiatrists should be aware of this risk and should do a comprehensive metastatic work-up for these patients who present with back pain. This ensures a good quality of life with the goal of keeping patients ambulatory.
Confounding Causes of Shoulder Weakness Following Posterior Cervical Discectomy and Fusion: A Case Report
Andrea Cordova, MD; Gary Inwald, DO
Case Diagnosis: Acute Shoulder Weakness
Case Description: 57 year old female admitted to the acute inpatient rehabilitation unit 5 days following a C3-C5 posterior cervical laminectomy with instrumented fusion of C3-C6 for progressively worsening symptoms of cervical spondylotic myelopathy including bilateral hand paresthesias, and gait and balance deficits. During the immediate postoperative period, the patient showed substantial progress in her gait and balance as well as a reduction of the bilateral hand numbness. On Postoperative day #8, she presented with acute onset right shoulder pain after reaching out and turning abruptly in her bed. Her physical exam was notable for significant weakness in right shoulder flexion, abduction and internal rotation which was not evident preoperatively. There were no reported sensory deficits. A Cervical Spine MRI was performed which revealed residual diffuse intramedullary signal abnormality predominantly at the C4-C5 level. Neurosurgery was consulted and indicated that the patient’s new onset weakness was secondary to an isolated right C5 palsy. She was started on oral steroids however showed little improvement after 3 days. On Postoperative day #12, a right shoulder MRI was performed for further evaluation and demonstrated a high-grade near full-thickness focal tear of the anterior most fibers of the right supraspinatus, along with supraspinatus and infraspinatus tendinopathy and infraspinatus muscle strain. The patient was then initiated on a therapeutic regimen including scapular mobilization, active and passive shoulder range of motion exercises as well as strengthening of the rotator cuff muscles with noted recovery in function.
Discussions: It is well established that C5 palsy with resulting deltoid motor weakness can occur following both posterior and anterior spinal approaches for cervical spine pathology. Prognosis and etiology is still not well understood as most cases go unreported. Majority of the cases will respond to either conservative treatment or short course of oral steroids. Other potential causes of acute shoulder dysfunction include brachial plexopathy, shoulder pathologies and suprascapular neuropathy.
Conclusions: Isolated C5 palsy following posterior decompression procedures for cervical spondylotic myelopathy is not an uncommon occurrence. Cervical spine MRI findings can be suggestive of this complication; however these were not conclusively established in this patient. Further radiologic testing did demonstrate concomitant right shoulder rotator cuff tendinopathy. This case demonstrates the importance of exploring all possible causes of acute shoulder weakness, especially in non-traumatic cases and those following cervical spine surgeries, in order to establish appropriately directed therapeutic regimens for optimal functional outcome.
Contrasting Functional Outcomes of Different Approaches to Retroperitoneal Mass Management
Lindsay N. Ramey, MD; Jennifer Baima, MD
Case Diagnosis: Retroperitoneal Tumors
Case Description: Patient 1 is a 39 year old healthy, active female found to have a 6 x 6 cm retroperitoneal mass atop the psoas muscle on CT, confirmed by MRI. It was discovered incidentally during ED workup for gastrointestinal complaints, which improved after viral illness resolved. She had no symptoms and examination was normal. Given its size, the mass was resected. Partial iliopsoas resection was required due to mass adherence. Final pathology showed a benign intramuscular hemangioma. Post-operatively, she had significant neuropathic pain, refractory to Neurontin, anti-spasm medication and opiods, as well as activity-limiting hip flexor weakness. She had partial relief with physical therapy, lyrica, accupuncture and trigger point injections, but remains functionally limited.
Patient 2 is an 82 year old male with multiple comorbidities who presented to the ED with diffuse left leg pain. Hip and knee X-rays were normal. He was diagnosed with ITB Syndrome. Despite physical therapy, his pain worsened and he developed leg weakness. Examination revealed left-sided positive straight leg raise, hip flexor weakness and absent patellar reflex, concerning for lumbar radiculopathy. MRI showed spinal stenosis with left L4 compression and a left retroperitoneal mass adjacent to the iliopsoas. CT confirmed a 4 x 2.5 x 4 cm mass, most consistent in appearance with liposarcoma without evidence of metastasis. Given vascular comorbidities, surgery was deferred in lieu of surveillance. Follow-up imaging has remained stable. His symptoms improved significantly with Neurontin and physical therapy suggesting spinal stenosis to be the source of his symptoms.
Discussions: Retroperitoneal masses can result in catastrophic outcomes if malignant. Surgical resection is typically recommended as biopsies are often inadequate for diagnosis. These cases contrast the symptomatic and functional outcomes of 2 patients with similar masses and different treatments. While the young, asymptomatic patient continues to struggle with pain and weakness following resection, the medically-complex, symptomatic, elderly male had significant improvement in pain and function without evidence of tumor growth using a conservative approach.
Conclusions: Conservative management of small, slow-growing retroperitoneal masses may be appropriate in some cases and may result in better functional outcomes. Other etiologies of symptoms should be explored and treated.
Conus Medularis Syndrome as Presenting Symptom in Neurosarcoidosis. A Case Report
Mary Apiafi, MD; Gary Inwald, DO
Case Diagnosis: Neurosarcoidosis
Case Description: A 62 year old African American female with past medical history significant for Coronary Artery Disease with recurrent myocardial infarction, type two diabetes, hypertension, cervical spine fusion, presented with complaints of lower back pain radiating to lower extremities, numbness, weakness, and bowel and bladder incontinence, for several months, progressively worsening. Physical examination was remarkable for poor balance, gait instability, weakness in proximal muscles of the lower extremity, brisk reflexes and up-going toes. Investigations: MRI Spine showed a 1.9cm Enhancing lesion of Conus Medullaris and sacral nerve roots. Spinal canal stenosis is seen at T11/T12, likely related to ongoing compression of the cauda equine. MRI brain demonstrated non-specific findings. CT chest demonstrated Hilar fullness not sufficient for biopsy. Gallium scan was negative post steroid administration. Lab studies were significant for elevated Serum ACE levels, low levels of CSF ACE, however this was after steroid administration. The diagnosis of Neurosarcoidosis was made based on clinical, CSF, serum and imaging findings, without systemic signs of the disease present. The patient was started on high dose steroids and admitted to acute inpatient rehabilitation for strengthening and gait training. Patient showed improvement on steroids and therapy program. Upon discharge, she was ambulating with a straight cane, with improved balance, weakness and ambulation.
Discussions: Sarcoidosis is an idiopathic granulomatous disease that affects multiple organs. It is commonly seen between the ages of 20 and 40 years. However it also occurs in children and older individuals. It frequently presents with bilateral hilar lymphadenopathy on chest radiograph, ocular or skin involvement. Diagnosis is based on clinical, imaging, histology, and CSF fluid analysis. The signs of spinal cord sarcoidosis typically mimic those of a spinal cord tumor or meningomyelitis, and may involve the cauda equina. Patients presents with insidious onset of weakness and paresthesia. Occasionally, sudden paraplegia may occur. Neurosarcoidosis usually occurs in the presence of multisystem disease. Involvement of the central nervous system occurs in 5-15% of cases of sarcoidosis. Systemic disease is not always evident, particularly early in the clinical course Neurosarcoidosis has no known cure and long-term therapy is often required, beginning with corticosteroids, followed by long-term Immunosuppressive therapy and adjuvants including physical rehabilitation.
Conclusions: Neurosarcoidosis can present without systemic manifestations or prior diagnosis of sarcoidosis, and should be considered in patients presenting with symptoms of transverse myelitis or cauda equina syndrome. Rehabilitation can play a significant role in patients ambulation and functional status.
Cost-Effectiveness and Efficiency in Diagnosis of Neuromuscular Disease
Vikki A. Stefans, MD; Julie Kaylor, MS, CGC
Objectives: To assess and provide guidance for the most cost-effective and efficient routes to specific neuromuscular diagnosis based on real experience with a variety of methods, with an emphasis on Charcot-Marie-Tooth disease (HMSN) and limb-girdle muscular dystrophy.
Design: The presentation will be based on our retrospective review of all recent diagnoses via our pediatric MDA clinic setting with cost data; outside company names will be omitted and patient data will be de-identified.
Results: The best routes to precise diagnosis of neuromuscular disorders have not been fully elucidated in this era of DNA sequencing. Effectiveness can be defined as getting a precise enough diagnosis to allow for optimal treatment, management and prognostication; correct genetic counseling; and ideally, also clinical trial eligibility. Efficiency can be considered in terms of costs and charges, as well as in turnaround time. At times, coverage constraints may determine the path to diagnosis or prevent narrowing down a diagnosis beyond a clinical phenotype. Most commonly, this occurs when policies do not cover genetic testing but will cover imaging, electrodiagnosis and/or biopsy. Cases will be presented to illustrate these points, as well as data to support cost effectiveness of recommended protocols in Charcot-Marie-Tooth disease and limb-girdle musuclar dystrophy specifically, based on recent experience over the past few years at a tertiary academic pediatric medical center.
Conclusions: It can sometimes be successfully argued that the cost of well-selected genetic testing will be lower than traditional methods, as well as inherently more specific. However, large panels may vary in effectiveness and cost-efficiency based on their specificity and selection of specific tests included which all relate to similar phenotypes rather than disparate ones, and ideally offer stepwise options focusing on the most common specific causes to be assessed for first. Also, the actual expenses involved in genetic testing will vary considerably between different companies for similar selections of single gene tests, panels, and microarrays; additionally, fully subsidized gene testing which is available for some conditions. Rare and complex presentations unlikely to be due to routinely tested genes may be best dealt with via whole exome sequencing as the first or second tier of testing. At times, a variant of unknown significance or unexpected finding will require proceeding with traditional methods in a confirmatory mode.
Critical Illness Myopathy while Awaiting Orthotopic Liver Transplantation: A Case Report
Lisanne C. Cruz, MD, MSC; Miguel Escalon, MD, MPH
Case Diagnosis: Fulminant hepatic failure requiring orthotopic liver transplantation (OLT), complicated by acute critical illness myelopathy.
Case Description: 38 year old female with a recent diagnosis of metastatic neuroendocrine cancer and antiphospholipid syndrome presented with fulminant hepatic failure secondary to portal vein thrombosis. While awaiting a liver transplant, the patient’s condition was complicated by sepsis, ventilator dependence, dysphagia, metabolic encephalopathy, acute kidney injury and acute illness myelopathy due to her prolonged hospital course in the ICU. The patient eventually underwent OLT and was admitted to acute inpatient rehabilitation for gait and strength training and tasks of daily living. Depression and pain were also managed. Following remarkable progress, the patient returned home and continued outpatient therapy.
Discussions: Individuals undergoing OLT are living longer and the focus has shifted from survival to quality of life post-transplantation. Similarly, the duration of disability before transplantation has become extended as the transplant list continues to grow. As such, individuals are often debilitated at the time of OLT, as demonstrated in our case. Rehabilitation that is more frequent, higher intensity and longer duration, such as an acute inpatient rehabilitation setting, may be necessary to counteract the effects of the pre-transplant inactivity, metabolic disturbances and post-transplantation immunosuppression. Similarly, pre-transplant rehabilitation may be necessary to improve function in order for these patients to withstand surgery and immunosuppression. Learning from the oncological rehabilitation model, improving function before, during and after transplantation may lead to better outcomes. Physiatrists are uniquely positioned to coordinate care for these medically complex patients all the while improving function, reducing pain, and improving their emotional wellbeing.
Conclusions: The care of patient’s pre and post-OLT requires intense resource allocation and a long-term planning and commitment to attenuate post transplant co-morbidities and optimize physical functioning. Physiatrists can fulfill this role through care coordination, recovering function and ultimately improving quality of life.
Cryoablation of a Residual Limb Neuroma Allowing for Ambulation: A Case Report
Ryan R. Ramsook, MD; Fairen N. Walker, MD; David Spinner, DO, RMSK; Geet Paul, MD; Lauren Terranova, DO
Case Diagnosis: Residual limb neuroma cryoablation
Case Description: A 57 year old man with a past medical history of right hip disarticulation in 1978 presented with excruciating right residual limb pain for over ten years. The knife-like 9/10 phantom pain and allodynia prevented him from using his prosthesis, resulting in him having to utilize bilateral crutches and a wheelchair for mobility. Ultrasound examination revealed right residual limb neuroma for which an ultrasound guided diagnostic nerve block was performed resulting in complete resolution of pain. One week later, patient underwent cryoablation of the neuroma under ultrasound guidance. He subsequently had excellent pain relief resulting in him being able to utilize his prosthesis for the first time in over nine years. Patient is now able to ambulate pain free in the community with one lofstrand crutch.
Discussions: Chronic pain is reported in up to 95% of patients with amputations. Persistent pain in amputees can be the result of many etiologies including the formation of a neuroma. Neuromas can develop at the site of transection of any peripheral nerve. While the pain from a neuroma is usually well localized to the injury site, it has also been implicated in phantom limb pain. A diagnostic nerve block with local anesthetic can help support the diagnosis. Pain stemming from neuroma may persist despite conservative management and may require interventional procedures including ultrasound guided cryoablation. Directing focal extreme cold temperatures at the neuroma causes demyelinazation and Wallerian degeneration resulting in significant pain relief by blocking nerve transmission.
Conclusions: This case illustrates an excellent outcome of a previously debilitating residual limb neuroma with the use of ultrasound guided cryoablation therapy. The interventional procedure resulted in improved functionality by allowing for ambulation with increased independence for the first time since a traumatic hip disarticulation over 35 years ago.
Cushingoid Facies from One Time Intra-Articular Joint Kenalog Injection in a HIV Patient
Justice Otchere, MD
Case Diagnosis: Cushingoid syndrome secondary to intra-articular Kenalog injection
Case Description: This is a 60 year old male with diagnosis of HIV who received one time dose of Kenalog 40mg preparation injected into the right subacromial space for uncontrolled pain due to degenerative change of the right acromioclavicular and glenohumeral joints. The injection was prepared with Kenalog 1cc and 2 cc each of lidocaine and bupivicaine. He reported facial swelling, mild tremors, cramping, neck hump and increase in shirt neck size by 1.5 cm two to 8 weeks after Kenalog injection. The serum cortisol and DHEAS of the patient 2 weeks after the Kenalog injection were 2 and 48 mcg/dl respectively. Cotrosyn test revealed increased cortiosol level 6.5 mcg/dl from baseline 0.9 mcg/dl 1 hour after Cosyntropin 0.25mg intramuscular injection.
Discussions: Intra-articular steroid injections are slowly absorbed into the systemic circulation; hence, there is potential for longer exposure to the external source of steroids intra-articular joint injections. Patients subjected to intra-articular steroid injections may therefore demonstrate symptoms of Cushingoid features. Serum cortisol and DHEAS levels in the patient were 2 mcg/dl and 48 mcg/dl respectively two weeks after the Kenalog injection demonstrating suppression of the HPA axis due to the direct consequence of the negative feedback of exogenous steroid in the systemic circulation. Low serum cortisol implies non-endogenous corticosteroid exposure or adrenal insufficiency; however, normal level of DHEAS made adrenal insufficiency less likely. Cotrosyn test rules out primary adrenal insufficiency and confirms secondary adrenal suppression from HPA from exogenous corticosteroid exposure.
Conclusions: Intra-articular corticosteroid injection is not a benign procedure and may lead to extra-articular dysregulation of other organ systems. Due to the potential deleterious effects of ICAI, serum cortisol level should be monitored prior to and after the injections.
Cutaneous Manifestations in Patients with a History of Cocaine Abuse
Ankit Patel, MD; Daniel Moore, MD
Objectives: Case Diagnosis: Levamisole, a cutting agent in cocaine, induced ulcers in patients with a history of cocaine abuse
Design: Case Description: Two patients with a history of cocaine abuse presented to a wound center with scattered lesions. WN, a 45 year old female, with a history of cocaine abuse, was thought to have Systemic Lupus Erythematosus (SLE) and started on steroids per Rheumatology. During a hospital admission, she tested positive for cocaine. The wounds were described as dry gangrene, with necrotic slough throughout, varying in size. She had a total of 10 ulcers. Her nose and shoulder wounds were treated with Povidone-iodine twice a day. Her right lower extremity and upper arm were debrided and a hydrofiber with silver was applied. A petroleum gauze was used on the remainder of the wounds. Thepatient wound were improving, however, she failed to return for follow up and returned approximately a year later as a hospital referral. During that hospital stay, she was diagnosed with vasculitis secondary to Levamisole. And this was identified as the cause of her vasculitis, not SLE. Due to financial constraints, the patient was used a topical triple antibiotic ointment. The wounds began to show significant improvement with the ointment and abstinence from cocaine. CR, a 47 year old causation female, who also had a history of cocaine abuse, also presented to the hospital with multiple wounds and was initially diagnosed with vasculitis secondary to SLE. Thereafter, she had repeated visits to the hospital for painful, foul smelling wounds. The wounds were described as full thickness ulcers with black necrotic debris. She had a total of 12 ulcers. The patient reported that her wounds healed after she quit using cocaine, but returned when she relapsed. These were found to be secondary to Levamisole contamination. The wounds were located on her right forearm, left hand, and right ankle. She was referred to the wound center. She was encouraged to take antibiotics apply an alginante dressing. She denied debridement due to pain. On subsequent visits, she underwent sharp debridement and the dressing was changed to a collagen and oxidized regenerated cellulose dressing. The wounds began to improve and her dressing was changed to a topic silver sulfadiazine dressing.
Discussions: These two patients were discovered to be obtaining adulterated cocaine from the same dealer. They were initially diagnosed with vasculitis secondary to SLE and exacerbated with use of oral steroids. However, the patients had ulcer exacerbation with relapses in cocaine, which presented as multiple scattered ulcers, varying in size, that were painful with a foul odor.
Conclusions: Patients presenting to wound centers with multiple scattered, foul, and painful ulcers should be asked about their illegal drug use, as use of Levamisole, a cutting agent in cocaine, may result in an appearance of ulcers similar to SLE and discontinuation of offending agent will likely result in significant improvement of ulcers.
Dehisce or Not to Dehisce: Are Sternal Precaution Necessary for Prevention During Rehabilitation
Kevin Jiang, MD; Marilyn Pacheco, MD
Case Diagnosis: Sternal dehiscence during acute rehabilitation
Case Description: Our patient is a 45 year old male with a history of morbid obesity, obstructive sleep apnea, hypertension, heart failure, type II diabetes, chronic kidney disease, and chronic hypercapnia who presented to the emergency room with increasing shortness of breath (SOB) and chest pain. He was admitted to the intensive care unit and intubated for impending respiratory failure secondary to severe aortic regurgitation and pulmonary edema. The patient failed multiple extubation attempts and the decision was made for urgent aortic valve replacement with a mechanical valve. Patient postoperative course was complicated by acute pulmonary edema and acute kidney injury. One month later, he was medically stable for acute rehabilitation.
On admission to rehabilitation, his only notable findings were normal vital signs with cardiovascular exam notable for a mechanical click and bilateral pitting edema. He had decreased breath sounds on his left lower lobe of his lung exam with a well healing sternal sternal incision with no signs of fluctuance. Labs were significant for a white blood cell (WBC) count of 11.6
One week later, patient started to complain of increasing phlegm and cough. During therapy, he also became tachycardic and SOB. A chest x-ray, urinalysis, and urine culture were obtained of which only the chest x-ray revealed a new infiltrate concerning for pneumonia. Patient was started on levofloxacin but despite treatment, patient continued to complain of increasing phlegm, nausea, and diaphoresis for the next two days with increasing puffiness around his chest. His vitals were notable for a temperature of 99.6 F, a BP of 118/70, P of 112, and R of 20. Labs were significant for a WBC count of 10.4. His urine cultures also grew back methicillin resistant staph aureus and blood cultures were obtained due to concern for bacterial seeding from his valve.
A computerized tomography scan of his chest was obtained and revealed a dehiscence at the sternotomy site of 3 cm x 11 cm with subcutaneous fluid extending to the pericardium containing tiny amounts of air suspicious for infection. Afterwards, the patient stated that he had been using his arms to transfer off gym mats and while using his walker. He also stated that staff had been pulling on his arms during transfers and that he had been leaning over his bedside table. Patient was transferred off the rehabilitation floor and taken for revision surgery.
Discussions: Many patients undergoing acute rehabilitation after sternotomy may still be observing 6–8 weeks of recommended sternal precautions. The incidence of sternal dehiscence remains low in the general population of about 1-5%. Several factors predispose patients to sternal dehiscence including diabetes, obesity, smoking, chronic obstructive pulmonary disease, osteoporosis, large breast size, and previous sternotomy. External factors that may affect the healing sternum include simultaneous bilateral arm movements, pushing, pulling, coughing, and sneezing. Cadaver studies have shown that forces needed to cause a 2 mm distraction in the sternum are 220 N for laterally directed forces, 263 N for anterior-posterior forces, and 325 N for rostral-caudal forces. Studies have shown that most push and pu ll forces measured with a dynamometer ranged from 4.5 N to 27.5 N. For example, opening a car door required only 12.5 N. However, coughing can generate forces of 400 N. Other investigators have noted that unsupported frequent coughing may be the single largest cause of mechanical stress on the sternum. More than likely, an underlying infection or his persistent coughing coupled with his pre-existing risk factors of morbid obesity and diabetes may have led to his sternal dehiscence.
Conclusions: Based off this case and literature review, slight deviations from the often times strict postoperative lifting and movement restrictions are unlikely to be the cause of sternal dehiscence during rehabilitation and may in fact be unnecessary. The focus should be on reducing unsupported coughing and sneezing. Unloaded arm movements within a pain-free range and loaded activity with the upper arms close to the body do not cause excessive stress on the sternal surgical site and may even be tolerated for inclusion into an exercise regimen.
Development of Spinal Glioproliferative Tumor of Donor Origin Following Intrathecal Stem Cell Therapy
Peter (I-Kung) Wu, MD, PhD; Alcinto S. Guirand, MD; Kevin O’Connor, MD; Kate E. Delaney, MD
Case Diagnosis: T11 ASIA C paraplegia due to spinal glioproliferative tumor of donor origin following intrathecal stem cell therapy.
Case Description: A 67 year-old man with a history of right middle cerebral artery stroke from carotid dissection with resultant left hemiplegia underwent several rounds of experimental intraventricular and intrathecal stem cell injections over 4 years in China, Argentina, and Mexico. After receiving both heterologous and autologous embryonic, mesenchymal, and neuronal stem cells, he regained strength in his left lower extremity and the ability to ambulate with a cane and ankle-foot orthosis. Four months following his last treatment, he developed back pain followed by paraplegia, hypoesthesia below a mid-thoracic level, and neurogenic bowel and bladder over 2 months. Brain and spinal magnetic resonance imaging (MRI) revealed an intradural mass spanning T9-S1, coating the conus and cauda equina nerve roots, with inflammation, swelling, and obstruction of cerebrospinal fluid. He underwent T10-T12 laminectomy with duraplasty and partial resection of the intradural, extramedullary mass. Pathology results revealed a proliferative, neovascularized, high-grade glioma, with genetic analysis revealing donor DNA. Bowel and bladder function and some right lower extremity strength returned during post-operative rehabilitation. With repeat MRI demonstrating progression of mass, the patient started a course of total spinal radiation therapy. Interval MRIs have demonstrated partial response to initial treatments.
Discussions: Stem cells have potential as a regenerative therapy for debilitating conditions, including stroke, spinal cord injury, myocardial infarction, and painful degenerative diseases. As increasing attention is given to developing cell-based therapies, much remains to be understood about their application, and awareness should be raised about their unique risks, including inflammation, immunogenic stimulation, graft rejection, abnormal proliferation, heterotopia, and neoplasm.
Conclusions: Cell-based therapies face significant challenges, including ethical considerations, and the need for further investigation to establish safety and efficacy. Standardized clinical guidelines are required to improve patient outcomes and avoid complications.
Devic’s Disease and Inpatient Rehabilitation: A Case Report
Annie Layno-Moses, MD; Ray Lee, MD
Case Diagnosis: Neuromyelitis optica
Case Description: This is a 67-year-old previously independent black female diagnosed with multiple sclerosis (MS) 2 years prior to presentation who presented to acute care hospital for two-day history of left-sided weakness and headaches. Computed tomography of head was negative for acute stroke. Magnetic resonance imaging (MRI) brain revealed distal brain stem and upper cervical cord inflammation versus demyelinating process concerning for Devic’s disease. MRI cervical/thoracic spine showed enhancement of cervical cord with swelling and possible focal enhancement in upper thoracic cord. She was treated with intravenous steroids with no improvement, then patient refused plasmapharesis. Neuromyelitis optica (NMO) serum antibody returned positive, and patient had 5 sessions of plasma exchange. Moreover, patient had unstable atrial flutter with troponin leak and was treated with amiodarone. Hematology/oncology and neurology planned to start rituximab after discharge. She was newly diagnosed with NMO in contrast to her previous diagnosis of MS. She had developed torticollis, a left-right disorientation, and neurogenic bowel/bladder. She scored 15/30 on SLUMS indicating severe neurocognitive deficits. Amantadine was started but demonstrated minimal improvement in cognitive function. The patient completed inpatient rehabilitation and was discharged home with family.
Discussions: NMO is a neuroinflammatory syndrome that is rare and well differentiated from MS. Physiatrists should be aware of the misdiagnosis of MS for NMO because of the clinical course of Devic’s disease—acute attacks are most often severe and may lead to irreversible effects if not treated appropriately and timely. A literature review revealed only three other cases with NMO in the rehabilitation setting. Similar to the other documented case reports, our patient made improvements in eating, bathing, upper, lower body dressing, and transfers. Minimal improvement was seen with cognition.
Conclusions: Acute inpatient rehabilitation is valuable in a patient with NMO for functional gains but may be limited in cognitive gains. Attention should be directed toward preventing complications from NMO.
Diagnosis and Treatment of Miller Fisher Variant of Guillain-Barre Syndrome in a Female with Descending Weakness and Ataxia
Anna Rozman, DO; Michelle Stern, MD
Case Diagnosis: Diagnosis and Treatment of Miller Fisher Variant of Guillain-Barre Syndrome in a Female with Descending Weakness and Ataxia
Case Description: 62 y/o female presented one week after viral illness with acute onset shoulder and neck pain, and unsteady gait. Shortly after hospital admission, patient progressively declined and became unable to perform basic activities of daily living (ADLs). She developed numbness and tingling in her extremities, but denied sensory loss. On exam she presented with right-sided nystagmus, severe posterior neck tenderness, positive head drop, proximal upper extremity weakness with decreased reflexes. During her hospital stay she progressed to areflexia with severe bilateral upper and lower extremity weakness, inability to ambulate, and right foot drop. Subsequent EMG showed abnormal F and H responses, consistent with early onset Guillain-Barre Syndrome (GBS). CSF showed albuminocytologic dissociation. Her disease course further progressed to urinary retention, diarrhea, intractable neuropathic pain, respiratory distress, and adjustment disorder. At this time the patient was given a five day course of IVIG along with aggressive comprehensive physical/occupational therapy. Upon discharge, she showed improvement with ADLs, distal extremity strength, and range of motion. After two weeks of acute rehabilitation, \patient was able to ambulate 30 feet with a rolling walker without an ankle-foot orthoses, requiring minimum assistance.
Discussions: GBS typically follows an infection, presenting with rapid ascending weakness, mild sensory loss, and diminished reflexes. Most cases present bilaterally, involving the lower extremities with subsequent upper extremity spread, and may be accompanied by sensory loss. Many patients present with severe back pain with associated lower extremity neuropathy. Rarely, there is associated ocular involvement (ie: nystagmus, ophthalmoplegia, ptosis). GBS is also known to mimic spinal cord lesions with bladder or gastrointestinal involvement. A rare variant of GBS, Miller Fisher Syndrome (MFS), presents with a triad of areflexia, ataxia, and ophthalmoplegia. However, in comparison with traditional GBS, patients with MFS usually present with head and neck involvement prior to ascending paralysis, as in this patient. Comprehensive treatment with IVIG within two weeks is important, along with possible corticosteroids, plasma exchange, supportive respiratory treatment, pain management, DVT prophylaxis, and intensive inpatient rehabilitation is paramount to full recovery.
Conclusions: Proper diagnosis of different GBS variants and identification of their specific treatment options, including early intensive rehabilitation, are all key factors in prognosis and return to function of GBS patients.
Diagnosis of Thoracic Spinal Tumor Misattributed as Musculoskeletal Back Pain
Aaditya Verma, DO; Alexandra M. Rivera Vega, MD
Case Diagnosis: Metastatic adenosquamous lung carcinoma with metastases to T3-5 causing spinal cord injury.
Case Description: 56 year old African American male referred to clinic for constant, severe, mid thoracic back pain. Onset was six months ago. The patient rates the pain 9/10 and the pain is sharp and does not radiate to the extremities. It is worsened with movements that require crossing upper extremities past the midline and will wake the patient up from sleep. He was seen in the emergency room multiple times, with X-ray imaging showing no abnormalities. Of note the patient was cachectic and reported unexplained weight loss, night sweats, fevers, and chills. We scheduled a repeat chest X-ray the day of the visit as well as scheduled a CT chest on one week follow up, revealing a mass causing near obliteration of the spinal canal at T4. The patient developed urinary retention and underwent surgical decompression and the tissue analysis revealed adenosquamous carcinoma, likely from the lung. The mass had to be repeated for tumor recurrence. The patient received palliative chemotherapy treatments and was eventually transitioned to hospice care at a nursing home.
Discussions: This case highlights the importance of checking for “red flag” symptoms as well as how not investigating concerning symptoms. Musculoskeletal back pain should resolve in 4–6 weeks with conservative treatments, but the patient had intractable back pain that lasted over six months and was cachectic, febrile, and had night sweats. No CT or MRI was ordered prior to the referral to our clinic.
Conclusions: When seeing a patient, red flag symptoms should always be kept in mind and screened for. They should be pursued and worked up if the constellation of patient symptoms paints a picture of an emergency diagnosis.
Diagnostic Dilemma of a Facial Nerve Palsy after Treatment for Guillian-Barre: A Case Report
Daniel McNeill, DO; Fred Fridman, DO
Case Diagnosis: Bell’s Palsy
Case Description: A 65 year-old male presented to the hospital with complaints of bilateral lower extremity weakness and paresthesias. Evaluation including lumbar puncture and EMG and recent history of a viral upper respiratory illness suggested Guillain-Barré Syndrome (GBS). He was treated with a 5-day course of intravenous immunoglobulin (IVIG), which improved his symptoms and he was transferred to an acute inpatient rehabilitation facility. On admission to acute inpatient rehabilitation the patient presented with full upper extremity strength, 4/5 lower extremity strength and proprioceptive deficits in his lower extremities. On day 3 he developed a right-sided facial droop within hours involving the entire facial nerve, sparing the other cranial nerves. He was transferred back to an acute care hospital for work up where he underwent repeat imaging and lumbar puncture. The results of these studies were equivocal, showing improvement from initial presentation. He was ultimately diagnosed with Bell’s palsy and was treated with 60mg prednisone tapering over 5 days which rapidly improved his facial nerve palsy over days while his lower extremity symptoms remained stable. Following treatment he continued to participate in therapy and his lower extremity weakness slowly improved. He was subsequently discharged home.
Discussions: This patient provided a unique diagnostic challenge as new facial weakness in the setting of recent GBS may include several diagnoses including: Recurrent GBS as many patients may have cranial nerve involvement typically involving multiple cranial nerves and is often bilateral; Treatment related fluctuations, diagnosed with improved GBS disability scale with treatment, a significant decrease within 2 months after treatment; Bell’s palsy, which is responsible for 80% of all facial nerve palsies and is a diagnosis of exclusion; and chronic inflammatory demyelinating polyneuropathy which is typically diagnosed with recurrence of GBS after 8 weeks, or with 3 episodes neurological decline.
Conclusions: New facial nerve palsy in the setting of recent GBS has a broad differential diagnosis that must be considered as treatments and prognosis may differ.
Differentiating Between Conversion Disorder and Hemiplegic Migraine – How Do You Tell?
Shannon L. Schultz, MD, MPH; Shangming Zhang, MD; David Gater, MD, PhD, MS
Case Diagnosis: Conversion Disorder
Case Description: A 38-year-old female with a complex social history was transferred to rehab for steroid-induced myopathy after asthma exacerbation. On rehab day 3, while on the phone, she had acute onset aphasia, right-sided weakness and headache without an aura . An MRI, CT, echocardiogram and EEG revealed no organic etiology. She returned to rehab with stuttered speech, right scalp allodynia, and right-sided weakness. Assuming the diagnosis of hemiplegic migraine, she was started on Verapamil. On her fourth rehab day, she developed new chorea-like movement of her left upper extremity. An additional MRA, lumbar puncture and EEG were obtained which were normal. Upon transfer back to rehab, her right upper extremity strength returned (4/5), stuttering resolved and left upper extremity chorea decreased. She continued having weakness (2/5) in the right lower extremity which showed significant improvement with transcutaneous electrical nerve stimulation. Prior to discharge she was seen by neuropsychology and was prescribed Celexa.
Discussions: Conversion disorder is a somatoform disorder presenting as neurologic symptoms not adhering to a known disease process. It is thought to arise secondary to stress in susceptible individuals, typically younger females. Worldwide, 50/100,000 individuals are diagnosed each year, with an incidence of 4-12/100,000 new cases per year. In the United States, $20 billion/year is spent on treating this disease. Aggressive rehabilitation, psychotherapy, neurology and stress management play vital roles in resolution of symptoms. In this case, a functional MRI would have been indicated had there been an aura to further differentiate between a hemiplegic migraine and conversion disorder.
Conclusions: It is important to complete a thorough workup to rule out an organic cause to any neurologic symptoms. Conversion disorder responds well to therapy modalities, with resolution typically within two weeks. A multidisciplinary regimen aimed at patient education and awareness while decreasing stressful situations is paramount to prevent recurrence.
Disability within Healthcare Professionals’ Curricula: A Mapping Review
Caleb Atkins, MD; Omair Ahmad, MD; Bhargav Mudda, MD; Liju John, MD; Margaret A. Turk, MD
Objectives: General consensus is that a deficiency exists in knowledge, skills and attitudes of healthcare professionals related to people with disability. The purpose of this systematic search was to identify recent publications about disability education, and review the publications to catalogue and analyze their recommendations about healthcare professionals’ education regarding people with disability.
Design: We conducted a comprehensive search of publications from 1990 to April, 2014, using 13 search terms related to education and disability over 5 databases. Publications underwent initial review by defined inclusion/exclusion criteria, then mapping review (classification on various subjects) for publication category. Further overview of the category with the most articles was for major themes, detailed curricular information, and teaching strategies.
Results: 1,068 articles were identified through this systematic search, which distilled to 226 publications after review using inclusion/exclusion criteria. Initial mapping noted 106 commentary/other (e.g., opinion-based, letter to the editor, workshop/meeting summary), 85 quasi-experimental, 39 qualitative, 2 systematic reviews, and 2 randomized controlled trials. The major themes of the commentary/other category were reform of health professional education, curriculum content deficiency, and recommendations for content/teaching strategies. Of these, 50 addressed disability, rehabilitation, or health knowledge; 35, clinical skills; 29, poor provider attitudes. 29 publications discussed a multifaceted approach (using at least 2 of the 3 major themes). 18 of 29 recommended contact with a person with a disability, within a variety of contexts, as a key strategy. Didactics (12/29) was next common.
Conclusions: The largest publication category about professionals’ education concerning disability is commentary-based. There is limited research, mostly quasi-experimental, about successful education strategies. This review of commentary/other publications noted contact with people with disability as the key recommended strategy, however there was no agreement on the context. Future review of scientific rigor of the research-based articles may provide more direction for choice of education strategy.
Disparity Between Radiologic Findings and Clinical Presentation in Severe Osteoarthritis: Is There a Role for Biomarker at Point of Care?
Melissa P. Osborn, BA; Paul Paily, MD; Prathap Jayaram, MD
Case Diagnosis: Bilateral knee osteoarthritis, stage IV
Case Description: The patient is a 69-year-old male with a history of hypertension, hypercholesterolemia, and borderline diabetes mellitus, who presented for follow up for severe bilateral primary knee osteoarthritis. He remains very active, swimming and playing competitive tennis, with a pain rating no higher than 3–4 out of 10. Current medication regimen includes Celebrex 200mg daily. Prior treatment strategies have included steroid and hyaluronic acid injections with mild benefit. He has no desire to undergo knee surgery. Physical examination showed marked lateral joint widening bilaterally, mild effusion, and genu varum of the right knee. Diagnostic imaging includes weightbearing plain film X rays of both knees revealing advanced tricompartmental osteoarthritic changes bilaterally: right greater than left, most severe in the medial femorotibial joint compartment with loss of joint space, subchondral cystic changes, and sclerosis, as well as intra-articular loose bodies in the left femorotibial joint space.
Discussions: The radiologic findings in this case are significantly more severe than the patient’s clinical presentation. This case demonstrates the value in understanding the chemotactic environment in osteoarthritis. There have been a fair number of studies that link clinical progression of primary osteoarthritis to biomarkers, which in this case would be clinically relevant for prognostication.
Conclusions: This case report demonstrates that radiographic imaging, while important, must be used in conjunction with physical exam findings, clinical correlation and potential chemotactic environment.
Distal Biceps Tendon Partial Tear Treatment with Platelet Rich Plasma
Quan M. Luong, DO; Yin-Ting Chen, MD
Case Diagnosis: Partial tear of distal biceps tendon.
Case Description: 56yo male with right elbow pain and weakness on flexion and supination and limited function since a lifting injury July 2014. MRI reveals tendinosis with grade II partial tear of the distal biceps tendon with adjacent hematoma at two months from injury. He completed a full course of physical therapy with home exercise program with no relief. Physical exam demonstrated tenderness to palpation along the distal biceps tendon. Strength was 4/5 in elbow flexion and supination; Hook test was negative.
Patient opted for conservative treatment, and proceeded to undergo a series of ultrasound-guided platelet-rich plasma (PRP) treatment performed at 8, 9, and 11 months from injury. PRP treatment was collected using 30 mL Harvest Kit, and injected under ultrasound guidance in ulnar-to-radial in Egyptian view. After the second treatment, patient had complete pain relief, restored to full elbow strength, and return of normal function.
Ultrasound exam was performed at each treatment session. Initial exam showed distal biceps tendon to be enlarged with possible hypoechoic lesion in-continuity near the insertion on the proximal radius. Second exam revealed enlarged distal biceps tendon with intratendinous calcific lesions near insertion. Final examination showed mildly thickened distal biceps tendon without significant discrete tendinopathic lesions with partial tear, not as appreciate as compared to previous studies.
Discussions: Ultrasound is effective in identifying partial and complete tears of the distal biceps tendon, providing a cost-effective, faster and more dynamic imaging modality compared to MRI, and provides a mean for guided biologics treatment. In this case, PRP led to improvement of symptom and function, and ultrasound was helpful for monitoring tissue quality improvement.
Conclusions: Ultrasound-guided PRP treatment may be considered prior to surgical intervention for the management of distal biceps tendon partial tear.
Does Performance Based Testing Stratify Fall Risk Among Older Primary Care Patients?
Sarah A. Welch, MA; Rachel E. Ward, PhD; Thomas G. Travison, PhD; Dan K. Kiely, MA, MPH; Jonathan F. Bean, MD, MS, MPH
Objectives: Fall history is a known predictor of future falls in older adults. For clinicians, the question remains of how to further stratify their patients to decide on whom to intervene. Feasible evidence-based tests have yet to be adequately identified. Tests that could serve this purpose include the short physical performance battery (SPPB), a battery of 3 tasks (chair stands, balance testing, and walk testing), each SPPB component individually, or the figure of 8 walk test (F8WT). Each test is quick, simple, and reliable to perform. Through an analysis of an existing longitudinal cohort study, we sought to identify which tests were predictive of fall counts over 4 years of quarterly follow up.
Design: We conducted an analysis of 424 primary care patients aged ≥65 years, and at risk for mobility decline. We stratified participants with (n=178) and without (n=246) a reported fall history. Negative binomial regression models were constructed of the primary outcome (number of falls) and rate ratios (RR) were calculated. Adjustment variables included age, sex, education, and race (model 1); plus Body Mass Index, Mini Mental State Exam, and comorbid health conditions (model 2); plus pain severity, reported history of depression, visual acuity, and activity level (model 3).
Results: Our findings identify that among patients without a fall history, the SPPB performance tests and F8WT did not predict future falls within the fully adjusted model. Among those with a fall history, in all 3 models, the worst SPPB balance had greater fall rates as compared to those in the highest balance category. Specifically, a score of 0 identified patients with 38% higher subsequent fall rates (RR=1.38 CI: 1.09-14.54). Our study is the first of its kind among primary care patients to demonstrate that the SPPB balance test is predictive of subsequent fall rates.
Conclusions: The SPPB balance component can identify primary care patients at a meaningfully greater risk for falls.
Does Weather Really Affect Spasticity in Stroke Survivors?
Xiaoyan Li, PhD; Henry Shin, MS; Ping Zhou, PhD; Sheng Li, MD, PhD
Objectives: It is clinical anecdotal observation that severity of spasticity is altered by weather and environmental temperature. But there is no quantitative assessment of such effect. Accordingly, the purpose was to quantitatively examine the effect of thermal stimulation (heat/cold) using an experimental thermal stimulator.
Design: Thirteen spastic-hemiplegic stroke subjects (5 female, 8 male, aged 53–78 years, history of stroke: 68 ± 42 months) participated in the experiment. Spasticity of elbow flexors was MAS of 1+ or less. A 50 degree of elbow extension was applied to the spastic arm at two speeds (5 deg/s and 100 deg/s) in a customized apparatus. At least 30 seconds of thermal stimulation (HEAT at heat pain threshold, COLD at 0 Celsius, or BASELINE at room temperature) was delivered to the skin of the contralateral hand via a thermode probe prior to stretching.
Results: Total torque (resistance to stretching) was velocity dependent, greater at 100 deg/s than at 5 deg/s. Total torque was also significantly affected by thermal stimulation. When normalized to total torque at baseline, percent change in total torque was also speed and temperature-dependent. Overall, COLD increased total torque by 11.0%, while HEAT decreased total torque by 6.3%. The reflex torque, after subtracting total torque at 5 deg/s from that at 100 deg/s, did not differ significantly across three thermal conditions. Since thermal stimulation was applied to the side contralateral to the spastic side, the effect of thermal stimulation is thus mediated by central mechanisms. Cold exposure has been shown to increase muscle spindle sensitivity via the thermoregulatory reflex, a precursor of shivering; while heat could inhibit the muscle spindle response.
Conclusions: In summary, the findings provide laboratory objective evidence for clinical anecdotal observation of alteration in muscle spasticity by cold and heat stimulation. The finding also supports the therapeutic role of heat stimulation in spasticity management.
Dropped Head Syndrome with Elusive Etiology: A Case Report
Benjamin T. Jensen, MD; Chris Duncan, MD; Scott Swasey, DO
Case Diagnosis: Dropped head syndrome (DHS) is a rare condition of severe cervical-thoracic kyphosis for which the differential diagnosis is broad. Inability to maintain neck extension affects quality of life and may lead to vertebral body fractures, spondylolisthesis, cervicalgia and myelopathy.
Case Description: A 69 yo male with history of diabetes complicated by peripheral sensory and motor polyneuropathy presented to the outpatient clinic with a two-year history of progressive cervical extension weakness. Past trails of physical therapy (PT) had not yielded any improvement. Previous evaluation by neurology diagnosed Myasthenia Gravis and began pyridostigmine. However MuSK antibodies and CT chest for thymoma were negative. Plus he had no improvement in neck strength. Pyridostigmine was stopped and he was sent for EMG, more physical therapy and a PM&R referral.
Our evaluation revealed active neck extension to 5 degrees past neutral and passive extension to 10 degrees past neutral. However after 30 seconds, his chin slowly flexed completely to his sternum. Sternocleidomastoids and rectus abdominus had normal tone. Strength and reflexes were normal. EMG of revealed only lower right cervical paraspinal 1+ fibrillations and sharp waves but normal morphology of motor unit action potentials. We sent him for focused neck extension strengthening, a temporary rigid cervicothoracic orthosis (CTO) and orthopedic spine evaluation.
Discussions: EMG findings do not suggest myopathy or peripheral nerve etiology as cause for his profound weakness. The minor denervation on EMG is likely related to diabetes. Although we felt the CTO would provide better functional alignment while strengthening occurred, our spine team felt continued PT was the best option. After this session he will be re-evaluated for surgical intervention.
Conclusions: DHS itself it uncommon and its etiology can be elusive. Prolonged cervical kyphosis can decrease quality of life and lead to anatomic complications. Further research is needed for diagnosis and management of this complicated syndrome.
Early Acute Rehab Intervention for Treatment of Mononeuritis Multiplex
Idris Amin, MD; Daniel Kao, MD; Dimir Abrar, MD
Case Diagnosis: 45 year old female presented with left upper extremity and bilateral distal lower extremity weakness for one month prior to arrival. The patient was previously independent in all activities, and reported that the weakness progressed to the point where she could no longer ambulate.
Case Description: The patient was enrolled in a comprehensive rehabilitation program, which included physical, occupational, and speech therapy. Simultaneously, the cause of the patient’s presenting symptoms was investigated. A lumbar puncture was performed, which helped rule out Guillain-Barre Syndrome, and a non-contrast head computed tomography scan, which showed a lacunar infarct in the central pons. The patient also underwent magnetic resonance imaging, revealing multiple small infarcts of the pons and middle cerebellar peduncles, consistent with vasculitis. An electromyography test showed severe distal axonal neuropathy. The patient’s labs were significant for elevated inflammatory markers, such as rheumatoid factor and myeloperoxidase. With the help of Rheumatology, the patient was diagnosed with Mononeuritis Multiplex. The patient was treated with steroids and received an infusion of intravenous immunoglobulins, with good clinical response. The patient was discharged home, after she was able to ambulate with modified independence using a rolling walker. Continuing with a rehabilitative program while the medical workup was ongoing proved beneficial in speeding up the patient’s recovery time and shortening her stay in the hospital.
Discussions: As the goals to treating Mononeuritis Multiplex include improving independence, the rehab team played an integral role in maximizing the patient’s mobility while undergoing an extensive medical work-up.
Conclusions: Early incorporation of rehabilitative therapy is essential in producing beneficial outcomes in patients with Mononeuritis Multiplex.
Early Confirmation of Deep Peroneal Neuropathy Responsible for Acute Foot Drop: A Case Report
Evan C. Grant, MD; Gary Fang, MD
Case Diagnosis: Deep peroneal neuropathy
Case Description: A 67 year old man with history of low back pain and radicular pain in the right leg was admitted to the hospital after 2 days of left foot drop. He had been painting his deck, and stood on a ladder with his leg leaning against a rung for a prolonged period. He awoke the following with left foot drop and numbness. Physical exam demonstrated dorsal foot numbness and foot drop with preserved eversion. His diagnosis in the ED was worsening lumbar radiculopathy, and a neurosurgical consult and MRI were requested. Nerve conduction studies (NCS) were done at three days post-injury to rule out peripheral neuropathy. Pertinent findings included reduced compound muscle action potential (CMAP) amplitude at the ankle, and at five centimeters above the ankle (2.5 millivolts and 2.2 millivolts, respectively), compared with 6.7 millivolts at the right ankle. CMAP was absent at the left fibular head and popliteal fossa. Left and right superficial peroneal sensory nerve conductions were normal, and comparable. These findings suggested left deep peroneal nerve conduction block below the fibular head. MRI and neurosurgical consult were cancelled, and the patient was discharged the following day.
Discussions: Deep peroneal nerve injury occurring from compression in the anterior leg and below the fibular head is far less common than common peroneal nerve compression at the fibular head. EMG/NCS are usually performed at least two weeks after a suspected injury. However, early NCS performed on an inpatient served to eliminate need for neurosurgical involvement and therefore hastened discharge.
Conclusions: Early segmental nerve conduction studies are useful in localizing some acute peripheral nerve lesions. This can reduce unnecessary workup and decrease length of stay. Prolonged compression of the deep peroneal nerve with a ladder rung is an uncommon mechanism of injury that deserves recognition.
Early Mobilization of Patients with External Ventricular Drains: Resource Utilization
Ashley Tarkiainen; Paula Bu, AB; Sara Melnyk, MS; Kristen Stout, PT, DPT; Syed O. Shah, MD, MBA; M Kamran Athar, MD; Nethra S. Ankam, MD
Objectives: Development and implementation of early mobilization protocols necessitates further study regarding the resources required. The purpose of this study is to examine the early mobilization of patients in the neurological intensive care unit (NICU) who have received EVDs and to document the number of individuals required to mobilize the patient and the number of years of experience of the primary therapist.
Design: We conducted a retrospective review of a prospective quality improvement (QI) database, which was developed using a checklist adapted with permission from another institution. From June 2014 through June 2015, physical and occupational therapists used this checklist to record observational data of patients with EVDs during standard of care mobility practices.
Results: The 86 patients included in the study participated in a total of 179 therapy sessions. 29.1% of the sessions were conducted by a therapist with < 2 years’ experience. 36.9% of the sessions were conducted by a therapist with 2 to 3 years’ experience. Only 27.4% of the sessions were conducted by someone with 10 or more years’ experience. The number of individuals ranged from 1 to 3 professionals. The majority of mobilizations involved 2 professionals (55.9%), while 1 professional was used in 39.7% of mobilizations and 3 professionals were used in 8 mobilizations (4.5%). The most common highest achieved activity levels were walking with the assistance of 1 person (65 occurrences, 36.3%), transferring from bed to chair with standing (30 occurrences; 16.8%), and walking with the assistance of 2 or more people (18 occurrences, 10.1%). Only 7 occurrences (3.9%) were of no activity.
Conclusions: Two professionals may be sufficient to mobilize patients with EVDs. In our institution, therapists who have < 2 years of experience are able to mobilize patients with EVDs.
Efficacy of Temporary Spinal Cord Stimulation (SCS) on the Management of Chronic Postherpetic Neuralgia (PHN)
Lawerence Kelleher, DO; Navdeep S. Jassal, MD; Benito Torres, DO; Joseph W. Frye, DO
Case Diagnosis: Postherpetic neuralgia.
Case Description: We present two Postherpetic neuralgia (PHN) patients, refractory to multiple pharmacologic and interventional treatment modalities, who subsequently underwent spinal cord stimulation (SCS) trials with temporary percutaneous leads for relief of PHN pain in the thoracic dermatomes. The lead was removed 12 days after placement in Patient A while Patient B had the lead removed 7 days after implantation. Both patients showed significant pain reduction according to the Visual Analog Scale (VAS) after temporary SCS (patient A from a 10/10 to a 3/10, patient B from an 8/10 to a 1/10 at 3 month follow up) and neither progressed to implantation of the device. In addition to reduced pain, they were able to maximize their function and limit the use of pharmaceuticals.
Discussions: PHN is defined as pain persisting for at least 120 days after the onset of acute rash and is due to neuronal injury affecting both the peripheral and central nervous system. PHN results from sensitization of peripheral nerves, which then augment central neurons leading to hyperexcitability, hyperalgesia and allodynia. These symptoms often create a scenario where the patient is unable to function in their daily life due to the severe pain they experience. By alleviating these patient’s pain, they were almost immediately able to return to their baseline function.
Conclusions: We believe this to be the first 2 reported cases that demonstrate the efficacy of limited duration SCS in the treatment of the chronic stages of PHN. Although most patients with PHN have been described to have irreversible clinical conditions of both peripheral and central sensitizations, we show significant pain reduction in our 2 patients achieved with SCS trial alone. In cases of decreased functiona with pain as the limiting factor early interventional procedures may play a role in the restoration of function.
Electrodiagnostic Studies in Conjunction with MRI to Diagnose a Proximal Median Neuropathy: A Case Report
Mary Apiafi, MD; Francis Lopez, MD, MPH
Case Diagnosis: Proximal Median Neuropathy
Case Description: 51 year old female with significant past medical history of diabetes, hypertension, and a chronic Smoker, presented for electrodiagnostic studies for complaints of pain, weakness and numbness in her right hand. Patient reported an acute onset of severe right hand and forearm pain while she was writing a letter, which was followed by numbness in the hand and forearm; her symptoms were only limited to the right upper limb. The symptoms persisted for several hours prompting her to visit the emergency department. Because of concerns for an acute CVA, she underwent a thorough workup up and was admitted to the inpatient unit. She was discharged when the completed workup was negative for a CVA. In clinic, patient stated that her pain, weakness, and numbness persisted, but was now localized to her right hand, mainly the lateral three digits. Physical examination was significant for wasting of abductor pollicis brevis, weakness in hand grip, wrist flexors and long finger flexors, and numbness at all finger tips. Provocative tests for Carpal Tunnel Syndrome were positive for Tinnel’s and carpal compression at the wrist. The left upper extremity was unremarkable. The examination of the neck, shoulders, and elbows were unremarkable. Nerve conduction and needle Electromyography studies were performed on the right upper limb. There was an absent median Sensory Nerve Action Potential. Expecting an abnormal median Compound Motor Action Potential, only mildly reduced median CMAP amplitude was obtained; the latency and conduction velocity was normal. Needle EMG studies were able to provide a clearer clinical picture as every muscle innervated by the median nerve (including the Anterior Interosseous Nerve) demonstrated abnormal spontaneous activity, including the pronator teres muscle. An MRI of the forearm was obtained and was significant for an abnormal hyperintense signal in the right pronator teres, flexor digitorum superficialis and profundus, and pronator quadratus which was compatible with severe denervation. Most importantly, a hyperintense signal was also observed in the median nerve at the level of the radial tubercle, extending distally 5.6cm. The patient was ultimately sent for surgical evaluation with a diagnosis of proximal median neuropathy at the level of the radial humeral tubercle.
Discussions: Compression of the median nerve at the elbow or forearm is a rare finding and is much less frequent than compression within the carpal tunnel. Proximal compression is mainly attributed to anatomic variations in the forearm, most commonly the pronator teres. Less common causes are compression by the accessory head of the flexor pollicis longus (Ganzer’s muscle), or a persistent median artery. Symptoms can vary according to entrapment site, but they are often erroneously attributed to a clinical diagnosis of carpal tunnel syndrome. Electromyography and nerve conduction studies may be helpful for diagnosing proximal median neuropathies, however, MR imaging can assist in further localizing the lesion by showing patterns of muscle denervation.
Conclusions: Proximal median neuropathies can share similar clinical features with carpal tunnel syndrome. However, nerve conduction and needle EMG studies in conjunction with MR imaging can help elucidate the diagnosis of a proximal median neuropathy ensuring proper management.
ESWT Treatment for Epin Calcanei
Emre Adiguzel; Berke Aras; Mehmet Ali Taşkaynatan; Arif Kenan Tan
Objectives: To define the efficacy of extracorporeal shock wave therapy (ESWT) in patients with epin calcanei.
Design: 10 patients (6 females, 4 males) with epin calcanei with minimum 12 weeks history were included in this study. Mean age was 46,8±7,6 years. Average treatment session was 3,6±0,8 sessions at average interval of 10,3±3,4 days. Procedure was administered with 1800 impulses per session at a pressure of 2,0 bars and at a frequency of 15 hertz. Pre-treatment data of patients were obtained from patient records retrospectively. Complaints of the patients on the third month after treatment were questioned by telephone calls. 100 mm analog scale for the pain level was used to measure the pain; walking interval without pain, walking distance, frequency of analgesics and orthotics use and night pain were questioned to evaluate the disease severity of the patients. Patients satisfaction after the ESWT treatment was assessed with a Likert scale. SPSS 15.0 program was used for statistical analysis.
Results: After ESWT treatment, we observed 58,5±27,0 mm decrease in pain scores. There was 2250,0±1687,3 m increase in walking distance and 2,9±2,5 hours increase in walking interval without pain. There was statistically significant improvement in pain scores, walking distance and walking interval after treatment. Night pain was decreased in 8 (80%) patients, the frequency of analgesic drug use was decreased in 9 (90%) patients and the frequency of foot orthosis use was decreased in 7 (%70) patients. There was no complication. After treatment, 7 (70%) patients were very satisfied, 1 (10%) patient was moderately satisfied, 1 (10%) patient was less satisfied and 1 (10%) patient was not satisfied.
Conclusions: ESWT could be an effective and safe option for the treatment of the epin calcanei.
Fabrication of a Prosthetic Foot Using 3-D Printing Technology
Mark F. Megerian; Shannon Wheeler, BS; D. Casey Kerrigan, MD
Background: In the United States, there are approximately 1.9 million individuals living with limb loss and 185,000 amputations performed annually, primarily the result of trauma, vascular disease, and diabetes. Approximately half of all major lower-limb amputations are transtibial. Materials, componentry, and functional specifications largely differentiate the many prosthetic feet currently available. However, a high-end prosthetic foot alone can cost as much as $5,000, which is prohibitive for many amputee patients. The use of 3D-printers to fabricate lower limb prosthetic components has been proposed due to cost, speed of fabrication, simplicity of manufacturing, and enhanced access in underserved or third-world healthcare environments.
Objective: To design and fabricate a lower limb prosthetic foot using 3D-printing technology.
Design: Using Autodesk Fusion 360 CAD software, a non-articulated flexible prosthetic foot was designed. The design incorporated a rigid connection to a prosthetic shank. The prototype was intended to provide mid-stance stability yet energy storage and return throughout the gait cycle. One of OESH’s 3-D manufacturing printers, which are specifically designed to print strong flexible material composites for shoe components, was used to print the prosthetic prototype using a nylon filament blend.
Results: The printing of the prosthetic foot prototype, done with the medial side of the prosthesis supported by the build platform, took approximately 11 hours at a materials cost of less than 15 dollars. Sanding of the finished prototype was performed for cosmesis and the prototype was trialed for fit in several types of footwear. Vertical compression load testing demonstrated that the rigid prosthetic compressed under loads during simulated early stance, provided appropriate mid-stance stability, and resumed its rigid shape when unloaded.
Conclusions: A lower limb prosthetic foot was successfully designed and fabricated using 3D-printing technology. Additional analysis of the functional performance of the prototype is required to further assess applicability to clinical care.
Femoroacetabular Impingement Causing Adhesive Capsulitis of the Hip
Bilal A. Khan, DO; Henna Farooque, DO; Laura Davids, MD; Yudell Edelstein, MD; Susan Stickevers, MD
Case Diagnosis: Femoroacetabular Impingement (FAI) causing Adhesive Capsulitis of the Hip (ACH).
Case Description: A 54 year old obese, pre-diabetic female reported right-sided groin pain radiating to the medial thigh several months after falling onto her right hip. Examination demonstrated reduced hip range of motion, weakness in hip flexion, and point tenderness over the right inguinal ligament. MRI of the right hip revealed a collapsed joint capsule with reduced volume and an obturator canal cyst measuring 1.6cm x 1.2cm x 0.8cm. Tiny cysts in the anterior femoral head and anterior acetabular column were identified with mild CAM-type FAI. After CT-guided aspiration of the obturator canal cyst, the patient reported a 50% reduction of pain that lasted one week. An attempted right hip fluoroscopic-guided injection was unsuccessful in penetrating the joint. A “rubbery” sensation was appreciated upon repeated attempts at entering the joint capsule. CT-guided intra-articular steroid injection was successful, however there was significant resistance to flow of contrast agent and medication. The patient reported complete relief of symptoms immediately after injection. Improvement in hip range of motion was noted within one week following injection. The diagnosis of ACH was made based upon the findings of reduction in hip range of motion, reduced joint volume, and “rubbery” consistency of the joint capsule noted upon attempted intra-articular entry.
Discussions: ACH has rarely been described in literature. This condition is associated with a reduction in active and passive hip range of motion. An arthrogram demonstrates joint volume of less than 8cc. ACH is typically is seen obese, diabetic females with a history of antecedent trauma or FAI. Hip joint cysts are commonly identified in patients with this condition. Therapeutic intra-articular joint injection is recommended followed by aggressive range of motion.
Conclusions: Adhesive capsulitis has most commonly been described in the shoulder and has rarely been identified in the hip. Further investigation is needed to determine the best course of treatment for patients with this condition.
Flipping the Classroom: A Novel Approach to Musculoskeletal Curriculum
Dixie R. Aragaki, MD; Kristine Cachola, MD; Timothy Cushing, MD; Sood Radhika, DO; Quynh Pham, MD
Objectives: U.S. medical schools are increasingly requiring musculoskeletal (MSK) curricula and clinical clerkships, but competency in basic MSK medicine can be improved with more innovative teaching strategies. The purpose of this study was to assess the effectiveness and student-perceived satisfaction of a traditional lecture-based versus a flipped classroom MSK curriculum for first year medical students.
Design: Retrospective cohort study of two first-year medical student classes enrolled in a core MSK curriculum in an urban university-sponsored medical school in the academic years 2014 and 2015. The 2014 cohort was taught with a traditional lecture-based MSK format while the 2015 cohort experienced a “flipped” classroom approach that placed more responsibility on the students to learn through student-centered activities, interactive discussion, clinical vignettes, problem-based learning, inquiry-oriented strategies, and group-generated discussion. Primary outcome measures were academic performance on a multiple-choice final exam and the students’ perception of the course measured by an online survey. These outcomes were compared between the two classes.
Results: The average number of correct responses in 2014 (traditional curriculum) was 154.18 with a SD of 23.28 and in 2015 (flipped classroom) the average was 149.57 with a SD of 26.26. There was no statistically significant difference (P value=0.2081) in the test performance between the traditional lecture-based format and the flipped classroom format. The flipped classroom approach received a significantly higher overall student satisfaction rating.
Conclusions: Although no statistically significant difference was found for the academic performance between the two classes, students of the flipped classroom format in 2015 expressed more satisfaction with the MSK course in 2015. This teaching approach could serve as an option for medical schools to enhance MSK education.
Functional Electrical Stimulation in the Long Term Treatment of Bell’s Palsy: A Case Report
David Gutierrez, MD; Huma Naqvi, MD; Katherine Power, MD
Case Diagnosis: Bell’s Palsy
Case Description: A 62yo M with a significant past medical history of HTN presents with chronic right-sided facial weakness for about 1 year secondary to Bell’s Palsy. Extensive work up had been pursued throughout the past year including labs, MRI and multiple CT scans of brain to rule out any other causes of weakness. Upon the physiatrist examination of the patient, the patient showed flattening of his right nasolabial fold and right-sided facial asymmetry including the inability to wrinkle his forehead or tightly close his eyes, consistent with Bell’s Palsy. His pupillary reflexes and extraocular movements were all intact. The patient was scheduled for facial muscle rehabilitation with Functional Electrical Stimulation. After four sessions of therapy, the patient showed improvement in VAS scores, an increase in right-sided facial muscle strength, and subjective gains of facial symmetry.
Discussions: Bell’s Palsy, or acute facial nerve palsy, is a common cause of facial weakness. That being said, Bell’s Palsy can cause a significant decrease in daily and social function. In terms of the treatment of Bell’s Palsy, a number of treatments including steroids, anti-virals, and electrical stimulation have been shown to have somewhat of a positive effect in the acute phase of the disease. However, few studies have explored functional electrical stimulation in the treatment of chronic or refractory cases of Bell’s Palsy. Adding FES to already established therapy in these cases may result in improved outcomes in regards to facial muscle weakness.
Conclusions: Functional Electrical Stimulation is a modality with a relatively low side effect profile that may provide useful in the treatment of chronic or refractory cases of Bell’s Palsy.
Functional Improvement after Choroid Plexus Carcinoma Resection: A Case Report
Elizabeth A. Barton, MD; Peter Hwang, MD
Case Diagnosis: Choroid plexus carcinoma
Case Description: A 24-year-old female with a 6-month history of left cranial nerve VI palsy presented to an acute care hospital for new-onset right hemiparesis, incoordination, bladder urgency, dysphagia, slurred speech, and headaches. Magnetic resonance imaging (MRI) revealed a pontine mass. The patient underwent extreme lateral infrajugular transcondylar resection of the mass, which required dislocation of the temporomandibular joint. Postoperative MRI showed no evidence of residual tumor. Pathology revealed choroid plexus carcinoma (CPC). The patient required tracheostomy and percutaneous endoscopic gastrostomy tube placement, and was then referred to an inpatient rehabilitation facility with the goals of improving strength, functional independence, and nutritional status prior to initiation of chemotherapy and radiation. Over the course of seven weeks, the patient received intensive therapy for balance and strength deficits, dysphagia, and trismus. Neuromuscular electrical stimulation was utilized for dysphagia, and the patient was monitored with videofluoroscopic swallow studies. Diet was upgraded from exclusive tube feedings to mechanical soft diet with ground meats and thin liquids, and she had a 10-pound weight gain. The patient progressed to ambulating 200 feet with assistance of a 4-wheeled walker at the modified independence level at the time of discharge. The total functional independence measure increased from 81 on admission to 116 at discharge. The patient was discharged home and began chemotherapy.
Discussions: After seven weeks of inpatient rehabilitation, the patient was discharged home with significantly improved functional and nutritional status. A search of the literature revealed no similar cases describing rehabilitation outcome in patients with such diagnosis.
Conclusions: Despite the poor prognosis associated with CPC, inpatient rehabilitation may be an important part of post-acute care for improving functional independence, stamina, and nutritional status. These factors may contribute to desired discharge to community status and more importantly, improve tolerance of subsequent cancer interventions that could positively impact survival.
Gabapentin-Induced Fever: A Case Report
Kevin M. Berry, MD; Eun Kwang Byun, MD; Mooyeon Oh-Park, MD
Case Diagnosis: Gabapentin-induced fever following bilateral total knee arthroplasty.
Case Description: A 66-year-old male with bilateral knee osteoarthritis and type 2 diabetes without diabetic neuropathy was admitted for comprehensive rehabilitation following bilateral total knee arthroplasty. On admission to the rehabilitation facility, the patient was taking gabapentin for control of post-operative pain. While on the rehabilitation unit, he developed fever on the 4th day after surgery and no attributable cause was found on the work-up; his surgical site was clean without signs of infection, there was no leukocytosis, urinalysis was negative, urine culture and blood cultures showed no growth, chest x-ray was negative for infiltrate, and no DVTs were found on ultrasound. He did not have any mental status changes. After 4 days of persistent fever, gabapentin-induced fever was suspected as a diagnosis of exclusion. Fever resolved without recurrence the day after gabapentin was discontinued. He completed his course of rehabilitation without further medical issues and was discharged home safely.
Discussions: Gabapentin is a commonly prescribed medication for neuropathic pain and is also increasingly utilized by orthopedists after joint replacement surgery. To our knowledge, this is the first case report of gabapentin-induced fever.
Conclusions: Fever is a common and troublesome occurrence in the inpatient rehabilitation setting, often leading to a costly and comprehensive work-up. While gabapentin is often prescribed for neuropathic and post-operative pain, clinicians should be aware of gabapentin for a possible cause of fever.
Genotype and Phenotype Dystrophinopathic Characterization in Puerto Rico: A Cohort Study
Manuel F. Mas Rodriguez, MD; Rafael E. Arias-Berrios, MD; Edwardo Ramos, MD
Objectives: Duchenne and Becker Muscular Dystrophy (DMD and BMD, respectively), commonly referred to as dystrophinopathies, are common forms of inherited muscle disease. Information regarding the epidemiology of these conditions, including genotype and phenotype traits, is still sparse. We collected data from all the Muscular Dystrophy Association (MDA) clinics in Puerto Rico in order to describe the prevalence, genotype and phenotype characteristics of these patients.
Design: Data was gathered from medical records from all four MDA clinics on the island. Patients selected were those with a recorded diagnosis of dystrophinopathy along with either a confirmatory molecular and/or muscle biopsy test, creatinine kinase levels ten times the normal value, or a positive family history. Data collected included molecular study results and the patient’s history of disease progression.
Results: 142 patients matched the inclusion criteria, with 58% and 29% being categorized into DMD and BMD, respectively. Estimated DMD and BMD prevalence in Puerto Rico was calculated at 4.67 and 2.33 per 100,000 males, respectively. Deletion was the most common form of mutation (67%) in the dystrophin gene, with exons in segment 45 to 47 being the most frequently affected. Patients diagnosed with DMD tended to be wheelchair-confined earlier than BMD patients, as expected.
Conclusions: This is the first study describing the dystrophinopathic population in Puerto Rico. This population is similar in to others describe in other geographical areas.
Guillain-Barre Syndrome (GBS), Acute Motor Axonal Neuropathy (AMAN) Variant Diagnosed during Acute Inpatient Rehabilitation: A Case Report
Haresh Sampathkumar, MD; Artin Minaeian, MD; Eduardo Lopez, MD
Case Diagnosis: Guillain-Barre syndrome (GBS), acute motor axonal neuropathy (AMAN) variant
Case Description: 78 year old female with a history of asthma presented with acute respiratory failure secondary to pneumonia. Patient’s medical condition improved but notable for complicated intensive care unit (ICU) stay. She was eventually admitted to acute inpatient rehabilitation for functional decline secondary to prolonged immobility. Patient’s slow functional progress in ambulation and persistent weakness in lower extremities after two weeks of admission to rehabilitation unit prompted further work up. Spine imaging ruled out spinal cord etiology. A diagnosis of Guillain-Barre syndrome (GBS), acute motor axonal neuropathy (AMAN) variant was established based on clinical findings, electrophysiological studies, positive anti-GM1 antibodies and lumbar puncture (LP). After a five day course of intravenous immunoglobulin (IVIG) followed by readmission at acute inpatient rehabilitation unit patient demonstrated improvement in strength and function evident on physical examination and improvement in FIM scores respectively. Patient was eventually discharged home.
Discussions: GBS AMAN variant is an uncommon condition in the United States with estimated 5-10% of all GBS cases. It’s commonly seen after a preceding infection. Patients with axonal variant respond well to immunoglobulin if treatment is initiated within four weeks of symptom onset followed by aggressive rehabilitation to maximize functional outcome. Acute Paralysis after prolonged ICU stay is most commonly due to critical illness polyneuropathy (CIP) or critical illness myopathy (CIM) or rhabdomyolysis and should be ruled out first followed by search for GBS AMAN variant since timely diagnosis can alter patient’s course and reduce disability.
Conclusions: Patients admitted with acute paralysis after prolonged ICU stay should be evaluated for any underlying acquired neuromuscular disease if they don’t make progress in rehabilitation since it could change the management. Besides routine testing for CIM, CIP and rhabdomyolysis clinicians should be alerted about the possibility of AMAN variant.
Heroin Induced Mononeuropathy
Jane Hwang, MD; Julie E. Witkowski, BS; Marilyn Pacheco, MD
Case Diagnosis: Heroin induced mononeuropathy
Case Description: A 26 year old Caucasian male with a past medical history of polysubstance abuse and depression presenting with a one day history of left lower extremity weakness and numbness after intravenous heroin use twelve hours prior. On initial physical exam, the patient was found to have a 1/5 hip flexor strength and 0/5 knee extensor strength on the left side. His sensory exam was significant for numbness to pin prick and light touch in the L1-L3 nerve distribution of the left thigh. Laboratory values were significant for rhabdomyolysis (CK 8920), acute renal failure (creatinine 2.50), and a troponin leak (2.20). An exhaustive infectious disease workup which included a lumbar puncture was essentially negative. Electromyography performed seven days after presentation was significant for a diminished left femoral axonal motor response. After a one week stay in our acute rehabilitation unit, the patient’s strength improved to a 3/5 hip flexor and 2/5 knee extensor.
Discussions: Heroin induced neuropathy is a phenomenon that has been scarcely reported or studied. Its etiology is unknown although current hypotheses include nerve compression, an immunologic response, or the toxic effects of heroin. Most cases in the literature have reported plexopathy or neuropathy together with rhabdomyolysis without significant improvement of the patients’ symptoms over time. Corticosteroid treatment has been suggested but did not result in improvement in recent cases. Physical therapy has been reported to demonstrate improvement of motor strength in one case report.
Conclusions: Heroin induced neuropathy is a phenomenon that has rarely been studied. Our case study reports mild improvement of strength with a one week stay in an acute rehabilitation unit. Patients with heroin induced neuropathy may benefit from an acute rehabilitation stay.
Herpes Zoster in a World Class Triathlete: A Case Report and Evaluation of Training Schedules in Relation to Immune Status
John S. Georgy, MD, MBA; Lawrence Lai, MD, MS; Jeffrey Shilt, MD
Case Diagnosis: Herpes zoster in a world class triathlete
Case Description: We report the unique case of a world class triathlete who developed a painful dermatomal rash following a period of particularly intense training, travel, and competition. His training schedule for three months following the illness and return to competition is documented. The athlete’s subsequent period of underperformance and profound fatigue suggest an inadequate recovery period.
Discussions: While the specific triggers and state of immune dysfunction that allow for an outbreak of Herpes Zoster are yet unknown, it is clear that alterations in the immune system play a role in the progression of this disease. Furthermore, it has been shown that extremely strenuous exercise and stress can have deleterious effects on the immune system including increased rates of upper respiratory tract infections and various effects on peripheral T-lymphocyte and NK cell counts. Competitive athletes are constantly forced to strike a balance between risk of decreased immunity from excessive strain and maximization of their training to increase their level of performance. The literature has not given any recommendations on returning to activities for training or racing endurance events for athletes with Herpes Zoster.
Conclusions: Immunological markers may be helpful to determine patients at risk for reactivation of Herpes Zoster. Cell-mediated immunity can decline with an interferon-γ enzyme-linked immunosorbent spot-forming cell (ELISPOT) assay even having received vaccinations 6 to 10 years prior. This suggests that cell-immunity declines in certain patients and reactivation of Herpes Zoster can occur even though these patients have been once unsusceptible to the virus. Investigations into this immunological marker for latent herpes zoster may help determine the existence of the virus in an affected athlete and aid physicians in guiding these athletes to return to competitive sports.
Hyperglycemia Induced Central Pontine Myelinolysis in the Setting of Uncontrolled Diabetes
Craig Van Dien, MD; Laurent Delavaux, MD; Iqbal Jafri, MD; Sara Cuccurrullo, MD
Case Diagnosis: Central Pontine Myelinolysis
Case Description: A 41 year old man with a history of uncontrolled diabetes mellitus (HBA1C >16%), medication non-adherence, and alcohol abuse was admitted for acute inpatient rehabilitation for functional deficits secondary to hyperglycemia induced central pontine myelinolysis (CPM). The patient initially presented to an outside medical center following a protracted history of progressively worsening generalized weakness, with later complications of decreased mobility and dysarthria. Hospital laboratory evaluation revealed hyperglycemia in excess of 700 mg/dl with concurrent renal failure and normal sodium levels (corrected sodium for hyperglycemia, 142 mmol/L). Initial physical exam findings included generalized weakness more pronounced on the left. CT head showed no acute intracranial hemorrhage. MRI however, identified bilateral symmetric confluent T2 signal abnormality in the central pons consistent with CPM. Following medical stabilization, the patient was transferred for acute inpatient rehabilitation for functional deficits including gait and ADL dysfunction, and dysphagia. Pertinent exam findings included decreased proprioception, diminished lower extremity reflexes, and increased lateral swaying bilaterally with gait analysis. The patient met his functional goals, demonstrating improvement in ambulation, ADLs, and transfers at time of inpatient rehabilitation completion.
Discussions: Though commonly associated with rapid correction of chronic hyponatremia, rarely demonstrated are cases of CPM in the setting hyperglycemia in the absence of sodium derangement. One proposed mechanism for demyelination includes disruption of the blood–brain barrier due to the rapid onset of a hypertonic extracellular space, at a rate that exceeds the brain’s mechanisms for compensation. This allows for the passage of inflammatory mediators, resulting in subsequent nerve damage and vasogenic edema. Prognosis is variable, and improves with early detection and management.
Conclusions: This is rare case of hyperglycemia induced CPM in the setting of uncontrolled diabetes mellitus with successful completion of acute inpatient rehabilitation. Early detection and management of CPM may improve functional outcome and overall prognosis.
Iatrogenic Unilateral Accessory Nerve Palsy and Cheiralgia Paresthetica as Complications of an Intensive Care Stay
Phuong U. Le, DO; Sparr A. Steven, MD
Case Diagnosis: Iatrogenic Unilateral Accessory Nerve Palsy and Cheiralgia Paresthetica as Complications of an Intensive Care Stay
Case Description: A 49 year-old woman presented with left sided shoulder and thumb pain for 6 weeks. Three months prior she underwent myomectomy surgery complicated by an intra-abdominal abscess leading to sepsis and prolonged intensive care unit (ICU) stay requiring intubation. Upon discharge, she experienced burning pain in the dorsolateral wrist and pain and difficulty moving her left shoulder.
There was evidence of scarring along the anterolateral neck and dorsolateral wrist and a depressed left supraclavicular area. Motor examination of the hand was normal, but there was mild weakness of the left trapezius, flattening of the sternocleidomastoid and the left scapula was displaced superiorly and laterally. There was decreased sensation over the dorsal surface of the left thumb and over the left trapezius.
Electrodiagnostic study revealed left spinal accessory neuropathy and a left distal radial sensory neuropathy which correspond to the patient’s sensory deficit in the dorsolateral thumb. With gabapentin, a short course of high dose intravenous steroids and occupational therapy, the patient experienced significant pain relief and improved range of motion and strength.
Discussions: A distal superficial radial sensory nerve injury also known as cheiralgia paresthetica is a rare diagnosis and usually results from trauma to the wrist. In this case, the likely etiology was from the insertion of intravenous line. Isolated spinal assessory nerve palsy often results from mechanical injury such as stretch, traction, or compression. It is possible that internal jugular vein (IVJ) central line insertions or aggressive neck manipulation may have been causative in this case.
Conclusions: Common ICU procedures including neck manipulation during IVJ insertion and peripheral line placement may result in traumatic neuropathies. This patient is unique as she appears to have suffered two discrete nerve injuries while in the ICU. Treatment to control neuropathic pain, IV steroids and occupational therapy may improve the pain as well as the function and quality of life of the patient.
Idiopathic Acute Brachial Neuritis Presenting as Unilateral Shoulder Pain and Weakness with Unusually Rapid Recovery after Prompt Steroid Treatment: A Case Report
Mustafa Khan, MD; Danny Wilkerson, MD; Johnathan Goree, MD; Noojan Kazemi, MD; Alexandra M. Rivera Vega, MD
Case Diagnosis: Acute Brachial Neuritis or Parsonage-Turner Syndrome
Case Description: A 59 year old right hand dominant male presented with sudden onset of left shoulder weakness with inability to abduct or forward flex his arm. Preceded by 1 week of achy shoulder pain. Influenza vaccine was administered 1 month ago. He denied recent trauma, surgery, illness, fever, or chills. Strength was 2/5 for deltoid, biceps, and rotator cuff muscles with scapular winging. Cervical MRI showed severe foraminal stenosis and compression of Left C5 nerve root and bilateral C6 and C7 nerve roots. The patient received a same day cervical epidural steroid injection, oral Methylprednisolone, and aggressive physical therapies. Shoulder MRI did not show any significant intrinsic shoulder pathology. Brachial MRI showed a STIR hyperintensity in the Left Supraspinatus, Infraspinatus, and Deltoid muscles, suggesting Parsonage-Turner Syndrome (Acute Brachial Neuritis). This was confirmed with nerve conduction studies/electromyography one month from the onset of symptoms.
Discussions: This is the first reported case, to our knowledge, that a patient received an epidural injection in addition to oral steroids and physical therapies, immediately after the onset of symptoms. Complete recovery could take from 1 to 3 years, however in our patient it took only two months for an improvement near to baseline.
Conclusions: Early recognition of Parsonage-Turner Syndrome is important in order to provide proper, early treatment consisting of steroids and aggressive rehabilitation. Epidural steroid injections are a minimally invasive procedure that could be considered as treatment.
Impact of Acute Inpatient Rehabilitation after Liver Transplantation in Patients with High Model for End Stage Liver Disease (MELD) Score
Sheena Bhuva, MD; Megan C. Reynolds, MS; Giovanna Saracino, MS; Sumeet Asrani, MD, MSC; Jacob Christiansen, BS; Simon Driver, PhD
Objectives: Subjects undergoing liver transplantation (LT) are globally older, sicker, have higher Model for End-Stage Liver Disease (MELD) scores, and more comorbidities in the current era. The impact of acute inpatient rehabilitation post-LT is not well studied. The objective was to compare outcomes of LT patients with a MELD score of ≥25 who did and did not receive acute inpatient rehabilitation.
Design: Adult subjects with a biologic MELD score ≥25 undergoing LT at a large transplant program (2004–2014) were identified using a prospectively collected liver transplant database including inpatient, outpatient, and rehabilitation care. Demographic, diagnosis-related, and outcomes variables were analyzed.
Results: 262 high risk patients underwent LT: 194 were discharged home, 68 to an acute inpatient rehabilitation facility (IRF). Patients were predominantly male (64%) and Caucasian (67%). 34% had Hepatitis C virus; 15% had nonalcoholic steatohepatitis (NASH) cirrhosis/cryptogenic cirrhosis. Between groups, patients admitted to IRFs were likely to receive care in the ICU immediately prior to transplant (44% vs. 21%, p=.002), have a higher MELD score (M=33 vs. 30, p=.002), and experience greater total ICU LOS (M=9 days vs. 4) and acute care LOS (M=21 days vs. 12, p= < .001). There was no significant difference in one-year mortality between groups (95% vs 94%, p= .69). Of the 68 patients admitted to IRFs, 53 were in an affiliated institution with charts available for review and demonstrated a significant difference in Functional Independence Measure (FIM) scores between admission and discharge (p= < .0001).
Conclusions: Though patients admitted to IRFs post-LT were (1) more acutely ill prior to transplant, (2) had poorer prognosis based on MELD scores, and (3) experienced longer hospitalizations, significant functional gains were made and one-year mortality rates were ultimately similar between groups. These preliminary findings are clinically significant and validate incorporating rehabilitation post-LT among the most critically ill patients.
Incidence of Sleep Disorders in Military Service Members with Traumatic Brain Injury
Justin L. Weppner, DO; Ryan West, MD
Objectives: The purpose of this study was to determine the prevalence and consequences of sleepiness and sleep disorders in military service members after traumatic brain injury (TBI).
Design: Subjects over 18 years old who were at least 3 months post TBI were prospectively recruited into the study. One-hundred male subjects with TBI were evaluation with polysomnography (PSG), multiple sleep latency test (MSLT), Epworth Sleepiness Scale (ESS), Psychomotor Vigilance Test (PVT), Profile of Mood States (POMS), and Functional Outcome of Sleep Questionnaire (FOSQ).
Results: Abnormal sleep studies were found in 47 subjects (47%), including 35 (35%) with obstructive sleep apnea (OSA), 5 (5%) with posttraumatic hypersomnia (PTH), 2 (2%) with narcolepsy, and 5 (5%) with periodic limb movements in sleep (PLMS). Among all subjects, 28 (28%) were found to have objective excessive daytime sleepiness with MSLT score < 10 minutes. There was no correlation between ESS score and MSLT. There were no differences in severity of injury or time after injury between sleepy and non-sleepy subjects. Sleepy subjects had a greater body mass index (BMI) than those who were not sleepy. OSA was more common in subjects with BMI ≥30. There is a high prevalence of sleep disorders (47%) and of excessive daytime sleepiness (28%) in subjects with TBI.
Conclusions: TBI patients should undergo complete sleep evaluations. Sleepy TBI subjects have more impaired cognitive function than other TBI subjects. Daytime sleepiness with some of the neuropsychological deficits of TBI subjects may be due to treatable sleep disorders, their diagnosis and treatment may have a favorable impact on care.
Incidental Ischemic Fasciitis in a 43 Year Old Man with Paraplegia
Mariana Murguia, MD; James Sliwa, DO
Case Diagnosis: We discuss the case of a man with paraplegia found to have an asymptomatic ischemic fasciitis lesion within the left gluteus medius.
Case Description: The patient is 43 years old with a history of thoracic syrinx who uses a wheelchair for mobility. Recently, routine imaging prompted a malignancy workup which was ultimately negative. However, he was noted to have two small lesions within the left gluteus medius with increased uptake on PET imaging. On MRI with contrast, the lesions were peripherally enhancing with surrounding edema. The patient had no pain or palpable mass at the site. Biopsy was consistent with ischemic fasciitis. Development of the lesion was attributed to localized pressure from increased wheelchair use. He has since been fitted for a new cushion.
Discussions: schemic fasciitis, also known as atypical decubital fibroplasia, is a finding of a deep subcutaneous lesion usually located at a bony prominence and subjected to chronic intermittent pressure. It is described in elderly patients with impaired mobility or debility. In contrast to pressure ulcers, the overlying skin remains intact. Microscopically, lesions are notable for an organized structure with central fibrinoid necrosis surrounded by reactive fibroblasts and chronic inflammatory infiltrate. Differential diagnosis for these lesions includes soft tissue sarcoma; however, the hypercellularity, atypical mitoses, and layering of endothelial cells more typically seen in sarcoma are not present in ischemic fasciitis.
Conclusions: Ischemic fasciitis is a benign subcutaneous lesion usually located over a bony prominence and related to chronic intermittent pressure. It is a rare diagnosis which may be found in patients with impaired mobility at risk for pressure wounds. It is important for physiatrists to be aware of the diagnosis and its similarities to soft tissue malignancy in order to manage their patients.
Increased in Vivo Glial Activation in Patients with Primary Lateral Sclerosis (PLS) Assessed with [11C]-PBR28 Positron Emission Tomography
Sabrina Paganoni, MD, PhD
Objectives: Multiple lines of evidence implicate the neuroimmune system in the pathology of amyotrophic lateral sclerosis (ALS). We recently demonstrated increased in vivo glial activation in the motor cortices of people with ALS by using [11C]-PBR28 positron emission tomography (PET). Glial activation correlated with disease severity and upper motor neuron burden scores. These findings suggest that [11C]-PBR28 may be a potential marker of upper motor neuron dysfunction in ALS. Thus, it may also represent a candidate biomarker for motor neuron disease that primarily affects the upper motor neurons such as primary lateral sclerosis (PLS). However, [11C]-PBR28 binding has not been studied in PLS so far. In this study, we assessed [11C]-PBR28 binding in people with PLS.
Design: Five patients with PLS and five age- and [11C]-PBR28 binding affinity- matched healthy volunteers completed a [11C]-PBR28 PET scan. Standardized uptake values were calculated from 60–90 min post-injection and normalized to whole brain mean.
Results: Voxelwise whole brain analysis showed increased [11C]-PBR28 binding in the motor cortices in patients with PLS compared to healthy controls (Z>2.3, cluster corrected at p < 0.05). The pattern of [11C]-PBR28 binding in people with PLS was similar to the one observed in a previous study in ALS.
Conclusions: Increased in vivo glial activation is present in the motor cortices of both PLS and ALS patients. These results suggest that glial activation may be implicated in both conditions. Studies are ongoing to characterize the longitudinal changes in [11C]-PBR28 binding in both populations and their correlation with disease severity and upper motor neuron burden.
Influence of Antagonistic Hamstring Co-Activation on Measurement of Knee Extensor Strength in Older Adults with or t Risk for Knee Osteoarthritis
Robert Welborn; Neil Segal, MD, MS; Laura Frey-Law, MPT, MS, PhD
Objectives: Knee extensor weakness is a known risk factor for progressive radiographic knee osteoarthritis (OA) and is associated with increasing pain and disability.There is also evidence that knee extensor muscle weakness is associated with poor performance and knee instability among individuals with OA. Therefore, accurate measurement of knee extensor strength is important for clinicians involved in the diagnosis and management of knee OA. Apparent strength deficits could reflect actual decreased strength of the agonists or increased antagonist muscle coactivation reducing the net torque measured. The purpose of this study was to determine if coactivation of the hamstrings during quadriceps strength testing is higher in those with lower net torque measured.
Design: Median level of hamstring coactivation was assessed using surface electromyography during maximal isokinetic knee extensor strength testing. Relationships between coactivation and quadriceps specific torque (net torque per unit thigh muscle mass) were assessed using linear regression, adjusted for age, sex, knee OA(KL grade), and knee pain(WOMAC).
Results: A total of 1139 knees (431 male, 708 female) met inclusion criteria. Mean (SD) age was 67.4 (7.7) years, BMI was 30.6 (5.7) kg/m2, and 37.9% of the knees had OA. Hamstring muscle coactivation was significantly associated with quadriceps specific torque (R2 = 0.04, p When adjusting for age and sex, hamstring muscle coactivation remained a significant predictor (p < 0.0001), however when additionally adjusting for OA radiographic severity and knee pain, coactivation no longer was a significant predictor (p = 0.8489).
Conclusions: Antagonistic muscle coactivation likely contributes to reduced net specific quadriceps strength. However, this relationship is attenuated by adjustment for knee pain and OA, indicating that coactivation may be an intermediary in the pathway between pain and reduced strength.
Inpatient Rehab for Lymphedema Management Prior to Total Knee Replacement (TKR)
Marjorie Maye S. Mamsaang, DO; Marlyn S. Ramos-Lamboy, MD; Bridget M. von Jeetze, MS, PT
Case Diagnosis: Inpatient Rehab for Lymphedema management prior to Total Knee Replacement (TKR)
Case Description: 76 year old woman presented with Stage II lymphedema in bilateral lower extremities and left upper extremity secondary to endometrial cancer and left breast cancer. Her past medical history was significant for Diabetes Mellitus Type 2, morbid obesity, rheumatoid arthritis and severe degenerative joint disease of the knee impairing her mobility and activities of daily living requiring total knee replacement (TKR). Orthopedics was concerned about post-operative complications due to the extent of lymphedema and TKR was postponed until swelling was minimized. The patient received outpatient Complete Decongestive Therapy (CDT) at a lymphedema clinic 4 times per week for 3 weeks with each session being 90 minutes long including full bilateral leg Manual Lymph Drainage, secondary sequences and compression bandaging. She also received education for home management consisting of compression, exercise, skin care and self-massage. All outpatient treatment options were exhausted and failed to reduce knee volume. Subsequently, the patient was admitted to Inpatient Rehab Unit where she received a modified protocol with intense lymphedema therapy 7 days a week. This included 24-hour compression with lymphedema bandages to the knees and CompressoGrip sleeves for the thigh during the days, and custom JoViPak night compression with CompressoGrip sleeves during evenings and overnight. After two weeks knee circumference measurements showed a 20% decrease in volume, allowing her to proceed with TKR. The patient tolerated the procedure well. On post-op day 3 she required transfusion of 1 unit of packed red blood cells. She was followed up for 3 months and no other surgical complications were reported.
Discussions: Lymphedema is swelling of extremities from accumulation of protein-rich fluid caused by impaired lymphatic flow, most commonly due to cancer in developed countries. The complication rate after TKR with lymphedema cases compared to patients without lymphedema is over 30% with the most common complication being wound infection associated with risk factors such as diabetes, rheumatoid arthritis, obesity, immunosuppressive use and corticosteroid use. Additional complications include thrombosis, cellulitis and worsening edema. Pre-operative management is traditionally outpatient physical therapy including CDT and patient education on manual techniques. In this patient’s situation, outpatient attempts failed to decrease edema. Sub-acute rehabilitation may not be an option for everyone since few facilities have dedicated lymphedema therapists. In this case inpatient rehab treatments were successful in reducing the limb allowing the patient to undergo TKR without post-operative complications associated to lymphedema. The patient’s post-operative transfusion was not a lymphedema mediated complication as the number of red blood cell transfusions required after routine joint replacements for all patients varies between 21 and 70%.
Conclusions: In severe cases of lymphedema not benefited from outpatient treatment, it is advantageous to consider inpatient rehabilitation for volume management prior to surgical intervention.
Intractable Rectal Pain Unresponsive to Escalating Opioid Therapy in Male with Rectal Adenocarcinoma is Responsive to Ganglion of Impar Block Leading to Decreased Hospital Stay: A Case Study
Chau Uong, DO; Raj Uppal, MD
Case Diagnosis: Male with history of rectal adenocarcinoma with rectal and perineal pain.
Case Description: 65 year old male with past medical history of pT4bN0 rectal adenocarcinoma status post neoadjuvant chemoradiation, abdominoperineal resection, urethroplasty, and suprapubic tube placement is admitted to the hematology/oncology service for increased rectal pain for 6 months not relieved with hydrocodone/acetaminophen 10/325 two tablets every 4 hours. His pain is located in the rectal and perineal area; characterized as burning and sharp; relieved with standing at 0/10; and worsens with sitting at 10/10. He is started on morphine 1 mg IV every 3 hrs and, subsequently, a fentanyl patch which was titrated up to 50 mcg/hr. Despite these efforts, his pain remains intractable; therefore, interventional pain service is consulted on the 10th day of admission. He is started on topiramate 25 mg twice daily and a ganglion of impar block is administered with a 25-gauge, 2-inch needle with 1 cc of 40 mg of triamcinolone acetonide and 5 cc of bupivacaine 0.5%. After which, the patient’s pain decreased to a 2/10 and he is subsequently discharged from the hospital 2 days later. At follow up in 2 weeks, the patient continues to have excellent relief from the injection and is able to sit without any pain.
Discussions: The ganglion of impar is the only unpaired autonomic ganglion in the body and marks the end of two sympathetic chains. It receives afferent pain fibers from the perineum, distal rectum, anus, distal urethra, vulva, and distal third of vagina. As such, a ganglion of impar block for this patient led to significant pain relief from his rectal and perineal pain.
Conclusions: Patients with intractable rectal and perineal pain from rectal adenocarcinoma unresponsive to opioid therapy may benefit from ganglion of impar block and possibly lead to a shorter hospital stay.
Iodine Starch Test for Evaluation of Hyperhidrosis in Amputees
Benjamin E. Wayment, MD; Colby Hansen, MD; Bradeigh Godfrey, DO; William L. Wagner, MD
Objectives: The iodine-starch test is a widely used method in dermatology for determining focal areas of sweating in palmar, plantar, and axillary hyperhidrosis. Use of this test in amputees presents unique challenges as sweating occurs on skin covered by a prosthesis. To date there is no described method to use the iodine-starch test to assess focal areas of hyperhidrosis in residual limbs of amputees. The aim of this study was to determine a preferred method for administering the iodine- starch test in amputees, in order to better focus treatment.
Design: We recruited 8 amputees with hyperhidrosis and used varied methods to apply the iodine-starch test. We applied betadine and corn starch, then covered the limb with plastic wrap before donning the prosthesis. Participants were then instructed to ambulate for 5 or 10 minute intervals. At the end of each interval the prosthesis was removed and the limb was assessed for sweat reaction, skin irritation, discomfort, and staining to the liner. Trials were repeated with a prosthetic sheath and then with a thick sock.
Results: Plastic wrap quickly produced sweating after a short interval. There were no skin complaints, but sweating quickly became too diffuse to interpret. Application was cumbersome and the plastic wrap would sometimes slip down causing leakage onto liners. The sheath was comfortable, with noticeable sweating by 10 min of ambulation, no skin complaints, and easier to apply. It stayed in place with minimal leakage onto liners. The sock was least preferred, noted to be most uncomfortable, and was too absorbent, making assessment of sweat reaction difficult. Sock trials were discontinued after repeated complaints.
Conclusions: Of the 3 methods the sheath is most comfortable, easiest to apply and did not cause any skin discomfort or irritation, making it the preferred method to apply the starch iodine test to residual limbs.
Isolated Teres Minor Atrophy Presenting as Shoulder Pain: A Case Report
Tyler D. Hedin, MD; David J. Petron, MD; Daniel M. Cushman, MD
Case Diagnosis: As one of the four rotator cuff muscles, the teres minor muscle functions primarily to externally rotate the humerus and is innervated by the posterior branch of the axillary nerve. It tends to receive less attention than its three counterparts, partly due to the fact that it is rarely injured in isolation and is likely the least-injured of the rotator cuff muscles. According to a recent study, the incidence of teres minor atrophy on routine magnetic resonance imaging (MRI) of the shoulder is around 3% to 5.5%, though this is often assumed to be clinically insignificant. This case describes a patient who presented with a chronic history of shoulder pain that had previously been diagnosed as rotator cuff syndrome. After a workup that included MRI and electrodiagnostic studies, he was found to have isolated teres minor atrophy and denervation without any other rotator cuff or axillary nerve-innervated muscle involvement.
Case Description: A 39 year old male presented to a sports medicine clinic complaining of an approximately 5-year history of relatively constant right shoulder pain that had been previously diagnosed as rotator cuff syndrome. A prior workup, including evaluation and plain radiographs, was reportedly normal. He initially noted the shoulder pain while weightlifting, but could not recall a traumatic injury to his shoulder or neck. His pain was primarily exacerbated by lifting items and was worse at night while lying on his affected side. On physical exam, there was no atrophy or deformity noted in the right shoulder, but he had significant tightness and myofascial tenderness throughout the scapular area on the right side. His strength examination was notable for subtle weakness with external rotation of the shoulder, documented as 4+/5. He had a positive Neer’s sign, Hawkin’s sign, Speed’s test, and cross arm sign, all of which recreated his typical pain. Sensation and reflexes were normal. He was initially prescribed a course of anti-inflammatory medication and physical therapy, which included isometric stretches, eccentric rotator cuff strengthening, and scapular stabilizer strengthening, all of which exacerbated his symptoms over one month. A subsequent MRI of his right shoulder was ordered given his lack of improvement, which showed severe teres minor atrophy without any other structural anomalies. He was referred for nerve conduction studies and electromyography (EMG), which showed a single, low-amplitude motor unit action potential in the teres minor muscle during maximal effort in external rotation of the shoulder, without evidence of spontaneous activity at rest. There was normal muscle unit action potential morphology without spontaneous activity in the deltoid, infraspinatus, trapezius, rhomboid, and biceps muscles. Given these findings, it was recommended that the patient continue with physical therapy focused on strengthening external rotation and shoulder girdle strengthening. In addition, dry needling of the periscapular muscles was added in an effort to relieve some of his myofascial pain. He was started on an evening dose of gabapentin to help with his shoulder pain, which was interfering with sleep. On a 4 week follow-up visit, his physical exam was largely unchanged, though the gabapentin was helpful for his right shoulder pain at night and had improved his sleep. It was recommended that he take this medication during the day as well to help with pain. At the time of this writing, he is continuing his physical therapy regimen and taking gabapentin three times daily.
Discussions: The axillary nerve arises from the posterior cord of the brachial plexus and traverses through a quadrilateral space bounded above by the subscapularis, below by the teres major, medially by the long head of the triceps brachii, and laterally by the surgical neck of the humerus. It then divides into anterior, posterior, and collateral branches. The posterior branch of the axillary nerve innervates the teres minor muscle as well as the posterior aspect of the deltoid muscle. However, a recent cadaveric study found considerable variability in the location of the bifurcation of the anterior and posterior branches of the axillary nerve. Quadrilateral space syndrome, as it was first described in 1983, noted the surgical observation of “fibrous bands” causing axillary nerve compression. However, more recent case studies have found other etiologies for nerve compression around the quadrilateral space including space occupying lesions, trauma, muscular hypertrophy, and overuse. Though rare, other teres minor injuries have been described, such as in volleyball players with repetitive overhead motion, external impingement from cysts, and bony abnormalities. Neuralgic amyotrophy has also been demonstrated to affect the axillary nerve in a somewhat selective manner, with relative sparing of some muscles while involving others.
Conclusions: Given the considerable anatomical variation in the nerve(s) supplying the teres minor muscle, there are several various points at which the axillary nerve or its posterior branch may be vulnerable to impingement or injury. Patients who present with activity-related posterior shoulder pain and/or weakness without evidence of other rotator cuff muscle involvement who are not improving with physical therapy should receive advanced imaging. Careful examination of the teres minor musculotendinous unit on MRI should be performed in these cases. EMG may further elucidate the acuity and extent of the teres minor atrophy, though ultrasound-guided location may be required.
Learning-Related Changes in the Functional MRI Response to Fear Conditioning after Acute Medical Trauma
Edward Ference, BS; Nathaniel Harnett, BA; Muriah Wheelock, BA; Kimberly Wood, PhD; Martin Setliff, MD; Peyton Thetford; David Knight, PhD; Amy Knight, PhD; Amy Knight, PhD
Objectives: Little research has investigated changes in fear learning following acute trauma (i.e. < 1 month post event). These changes may be important to understanding Posttraumatic Stress Disorder (PTSD) susceptibility. The current study investigated the relationship between brain measures, behavioral measures, and PTSD symptom expression following acute medical trauma. We hypothesized trauma exposure would be associated with elevated self-reported psychosocial risk factors and PTSD symptoms, as well as impaired Pavlovian fear conditioning.
Design: 12 participants recruited from the university acute trauma unit completed self-reported surveys of psychosocial risk factors and PTSD symptoms, and a Pavlovian fear conditioning task during fMRI. Healthy controls (n=9) were recruited from an ongoing imaging study.
Results: PTSD symptom severity within 1 month of trauma correlated with symptom severity at 6 months post trauma (p < 0.05) and with psychosocial risk factors within 1 month of trauma (p < 0.01). During fear conditioning, healthy controls showed greater expectancy for threat during warning than safety cues. In contrast, trauma-exposed individuals showed equivalent threat expectations to warning and safety cues. Functional MRI revealed greater activation to warning and safety cues in the dorsomedial prefrontal cortex (dmPFC) in trauma-exposed compared to healthy control individuals (p < 0.01). Trauma-exposed individuals exhibited learning-related activity within left amygdala (p < 0.01), which was modulated by anxiety and depression symptoms. Finally, greater activity to warning than safety cues was observed within the hippocampus for healthy controls; the reverse occurred in trauma-exposed individuals (p < 0.01).
Conclusions: These data suggest initial psychosocial risk factors and PTSD symptom severity can predict future PTSD development. The trauma exposed group showed increased activity in the dmPFC, which is important for emotion regulation, but expected a threat after both the warning and safety cues. The group differences in the amygdala and hippocampus suggest trauma can cause dysregulation in fear response pathways.
Leukoencephalopathy after Intrathecal Methotrexate in a Patient with HTLV-1 Associated Adult T-Cell Leukemia and its Impact on Acute Rehabilitation
Matthew J. Kortes, MD; Brian D. McMichael, MD; Matthew Dawson, MD
Case Diagnosis: A 53 year old male was diagnosed with HTLV-1 Associated Adult T-cell Leukemia and developed methotrexate induced leukoencephalopathy after treatment with intrathecal methotrexate for leptomeningele involvement. Rapid progression of leukoencephalopathy limited the effectiveness of rehabilitation illustrating the importance of determining stability of disease progression prior to establishing rehabilitation goals in patients with methotrexate induced leukoencephalopathy.
Case Description: Ten weeks prior to admission (PTA), a 53 year old male presented with nausea and headaches and was subsequently diagnosed with HTLV-1 associated adult T-cell leukemia with leptomeningeal involvement on MRI. Because of leptomeningeal involvement he was started on intrathecal methotrexate, cytarabine and dexamethasone (4 cycles) with alemtuzumab after the first cycle. He had completed cycle 7 of alemtuzumab when he presented with near syncope and dizziness two weeks PTA. MRI demonstrated extensive patchy and confluent areas of T2/FLAIR hyperintensity in the periventricular and frontal parietal regions. Brain biopsy demonstrated reactive astrogliosis. Analysis of cerebrospinal fluid on two occasions was negative for malignant cells. Electrodiagnostic studies excluded acute demyelinating peripheral polyneuropathies. The patient was transferred to the oncological rehabilitation service for rehabilitation for mild cognitive decline and bilateral leg weakness resulting from methotrexate induced leukoencephalopathy. After briefly functionally improving over several days the patient then markedly declined over a week and was transferred back to oncology.
Discussions: Progressive methotrexate induced leukoencephalopathy is an uncommon complication of treatment of HTLV-1 Associated Adult T-cell Leukemia and has limited treatment options. This patient continued to decline during rehabilitation even after treatment with corticosteroids. Prognosis after methotrexate leukoencephalopathy may range from acute and fulminant to chronic and will affect rehabilitation considerations.
Conclusions: Methotrexate induced leukoencephalopathy may not be amiable to rehabilitation during the active phase as progression may outpace rehabilitation progression. Neurological symptoms should stabilize before rehabilitation potential can be successful predicted and a plan successfully executed.
Listeria Monocytogenes Brain Abscess: A Rare Complication of Dermatomyocitis
Alex B. Behar, MD, ATC/L; Andrew Joon. Park, BS; Jonathan VandenBerg, DO; Chirag D. Shah, MD, JD
Case Diagnosis: 40 year old female with past medical history of resistant amyopathic dermatomyositis diagnosed 1.5 years prior to admission with EMG. She was previously on chronic immunosuppression and now presents with progressive R sided weakness and headache over the last month.
Case Description: The patient presented to the county hospital where an MRI showed a left sided ring enhancing lesion in the left frontoparietal lobe. Attempted closed biopsy failed due to intraoperative hemorrhage and converted to open biopsy. Pathology and cytology of lesion consistent with Listeria Monocytogenes with the etiology being chronic immunosupression for her dermatomyocitis. Post-op, the patient presented with dense right sided hemiplegia, severe expressive aphasia, and dysphagia caused by candida esophagitis leading to G-tube placement.
Discussions: Patients with dermatomyositis, a connective tissue disorder, have higher risks and incidences of infection, usually from the disease itself or secondary to treatment side effects. In this patient, due to her history of chronic immunosuppression for the dermatomyocitis, she developed a large brain abscess causing right sided hemiparesis and expressive aphasia. As a major complication of connective tissue disorders, patinets should always be montiored for uncommon infections due to their immunocompromised state. Although rare, listeriosis occurs in 5.4 cases per 1,000,000 people with 1% of all brain abscess being associated with Listeria Monocytogenes. Listeria should be part of the working differential diagnosis of hemiparesis with a ring enhancing lesion in patients with dermatomyocitis.
Conclusions: To conclude, because of the size, location, and comorbid complications of the listeria brain abscess, the patient’s rehabilitation will be very taxing on any patient while also batteling the debilitating disease of dermatomyocitis, whos symptoms include severe dermal erythema, proximal muscle weakness, and pain.
Low Back Pain Secondary to Baastrup’s Disease in a Patient with Inflammatory Myopathy: A Case Report
Abir Naguib, MD; Yumei Wang, MD; Eathar Saad, MD
Case Diagnosis: A 48 year old female with inflammatory myopathy presented with persistent severe low back pain that did not respond to conservative measures or interventional pain management.
Case Description: The patient initially presented a few years prior with proximal muscle weakness and fatigue manifested as difficulty getting out of a chair, climbing stairs and combing her hair. CPK levels were elevated and EMG examination revealed diffuse myopathic units and denervation potentials in all extremities, lumbar and thoracic paraspinals which was consistent with inflammatory myopathy. Muscle biopsy confirmed the diagnosis. She was started on steroids and immunosuppressants. During her course she began to complain of severe LBP of unknown etiology. The pain was aggravated on extension of the lumbar spine and did not respond to conservative measures. It did not radiate to the legs and she denied any sensory symptoms. She had weak abdominal and back muscles and was referred to rehabilitation for physical therapy with emphasis on core strengthening. Her pain did not improve but was aggravated by exercise and associated with a rise in CPK levels. Imaging of the spine revealed normal disc spaces but showed diffuse narrowing of the lumbar interspinous spaces with “kissing spines”, a condition known as Baastrup’s disease.
Discussions: Baastrup’s disease is a condition of unknown etiology characterized by close approximation of the adjacent spinous processes usually occurring at L4-5. Symptoms include LBP with midline distribution that worsens during extension and is relieved during flexion. It usually occurs after age 70 secondary to degenerative changes of the spine and is therefore not common to occur in younger ages with no spinal degenerative changes. Involvement of the paraspinal muscles in inflammatory myopathy with resulting weakness can predispose to increased lumbar lordosis which can eventually result in the approximation of the spinous processes characteristic of Baastrup’s disease.
Conclusions: It is important to assess and maintain core muscle strength in patients with LBP. Management can be especially challenging in patients with progressive muscle weakness. LBP in Baastrup’s disease may be resistant to conservative treatment and non-amenable to interventional management as epidural injections and may require surgical excision of the spinous processes. To date there have not been any reports in the literature on Baastrup’s disease as a potential complication in patients with myopathy.
Lower Extremity Weakness Related to SI Joint Dysfunction Reversed with Single SI Joint Injection
Kelsey S. Neufeld
Case Diagnosis: 50 yo female patient with proximal muscle weakness of lower extremity, decreased ROM, and gait/flexibility impairments secondary to SI joint dysfunction after sustaining a fall 6 months prior.
Case Description: The patient presented to the PM&R outpatient clinic with difficult transfer ability from squatting position to standing without using her UE for secondary strength. She suffered a fall 6 months prior to her R side with no evidence of acute pathology on initial plain film imaging completed at time of fall. She continued to have right low back/hip pain with progression to R proximal lower extremity weakness, difficulty ascending stairs, and an inability to sit for longer than 10 minutes. In addition, her sit to stand transfers were difficult and she presented with an altered gait. Upon initial examination, she had completed a 4 month physical therapy regimen for her back pain with mild relief prior to examination in PM&R clinic but weakness persisted. She denied any bladder or bowel incontinence, LOB or paresthesias. Upon physical exam her SLR was negative, 4/5 proximal muscle strength of bilateral hip flexors, FABRE + on R, and R SI joint pain, her gaenslen’s test was negative b/l. Due to her continued weakness and pain pattern of R lumbar/buttock pain that radiated to the R buttock: a lumbar MRI was obtained and was unremarkable for any evidence of disc herniation, spinal stenosis or foraminal compromise. Her weakness and pain patterns continued and she underwent an EMG study of the RLE which demonstrated normal motor and sensory NCVs of the RLE and needle studies with normal recruitment and MUAP patterns, the study demonstrated no evidence of a radiculopathy, plexopathy or neuropathy to explain her LE weakness. Given her unremarkable MRI and EMG and continued R SI joint pain and weakness she opted to try a diagnostic SI joint injection as a therapeutic measure for pain improvement. She underwent a R SI joint injection (40mg kenalog with 2ml of 1% lidocaine & 2ml of 0.25% bupivicaine) under fluoroscopy with no complications and tolerated the procedure well. She was instructed to continue her physical therapy course and follow up in 4–6 weeks. In therapy/follow up she reported significant relief of her pain symptoms and reported to feel stronger in the lower extremity. Her transfer ability improved and was able to transition from tall kneel to standing without symptoms or requiring UE support (while leading with either LE). She also had improvement in standing and sitting tolerance time as well as car transfers, ascending stairs and ambulation.
Discussions: At 4 weeks post right sacroiliac joint injection the patient was able to improve functional ability in regards to ambulation, transfers, and pain control. She had increased muscle strength of bilateral hip flexors on manual muscle testing after injection with adequate pain control. This is the first reported case, to our knowledge, of proximal lower extremity weakness related to sacroiliac joint dysfunction that was adequately reversed with singular SI joint injection under fluoroscopy.
Conclusions: SI joint dysfunction may be associated with proximal lower extremity weakness that contributes to functional limitations, but also may be reversible with SI joint injection under flouroscopy.
Maggot Debridement Therapy (MDT): A Case Study Using MDT on a Non-Healing Upper Extremity Traumatic Amputation
Lawerence Kelleher, DO; Jennifer Hankenson, BA
Case Diagnosis: Traumatic upper extremity amputation resulting in chronic non-healing wound
Case Description: A 22 year old male was admitted for comprehensive inpatient rehabilitation status post polytrauma and resultant traumatic right transhumeral amputation. On admission, the patient had a chronic post-traumatic wound and was initially treated with hyperbaric oxygen therapy, MIST treatment and was followed by the wound care team. He showed little improvement and subsequently underwent maggot debridement therapy (MDT). The wound was cleansed with Dakin’s solution, rinsed thoroughly with normal saline, dried and sterile larvae applied. A “cage” was fashioned to prevent the escape of maggots and a dressing was applied to the wound. The dressings were changed daily or as needed to prevent moisture from drowning the maggots. After 3 days, the maggots were removed and the wound was treated with ultrasound MIST therapy for 6 minutes followed by dressing with Santyl and Dakin’s solution. Wound dimensions decreased to 10 x 3 x 3.5cm from 11 x 5.5x5.5. He then underwent successful wound closure, healed completely, was fitted with a prosthetic and is now undergoing OT.
Discussions: Chronic wounds are defined as those not following an orderly manner of healing which subsequently do not achieve closure. In the amputee population, chronic wounds are a barrier to progressing to prosthetic use. MDT is known to be effective in the treatment of diabetic and pressure related wounds while also showing benefits in degloving injuries. It provides more precise, less labor and time intensive debridement than traditional methods as only necrotic tissue is eaten. MDT has three core benefits: debridement, disinfection and advanced healing.
Conclusions: We believe this to be the first case of MDT promoting wound healing in a traumatic UE amputation. Future studies should be conducted to look at the benefit of multiple applications of MDT for improved wound healing in the amputee population.
Marsupialization of a Skull Flap as an Unusual Cause of Meralgia Paresthetica: A Case Report
Fairen N. Walker, MD; Kirk Lercher, MD
Case Diagnosis: Meralgia Paresthetica
Case Description: A 66 year-old female with a history of right middle cerebral artery infarct with hemorrhagic conversion status post right decompressive hemicraniectomy and marsupialization of the cranial bone flap in the right lower abdominal quadrant was admitted to acute inpatient rehabilitation facility two months following the initial infarct because of a mechanical fall resulting in a subsequent right temporal intracranial hemorrhage posterior to the existing hemicraniectomy site. During her acute rehabilitation stay, she reported burning pain starting at the marsupialization site and radiating down the antero-lateral thigh. Physical exam revealed the marsupialized skull had migrated down into the right groin. Hip X-ray ruled out heterotopic ossification, acute fracture, periosteal reaction, or osseous destruction but showed mild bilateral hip arthrosis. She was clinically diagnosed with meralgia paresthetica. Ultrasound guided nerve block of the lateral femoral cutaneous nerve was attempted. However, the nerve was unable to be visualized on ultrasound as it was obscured by the marsupialized cranial flap. She was started on gabapentin, which greatly reduced her symptoms and reported pain scores. She was scheduled by neurosurgery for removal of the cranial bone flap and cranioplasty three months from the hemicraniectomy date.
Discussions: Meralgia paresthetica is neuropathic pain described as burning, tingling, and/or numbness in the antero-lateral thigh which is due to compression of the lateral femoral cutaneous nerve. It is typically caused by tight clothing, pregnancy, or obesity.
Conclusions: This case illustrates a rare cause of meralgia paresthetica as a complication of decompressive hemicraniectomy with marsupialization of the skull flap in the lower quadrant of the patient’s abdomen. This should be considered by physiatrists in their differential diagnosis of lateral thigh pain in this patient population. It further underscores the importance of monitoring sites of recent surgical interventions seen in a large proportion of patients admitted to acute rehabilitation facilities.
Massive Mortality Risk Not a Barrier to Acute Rehabilitation
Atira H. Kaplan, MD; Francis Lopez, MD, MPH
Case Diagnosis: Pelvic Crush Injury
Case Description: A 57-year-old male struck by a truck sustained multiple injuries, including open-book pelvic ring fracture, left lower extremity degloving injury from the pubis to the left knee, and urethral injury. The patient underwent pelvic external fixation, suprapubic catheter placement, debridement of left lower extremity necrotic tissue, placement of split thickness graft, formation of diverting loop colostomy, and removal of pelvic external fixator. The patient’s hospital course was complicated by sepsis, acute kidney injury, respiratory failure requiring tracheostomy, left foot necrotizing fasciitis, adrenal insufficiency, and pericardial tamponade. After nearly four months in the SICU, he was transferred to acute inpatient rehabilitation, where he required two-person assist for bed mobility, maximum assistance to maintain static short-sitting, and maximum assistance for sit-to-stand pivot transfer from bed to chair. Upon discharge from acute rehabilitation, nearly six months after the initial trauma, he was able to transfer from supine to sit with standby guarding, sit to stand using a rolling walker with supervision, ambulate 175 feet using a rolling walker with standby guard and portable oxygen.
Discussions: Pelvic crush injury is often associated with multiple medical complications and a high mortality rate. Despite the tenuous medical stability of the patient, he completed an extensive acute rehabilitation course and gained a significant improvement in function, highlighted by an improvement in FIM score from 27 to 52.
Conclusions: This case illustrates the importance of accommodating patients in acute rehabilitation units despite active medical and surgical complications. A poor prognosis should not preclude providers from offering the full extent of rehabilitation services as the outcome may exceed expectations.
Maximizing Independence in a 40 Year Old Female with Multi-Minicore Disease in Acute Inpatient Rehabilitation: A Case Report
Rishi Shah, MD; Padma Srigiriraju, MD
Case Diagnosis: Multi-Minicore Disease was diagnosed via muscle biopsy.
Case Description: 40 year old female with past medical history significant for Marfan syndrome, multi-minicore disease, scoliosis, mitral valve repair and chronic obstructive pulmonary disease presented to acute care hospital with left leg edema and pain for two days. Work up revealed DVT and patient was placed on anticoagulation. Patient was noted to have significant weakness and subsequently transferred to acute inpatient rehabilitation for functional upgrading. Upon admission patients FIM (Functional independence measure) was 52 for motor and 34 for cognition for a total of 86. A comprehensive rehabilitation program was implemented for this patient including instructions for sub-maximal exercises. To insure sub-maximal exercising creatinine phosphokinase (CPK) was closely monitored and trended. Patient was noted to have gait instability along with inability to independently lateral rotate her neck.
Discussions: Multi-minicore disease is a rare autosomal recessive congenital myopathy. Patients are diagnosed with a muscle biopsy showing multiple cores. Genetic testing will reveal a mutation in the selenoopretein N (SEPN1) gene and ryanodine receptor (RYR1) gene. These patients suffer from early scoliosis, distal weakness, muscle wasting and respiratory impairment.
Conclusions: There is no standard care for rehabilitation in patients with multi-minicore disease. We suggest these patients undergo acute inpatient rehabilitation after acute care hospital stay. Also, we recommend a comprehensive rehabilitation program be initiated with therapies done at a sub-maximal level and close monitoring of CPK levels and trends. We wear able to see significant gains as this patient was discharged home with a discharge FIM of 75 motor and 34 cognition for a total of 102 and a FIM gain of 23.
May-Thurner Syndrome: A Rare Cause of a Common Problem
Thomas Lione, DO; Sylvia John, MD
Case Diagnosis: May-Thurner syndrome (MTS) is a rare cause of deep venous thrombosis (DVT) due to an anatomical variant in which the right common iliac artery compresses the left common iliac vein against the lumbar spine resulting in left lower extremity DVT. This anatomical variant has been shown to exist in up to 20% of the population, but is not typically included in the differential diagnosis of DVT, particularly in patients with additional risk factors such as those with multiple sclerosis (MS).
Case Description: A 59 year-old female with MS, hypothyroidism, and Graves’ disease admitted to an acute rehabilitation facility after MS exacerbation developed acute left lower extremity edema five days after admission. Venous Doppler ultrasound revealed DVT of the left common femoral, popliteal, and saphenous veins. MRA of the abdomen without contrast was performed, which revealed compression of the left common iliac vein by the right common iliac artery and complete thrombosis of the left common iliac, external iliac, and common femoral veins. Vascular surgery consultation was obtained and anticoagulation was initiated with subsequent endovascular intervention upon discharge from the rehabilitation facility.
Discussions: MTS is a progressive disease with the potential to cause long-term disability and fatal sequelae. Diagnostic accuracy is important to guide proper treatment, which includes anticoagulation, endovascular intervention, or surgical thrombectomy. It is also known that chronic cerebrospinal venous insufficiency (CCSVI) is related to the pathogenesis of MS and it has been suggested by physicians performing CCSVI venography in MS patients, that there is an increased incidence of MTS in this population, although evidence of a connection is limited.
Conclusions: Although this variant is rare and the diagnosis may be challenging, with early detection and management, MTS can be a well-managed disease and should be considered as a rare etiology of DVT, especially in patients with increased risk factors such as MS.
Medial Hallucal Entrapment Neuropathy Caused by Tophaceous Gout of First Metatarsophalangeal Joint
Ayesha Khan, MD; Phuong U. Le, DO; Se Won Lee, MD; Dennis Kim, MD
Case Diagnosis: Medial hallucal neuropathy of foot caused by tophaceous gout
Case Description: We report a case of a 36 year old male with history of Gout for 10 years who presented with worsening pain at right first metatarsophalangeal (MTP) joint.
The pain was located on the medial aspect of right first MTP joint. It was aggravated by prolonged standing and alleviated with rest, ibuprofen and topical analgesics. Patient’s been on allopurinol, colchicine and also received multiple steroid injections for his foot pain in the past. Pain was burning in nature, and radiated up to the medial foot and ankle and also distally to the tip of great toe. On physical examination, there was minimal effusion of 1st MTP joint. Ultrasound examination of joint showed characteristic double contour sign representing urate crystals accumulating on hypoechoic hyaline cartilage with “snow storm” appearance with joint effusion. Patient’s symptoms (burning pain with radiation) was reproduced (Valleix sign) on sonopalpation of medial hallucal nerve on the medial side of right first MTP joint.
Patient was advised to use roomier foot wear, with doughnut pad for the entrapped right medial hallucal nerve over the tophaceous joint.
Discussions: Entrapment and compressive neuropathies of upper extremity caused by tophaceous gout are widely reported, however entrapment neuropathy of foot is under recognized. Hallucal neuropathy is a well known complication in hallux valgus surgery (Bunion surgery). Considering the proximity of medial hallucal nerve to the tophaceous gout, compressive neuropathy by tophaceous gout can be included in the differential diagnosis of hallucal neuralgia.
Conclusions: This case illustrates the utility of comprehensive history, physical examination with point of care ultrasonography in the evaluation of medial forefoot pain. Medial hallucal entrapment neuropathy by chronic tophaceous gout should be included as a possible cause of fore foot pain.
Metabolic Expenditures during Exoskeleton-Assisted Walking in Person with Multiple Sclerosis
Taimoor Afzal, PhD; Marcie Kern, PT, MS; Shih-Chiao Tseng, PT, PhD; John Lincoln, MD, PhD; Shuo-Hsiu Chang, PT, PhD
Objectives: Wearable exoskeletons are designed and can be utilized to facilitate walking in individuals with neurological conditions such as spinal cord injury. However, the amount of assistance provided during exoskeleton-assisted walking is unclear. Therefore, the aim of this study was to investigate the feasibility and efficacy of using exoskeleton for walking in person with multiple sclerosis (MS).
Design: One subject with expanded disability status scale (EDSS) score 6.0 received 12 training sessions in exoskeleton-assist walking using the wearable exoskeleton (EKSO®, Ekso Bionics, Richmond, CA). Outcome measures were performed at the end of the training. Metabolic expenditures during timed up-and-go test (TUG), 25-ft walk test (25FTWT, self-selected and fast speed) and 6-minute walk (6MWT) were measured and compared between exoskeleton-assisted and unassisted walking. Muscle activation profiles were also recorded and analyzed using surface electromyography (sEMG) in major muscles of upper and lower extremities.
Results: The preliminary data showed that maximal oxygen consumption (VO2max) and heart rate (HR) during the 6MWT (approximately 7.5% and 6%, respectively) were lower in exoskeleton-assisted walking than in unassisted walking. During 25FTWT at fast speed, the VO2max and HR were higher (approximately 3% and 10%, respectively) in exoskeleton-assisted walking than in unassisted walking. For sEMG, all muscles of the lower extremity except semitendinosus, showed lesser activity during 25FTWT at self-selected speed and 6MWT in exoskeleton-assisted walking than in unassisted walking. Similar to the pattern observed in metabolic cost, muscle activities were greater during 25FTWT at fast speed in exoskeleton-assisted walking than in unassisted walking.
Conclusions: Walking with exoskeleton may enable MS patients to walk more efficiently by reducing the metabolic expenditures and muscle activity, especially in long distance walking. Wearable exoskeleton could provide sufficient assistance in performing daily living activities, leading to better quality of life.
Metastatic Horner’s and Brachial Plexopathy: A Case Report
Julie Larson, MD; Wilson Chang, MD, MPH; Reza Taher, MD; Michael Larson, MD; S.Kamal Fetouh, MD
Case Diagnosis: Metastatic Horner’s and Brachial Plexopathy caused by a metastatic breast cancer lesion in a patient with history of breast cancer.
Case Description: A 41 year old female with a PMH significant for breast cancer with known mets to the spine and lung with persistent pain in neck and left shoulder and associated left arm numbness. Patient had failed multiple therapies for pain including steroid injections to the shoulder joint, physical therapy, topical ointments, and chiropractic therapy prior to referral to the oncology rehabilitation clinic.
Discussions: Patient’s history and physical exam was consistent with a C8-T1 radiculopathy. She was scheduled for an epidural steroid injection. However, before her injection she returned to clinic with worsening symptoms and was noted to have right sided ptosis and miosis. She confirmed anhidrosis of the right side. CT of chest, MRI of brachial plexus, MRI of brain, and MRI of cervical spine were ordered. Official radiology report was initially negative for acute pathology or new mass within brachial plexus, brain, or chest. Patient continued to have progressively worsening C8-T1 paresthesias and myalgias resembling a C8-T1 radiculopathy. Imaging reviewed with the radiologist. In retrospective review, nodular enhancement at the margin of the right lung apex with some milder enhancement seen just outside the C8,T1 and T2 neural foramina was noted. Official radiology reports were addended to note the above findings with concern for new metastatic disease. Patient was diagnosed with Horner’s Syndrome secondary to metastatic mass of right brachial plexus.
Conclusions: In patients with known history of malignancy, one must always consider metastatic lesions with a presentation of new pain, weakness, and/or altered sensation. To our knowledge, this is the first documented case of a single metastatic lesion causing both a brachial plexopathy and Horner’s Syndrome. This case reiterates the importance of a physical exam. Had the patient presented to a pain clinic that relied upon imaging results without emphasizing physical exam, her other symptoms may have been overlooked and cancer may have progressed.
Mid-Back Pain as an Initial Presenting Symptom of Klippel-Feil Syndrome in an Adult Female: A Case Report
Matthew G. Hadilaksono, DO; Borna Kavousi, MSC, MD; Sanjeev Agarwal, MD
Case Diagnosis: Klippel-Feil syndrome in a thirty seven year old female
Case Description: his case presents a 37 year old obese female who had been treated in the clinic for persistent mid-back pain for months. Her initial x-rays showed mid-thoracic spondylosis. Patient eventually developed neck discomfort along with radicular symptoms, at which time further imaging was obtained. Her cervical spine MRI revealed C3-C4 and C5-C6 vertebral bodies and posterior elements fusion, as well as multilevel degeneration and spinal canal/foraminal stenosis with cord signal abnormalities. This anomaly is consistent with the diagnosis of Klippel-Feil Syndrome. Patient was subsequently treated conservatively with physical therapy and pain control; additionally, patient was educated regarding cervical spine precautions.
Discussions: Klippel-Feil syndrome (KFS) is a rare congenital condition that is characterized by fusion of two or multiple cervical vertebrae due to disruption in proper fetal bone development, which has been linked to GDF6, GDF3, and MEOX1 gene mutations. The incidence of KFS is approximately 1 in 42,000 births with female predilection. Although deformities exist since birth, patients with KFS may present with various symptoms at different ages. This case highlights an atypical initial presenting symptom of KFS that deviates from the usual cervical spine complaints. The initial presenting symptom in this case was thoracic spine pain that was most likely as a result of altered mechanics of vertebral motion below the level of the congenital fusion. Other impairments in KFS that may co-exist with cervical spine fusion include hearing loss, torticollis, genitourinary and cardiovascular abnormalities.
Conclusions: Patients with Klippel-Feil syndrome typically presents with neck pain due to congenital cervical vertebral fusion. Although the anatomical anomaly exists since birth, clinical symptoms may not present or discovered until later in life. Awareness of the presence of other clinical symptoms affiliated with KFS may aid in its earlier diagnosis and treatment.
MNGIE Syndrome: Implications of Acute Inpatient Rehabilitation for a Rare Neuromuscular Disorder
Anish A. Mirchandani, DO; Jesuel Padro-Guzman, MD; Katherine Yao, MD
Case Diagnosis: A 58-year-old woman with Mitochondrial Neurogastrointestinal Encephalopathy (MNGIE) syndrome is admitted to acute inpatient rehabilitation after a stem cell transplant.
Case Description: A 58-year-old woman with Mitochondrial Neurogastrointestinal Encephalopathy (MNGIE) Syndrome was admitted for a planned stem cell transplant (SCT) as part of the treatment for her condition. The patient was diagnosed with MNGIE syndrome 3 years prior with genetic testing and muscle biopsy. Her symptoms, which were progressively worsening, included: abdominal pain, diarrhea, weight loss, hearing loss, ptosis, ophthalmoplegia, and painful peripheral neuropathy associated with loss of sensation in her hands and feet, as well as bilateral foot drop requiring ankle foot orthotics. Prior to admission, she was a household ambulator with her orthotics and used a Rollator for community ambulation. She was admitted to the inpatient rehabilitation unit (IRU) 23 days after her SCT. Her hospital course was complicated by bowel obstruction, cardiac arrest, sepsis, graft vs. host disease (GVHD), recurrent C. Difficile infection, anemia, and malnutrition that required prolonged total parenteral nutrition. Her impairments at the time of admission to the IRU included balance deficits, distal lower extremity weakness, sensory deficits, decreased endurance, and decreased coordination. Upon her initial evaluation, the patient required substantial assistance in majority of her activities of daily living. After a total of 15 therapy days the patient was discharged home from the IRU with home therapy services. By the time of discharge from the IRU, the patient made significant functional gains and was at a modified independent level in most of her activities of daily living.
Discussions: MNGIE syndrome is a rare progressive condition with a variety of characteristics, which include: gastrointestinal dysmotility, cachexia, episodic abdominal pain, diarrhea, ptosis, ophthalmoplegia, hearing loss, demyelinating peripheral neuropathy, and muscle weakness. To our knowledge, this is the first reported case of a patient with MNGIE syndrome who was treated in acute inpatient rehabilitation. This case highlights the clinical and functional challenges facing patients with this condition. Despite the easy fatigability of patients with mitochondrial disorders, the overall positive outcome of this patient has implications for the role of inpatient rehabilitation for the functional recovery in these rare cases of MNGIE syndrome.
Conclusions: This case illustrates the clinical challenges and functional compromise in patients with the rare diagnosis of MNGIE syndrome and the importance of an inpatient rehabilitation program for favorable outcomes.
Motoric Cognitive Risk Syndrome in Korean Elderly: KLoSHA Cohort Study
Goo Joo Lee, MD; Hyun-Kyung Do; Jea-Young Lim, MD, PhD
Objectives: Association between cognitive function and physical performance reported several times. Recently, one study documented that prevalence of dementia in elderly who is normal cognitive function and low physical performance is higher than elderly who is normal cognitive and physical function. The aim of the present study is to determine that low physical performance affects decline of cognitive function in elderly.
Design: A participant of 1,118 Korean elders was randomly sampled from the local residents, aged 65 years or older living in Seongnam, Korea. Self-report surveys, face to face interviews, and physical and psychological evaluations were conducted on 714 volunteers. Cognitive function was assessed using Korean version of the Consortium to Establish a Registry for Alzheimer’s Disease Assessment Packet (CERAD-K) and Korean Version of Hasegawa Dementia Scale (HDS-K). Physical Functions were assessed using SF-36, Activities-specific Balance Confidence (ABC) scale, Tinetti Performance-Oriented Mobility Assessment (POMA), Inbody, isokinetic muscle strength of knee, and body composition measurement. Follow-up surveys were conducted using the identical methodology after 5 years. In first wave, exclusion criteria was dementia or mild cognitive impairment patients according to the DSM-IV diagnostic criteria, and older than 75. In second wave, subjects who had stroke, Parkinson syndrome, death, or follow-up loss were excluded. Finally, data of 203 participants, 104 men and 99 women, was used for linear regression analysis.
Results: Incidence of motoric cognitive risk (MCI) syndrome was 5.9% in this study. High MMSE-KC scores in second wave were observed in women who were high knee extensor strength and low body mass index body at the first wave, independently of primary MMSE-KC score and education periods. However, there were not statistically significant variables to predict decline of MMSE-KC score in men.
Conclusions: Motoric cognitive risk syndrome was verified in Korean elderly cohort. Physical performance and body composition affect cognitive function in elderly women.
Noninvasive Magnetic Resonance Imaging Allows for Visualization of Immediate Tissue Composition Changes Following Manual Lymphatic Drainage Therapy
Paula Donahue, PT, DPT, MBA; Rachelle Crescenzi, PhD; Allison Scott, BA; Shelia Ridner, PhD, BSN; Manus J. Donahue, PhD
Objectives: Breast cancer treatment-related lymphedema (BCRL) is a lifelong condition resulting from lymphatic dysfunction following cancer therapies. Manual lymphatic drainage (MLD) is a component of complete decongestive therapy used to manage lymphedema; however, studies utilizing limb volumetrics to evaluate MLD benefit are inconclusive, leading to more variable clinical use despite subjective benefits reported by patients and therapists. Our objective was to apply more sensitive internal MRI measurements of tissue composition to quantify hypothesized changes in deep tissue before and after MLD.
Design: Controls (n=19;age=22-74yrs) and patients with unilateral BCRL (Stage 0–2;n=12;age=33-77yrs) were scanned using a noninvasive multi-echo MRI protocol in sequence with structural imaging and non-MRI measurements of limb volume, bioimpedance, and dielectric-constant. Patients received repeat MRI following 50-minute MLD and a subset of controls (n=5) were scanned twice to assess reproducibility. T2 relaxation time, a well-known surrogate marker of tissue composition, was quantified in upper arm and axilla. Pearson’s correlation testing, t-statistics and corresponding two-tailed p-values, and linear regression analyses were performed.
Results: Non-MRI measures were tightly correlated before and after MLD (R=0.87-0.99;p<0.001). Tissue-water T2 was less correlated (R=0.56; p=0.06) and elevated in patients vs. controls (p=0.044), consistent with increased edema. T2 increased in the unaffected arm post-MLD (p < 0.001) consistent with fluid being redirected to healthy axilla during MLD; affected arm T2 changed more variably and depended on location and BCRL stage, with T2 variation increasing from controls to patients with BCRL Stage 0 and Stages 1–2.
Conclusions: Internal MRI measurements of deep tissue composition provided evidence of tissue structural changes following MLD in BCRL not detectable using conventional measures of limb volume, bioimpedance, and dielectric constant. Results provide a basis for more sensitive internal mechanistic investigations of MLD and its utilization in condition management.
Notable Electrodiagnostic Findings of the Peripheral Nervous System in the Setting of Multiple Sclerosis
Larry B. Guinto; Bryan Anderson; Adrian Cristian, MD
Case Diagnosis: Peripheral Lesions in Multiple Sclerosis
Case Description: A 58-year-old, right-handed man with a history of Multiple Sclerosis presented to our clinic with complaints of pain, weakness, and tingling in the right upper extremity. He denied any recent trauma, speech or swallowing problems, infections, or symptoms in the contralateral extremity. A recent MRI of the C-spine showed central disc protrusion causing left-sided cord deformity from C4-C7 and brain MRI showed extensive cerebral white matter pathology consistent with MS. On exam, pain was elicited on ranging of the right shoulder. Fromnet’s sign was positive with notable thenar and hypothenar atrophy of the right hand. Electrodiagnostic study was performed to determine the cause or origin of pain. After an extensive electrophysiological evaluation, conventional lesions of the peripheral nervous system were not readily identifiable.
Discussions: Multiple Sclerosis is characterized as a demyelinating disease of the central nervous system. In rare cases, however, electrodiagnostic findings suggest that peripheral nerve pathology can occur. There are several documented cases that describe such findings for patients with a history of multiple sclerosis. EMG results obtained from this patient were inconsistent with a right-sided ulnar, median, or radial neuropathy, brachial plexopathy, cervical radiculopathy, motor neuron disease, myopathy, or peripheral neuropathy. Such findings may be caused by, but not limited to: altered supernormality, post-infectious inflammatory polyneuropathy manifestations, ventral root demyelination, peripheral nerve demyelination, and factors associated with advanced MS such as malnutrition, cytotoxic drugs, or hereditary factors. This case provides further evidence that the myelin in peripheral nerves of patients with MS can indeed be affected and should be noted.
Conclusions: While EMG is commonly performed to rule out other causes of neuropathy, it is worthwhile to consider the possibility of peripheral nerve findings when evaluating patients with a history of MS.
Nutritional Status on Dysphagic Patients Who Died in Hospital
Mitsumasa Yoda, MD, PhD; Kyoko Sato; Nobuyuki Kawate, MD, PhD
Objectives: Our hospital is an acute care facility with 1014 beds. Dysphagia rehabilitation is discussed on ward rounds conducted by a multidisciplinary team including a physiatrist, a dentist, a dental hygienist, a nurse, and a dietitian. This multidisciplinary team is generally providing care for more than 40 dysphagic patients. Despite these efforts, some of patients die in hospital. This study aimed to determine the factors predicting death in dysphagic patients.
Design: 337 in-patients with dysphagia under the care of the multidisciplinary team between January and December 2014 were retrospectively investigated by reviewing their medical records. The clinical characteristics of the patients who died in hospital were analyzed.
Results: A total of 45 patients died in hospital. The underlying diseases varied; the most common were respiratory inflammatory diseases (n = 15). Twenty-two patients died due to the progression of an underlying disease such as malignancy. More than half of patients died due to deterioration of their general conditions in relation to complications such as pneumonia. The mean serum albumin levels at the start of intervention for those who died (2.3±0.5g/dl) were significantly lower (p < 0.01) than for the 70 patients who achieved sufficient oral intake after the start of intervention (2.8±0.6g/dl). After the intervention, the mean serum albumin levels for those who died decreased to 2.0±0.4g/dl, whereas the mean serum albumin levels for those who achieved oral intake increased to 3.2±0.6g/dl.
Conclusions: The results of the present study showed that most mortalities were attributable to deterioration of general condition including nutritional status rather than to fatal diseases such as malignancy and severe stroke. The dysphagic patients who died had been suffering from malnutrition even after the intervention, suggesting the importance of nutritional intervention.
Oncological Etiology of Hip Pain without History of CA
Eduardo Chen, MD; Kevin Trinh, MD; Emily N. Gray, MD; Craig H. Rosenberg, MD
Case Diagnosis: After osteoporosis, metastatic disease is the most common cause of pathological fractures. 60% of patients with identifiable primary tumor may already have metastasis. 61% of all pathological fractures occur in the femur. Our patient presents with isolated worsening left hip pain for the past 5months that was not related to an inciting event. A comprehensive history and physical was performed in order to investigate pain that did not match imaging that ultimately led to the diagnosis of a metastatic pathological femur fracture.
Case Description: 67 year old Caucasian female initially sent for pain management evaluation secondary to persistent left hip pain that had been progressively worsening over the past 5 months. Symptoms began in early 2015 without a clear inciting event. Hip pain was refractory to conservative measures including acupuncture, steroid taper x2, muscle relaxants and oral analgesics. Initial x-ray of the hips showed mild bilateral hip degenerative changes. Pain was described as an ache, 7/10 on VAS, located in the left gluteal/inguinal/ proximal anterior thigh region. She reported that she was not able to bear weight on the left lower extremity. Described pain as worse with activity and improved with rest. She denied any associated bowel or bladder incontinence.
On physical exam, pain was provoked with PROM of the left hip; passive right hip IROM was limited and elicited significant concordant pain in the left in gluteal region. Strength 3-/5 left HF was limited by pain. Special tests included SLR, Fabers, Gaenslens and Yoemans, which were all negative. Gait and station was antalgic, and she ambulated with a RW. The patient was subsequently scheduled for a left intra articular hip injection. She was sent for a MRI of the left hip prior to injection to evaluate for a possible labral tear. MRI results showed a pathologic left femoral neck subcapital fracture and a tumor.
Core biopsy revealed an adenocarcinoma consistent with primary lung cancer. CT C/A/P revealed an irregular right upper lobe mass, highly suspect for primary pulmonary malignancy, mediastinal and right hilar lymphadenopathy. Pt subsequently underwent left proximal femur arthroplasty and she was discharged to acute inpatient rehabilitation where she tolerated therapy well. She was subsequently discharged to home.
Discussions: Diagnosing hip pain can be a challenge as its presentation can result from multiple etiologies. A study by Decroisette reports that lung cancers can commonly metastasize to bone. As for our patient, despite her not having a history of primary malignancy, workup revealed an oncological etiology for her hip pain. Missed hip fracture on radiograph is estimated at 3-4%, and up to 9% in some cases. Intra articular hip injection in a missed hip fracture has been rarely reported in literature. To our knowledge, one case was reported in 2015 after a stress fracture of the femoral neck. Due to the inhibition of bone healing, it is contraindicated to perform corticosteroid injections in the presence of a joint fracture. As in our case, this was avoided with the proper workup. Not all cases of hip pain are related to arthritis, other differential diagnoses should be considered in patients with minimal radiograph of OA.
Conclusions: The etiology of hip pain can come from many different sources, which makes it imperative to perform a thorough H&P/PE. We hope this case highlights the importance of proper history and exam in order to avoid misdiagnosis, delayed treatment of CA and unnecessary/contraindicated procedures (intra articular injection).
Oropharyngeal Muscular Dystrophy in a 32 Year Old Female: A Case Report
Michael A. Bush-Arnold, MD; Dale Strasser, MD
Case Diagnosis: Oropharyngeal Muscular Dystrophy in a 32 year old female: A Case Report
Case Description: A 32 year old female with no past medical history and a strong family history in her father and great grandfather of oropharyngeal muscular dystrophy presented to an outpatient clinic with muscular pain, fatigue, and occasional dysphagia. Muscular pain was associated with activity and located in the bilateral thighs and calves. Physical exam was pertinent for weakness in the orbicularis oculi and proximal bilateral lower extremities of 4+/5 strength. The patient was referred for genetic testing and tested positive for 13GCN repeat allele in PABPN1 gene. The patient’s symptoms have progressed over the past three years to worsening ptosis, increased bilateral upper extremity weakness of 4+ to 5-/5, bilateral lower extremity weakness of 4 to 4+/5, and worsening dysphagia. She currently walks with a cautious gait and using a Lofstrand crutch on her right side.
Discussions: Oculopharyngeal muscular dystrophy is caused by mutations in PABPN1 gene and is characterized by muscle weakness that normally begins after age 40. The disease is common in the French Canadian population of Quebec. The initial presenting symptom is ptosis followed by dysphagia. The disease progresses to proximal muscle weakness particularly in the upper legs and hips and may require an assistive device for ambulation. Most cases of oculopharyngeal muscular dystrophy are inherited in an autosomal dominant pattern resulting in a PABPN1 protein with an expanded polyalanine tract between 12 and 17 alanines as in this patient.
Conclusions: Clinicians should have a high clinical suspicion of oropharyngeal muscular dystrophy in individuals with a strong family history and test for the disease earlier.
Osteoporosis and Compression Fractures in a patient with Both Ulcerative Colitis and Ankylosing Spondylitis: A Case Report
Joshua Minori, DO; Edward Park, MD
Case Diagnosis: Patient with both ulcerative colitis (UC) and ankylosing spondylitis (AS) develops complications of osteoporosis.
Case Description: The patient was a 58 year old male who presented to clinic complaining of whole spine pain that began in his twenties. He had a history of diabetes, hypertension, ulcerative colitis (UC), ankylosing spondylitis (AS), osteoporosis and polyarticular joint pain. Chart review revealed thoracic compression fractures at age 48, dual-energy x-ray absorptiometry (DXA) T-score −3.12 and Z-score −2.7 at age 50, and bilateral sacroiliitis on imaging at age 53. Initial work up showed DXA T-score −2.5 and Z-score −1.9, negative human leukocyte antigen B27 (HLA-B27) and estimated sedimentation rate of 60. He was referred to Rheumatology and Endocrinology for management of spondyloarthropathies and chronic symptomatic osteoporosis.
Discussions: AS is prevalent in 4-10% of patients with inflammatory bowel disease (IBD). Both conditions are associated with a high risk of osteoporosis and subsequent fractures. The overall incidence of low bone mineral density (BMD) has been estimated to be as high as 42% in IBD and 62% in AS. In AS, anteroposterior DXA is limited in monitoring osteoporosis due to syndesmophyte formation and often shows pseudo-improvement of T and Z scores. AS is diagnosed by a history of inflammatory back pain with imaging showing signs of sacroiliitis. Early diagnosis is difficult because of the slow onset of bony changes, nonspecific laboratory findings and an inconsistent association between AS and HLA-B27. However, clinicians should be aware that there is a high frequency of osteoporosis in early disease stages as defined by < 10 years from onset to avoid delayed diagnosis and treatment.
Conclusions: Physiatrists who frequently see patients with chronic back pain must be aware of the correlation between UC and AS and the risk for osteoporosis so that debilitating and life altering complications can be prevented.
Outcome Measures of Benign Versus Malignant Cancer Patients in an Acute Inpatient Rehabilitation Facility
Ashish Khanna, MD; Giuseppe Amore, MPH, CPH; Wali Jahangiri, BS; Yulia Rivelis, BA; Adrian Cristian, MD; Marc K. Ross, MD
Objectives: To compare the outcomes of benign and malignant cancer patients in an Inpatient Rehabilitation Facility (IRF)
Design: Five year retrospective chart review of 144 inpatient rehabilitation patients admitted for cancer diagnoses, of which 42 were benign and 102 malignant.
Results: The types of benign neoplasms consisted of 91% CNS, 7% bone/soft tissue, and 2% hematological. The types of malignant neoplasms consisted of 43% CNS, 17% GI, 15% bone/soft tissue, 9% lung, 4% each urogenital and hematological, 3% each breast and endocrine, 1% each skin and immunological. The average age was 58.22 for benign cancer patients and 65.87 for malignant. Average admission Functional Independence Measure (FIM) scores were 54.98 for benign and 57.34 for malignant. FIM gains were 22.69 and 16.27, respectively. Length of stay (LOS) was 17.05 days for benign, and 15.34 for malignant. FIM efficiency was 1.71 for benign and 1.42 for malignant. Discharge placement for both groups were home (benign 64.3%, malignant 55.9%), subacute nursing facility (benign 14.3%, malignant 11.8%), subacute (benign 9.5% and malignant 5.9%), and 2% expired in the malignant group.
Conclusions: The most common type of neoplasm for both benign and malignant cancers was CNS in origin. The average ages were analogous. Benign and malignant cancer patients had similar outcomes in LOS, admission FIM, FIM gain, and FIM efficiency. Discharge placement was also similar, except that malignant patients had more than double the rate of acute discharge. This research demonstrates that those patients admitted to an IRF with malignant cancers can be expected to make similar functional gains at a similar rate as those with benign cancers and have similar placements post-discharge. Increased surveillance may be warranted for the malignant patients, however, given the increased rate of acute discharge.
Outcomes of Acute Rehabilitation on Patients Undergoing Hemo-Dialysis
Raj D. Murthy, MD, MPH; Hossam Adham, MD; Adrian Cristian, MD; Jemmry Pantin
Objectives: Evaluate co-morbidities, complications, discharge destinations and functional independence measure (FIM) of acute rehabilitation on patients undergoing Hemo-Dialysis (HD).
Design: Retrospective study.
Results: The average age of HD-patients was 64.5 years, while the average age of non-HD-patients was 69 years. The Mean FIM scores on admission were 63.8 for HD-patients and 60.11 for non-HD-patients. The Mean FIM scores on discharge were 78.6 for HD-patients and 81.08 for non-HD-patients. The mean total FIM gains were 14.4 for HD-patents and 20.97 for non-HD-patients. Of the FIM gains, HD-patients had cognitive gains averaging 4.2 and motor gains averaging 11.12. Non-HD-patients had cognitive gains averaging 5.22 and motor gains averaging 15.74. Length of stay for HD-patients was 15.4 days, and non-HD-patients was 16.4 days. 54% of HD-patients were discharged to the community, while 62% of non-HD-patients were discharged to the community. HD-patients had an acute discharge rate of 24%, while non-HD-patients had an acute discharge rate of 15.1%. Reason for acute discharge of HD-patients included: Gout, New onset A-fib, Sepsis, Mediastinal Biopsy, Trans-metatarsal Amputation and EKG changes.
Conclusions: Compared to non-HD patients, those patients undergoing HD had lower FIM gains particularly in the motor domain, as well as in the cognitive domain. They also had shorter length of stay and a higher rate of acute discharge. This research demonstrates that HD patients admitted to acute rehabilitation make functional gains and can be discharged to the community. However due to the complexity of their medical illness, they require longer length of stay, very close monitoring and an individualized and tailored program while undergoing rehabilitation. Physical rehabilitation of patients on HD is more complex due the severity of their illness, but adoption of routine counseling and encouragement of physical rehabilitation has the potential to improve physical functioning, optimize quality of life and the overall health of dialysis patients.
Painful Garrod’s Nodes
Edward A. Dolomisiewicz, MD; Christopher J. Forster, MD; Aaron W. Pumerantz, DO
Case Diagnosis: Dorsal Dupuytren’s nodules, sometimes described as Garrod’s nodes, are subcutaneous fibromatoses overlying the dorsal proximal interphalangeal (PIP) joints. These lesions are usually painless, and if severe, may interfere with extensor tendon function in the hand. We report a case of an active duty service member who presented with progressively painful Dupuytren’s nodules.
Case Description: A 34 year-old Caucasian female Navy aviator was referred for nonsurgical management for multiple tender nodules involving the PIPs of her hands. MRI axial T1 fat suppressed post contrast revealed increased signal and enhancement most notable over extensor surface of 5thPIP joint, consistent with fibromatoses. An extensive rheumatologic evaluation was performed, and after other diseases were excluded, she was diagnosed with Garrod’s nodes associated with Dupuytren’s disease. She deferred invasive treatments in favor of topical and oral analgesics.
Discussions: The prevalence of Dupuytren’s disease in the United States is estimated to be 3 per 10,000 adults in a population-based study. Most of these patients did not see a physician until 23.1 months after symptom onset and only 9% received a diagnosis of Dupuytren’s. Almost half were advised to “wait and see” or received no treatment. This information suggests that patients are not receiving an accurate diagnosis with subsequent timely interventions that may affect long-term outcomes. Treatment involves maintenance or restoration of hand function, or in this case, pain management. The level of disability and impact on quality of life should be used to guide the therapeutic approach.
Conclusions: This case highlights an atypical presentation of painful Garrod’s nodes associated with Dupuytren’s disease. Unfortunately, the underlying pathophysiology remains unclear and therefore definitive interventions preventing disease progression are currently unavailable. Moreover, early diagnosis and treatment is important in order to maintain optimal hand function and to screen for other disabling disease manifestations which may interfere with quality of life.
Paraneoplastic Necrotizing Myopathy Secondary to Nasopharyngeal Cancer
Tony C. T. Lo, DO, MS; Bi-Ying Yeh, MD; Kenten Wang, DO, MS
Case Diagnosis: Paraneoplastic necrotizing myopathy secondary to nasopharyngeal cancer
Case Description: A 58-year-old, previously healthy Chinese female presented with profound, progressive proximal muscle weakness, becoming unable to walk, swallow or hold her head up within weeks. Creatine kinase level was elevated to 11513 U/L. Steroids and methotrexate were started for suspected polymyositis. Although creatine kinase improved to 422 U/L, she failed to make significant gains in inpatient rehabilitation. Muscle biopsy revealed atrophy and necrosis with no inflammatory infiltration. Symptoms of nasal congestion refractory to medications eventually led to the discovery of nasopharyneal basaloid squamous cell carcinoma. After radiation and chemotherapy were initiated her strength improved with exercise therapy.
Discussions: Necrotizing autoimmune myopathy (NAM) belongs to the family of inflammatory myopathies, including polymyositis and dermatomyositis. NAM similarly presents with symmetric proximal weakness, but is distinguished by the histologic appearance of marked necrosis and the predominance of macrophages rather than inflammatory cells. Although nasopharyngeal carcinoma has been associated with dermatomyositis, its link with necrotizing myopathy is unknown. The effectiveness of exercise therapy in down-regulating inflammatory genes in other myopathies is well-described in literature but not in NAM. In our patient, CK levels significantly improved after undergoing exercise therapy and medical treatment. Our patient’s gains were likely limited initially by her underlying malignancy, but she regained enough strength to ambulate short distances after addressing the cancer and undergoing further rehabilitation, demonstrating the benefits of exercise therapy.
Conclusions: Though the link between nasopharyngeal carcinoma and necrotizing myopathy is not well-understood, suspicion should remain high for malignancies. More aggressive workup is indicated in patients who do not improve. Although there is little evidence supporting physical therapy in NAM, studies have demonstrated safety and effectiveness of exercise in other inflammatory myopathies. We presume a similar effect in NAM once underlying causes are addressed, though further research should be done to validate this point.
Parsonage-Turner Syndrome: An Unusal Presentation of Acute Unilateral Upper Extremity Pain and Weakness
Yogen Patel, DO; Joy Bhat, MD
Case Diagnosis: A 76 year-old-female presented with 2 day history of acute onset of right upper extremity pain, weakness and numbness.
Case Description: The patient felt like her weakness was progressively getting worse; now having difficulty lifting the arm. She denied any recent trauma, overuse or illnesses. Given concern for a possible stroke, CT head without contrast was completed and negative for any acute intracranial abnormality. Radiculopathy was ruled out with CT of the cervical spine. Given physical exam findings of proximal muscle weakness, MRI of the right shoulder was performed which revealed diffuse edema involving the supraspinatus, infraspinatus, and proximal deltoid without atrophy and the patient was diagnosed with Parsonage Turner Syndrome. The patient was referred to outpatient physical therapy for range of motion exercises and strength training. With the use of modalities such as TENS, she noted 80% improvement in pain and proximal muscle weakness over the following month.
Discussions: PTS is a rare inflammatory disorder of the brachial plexus of unclear pathophysiology with an incidence of 1.64 cases per 100,000 people. Many patients have reported an inciting event such as infection, surgery, pregnancy, exercise, or vaccination. It usually presents with acute onset of shoulder girdle pain that progresses to weakness and numbness. Diagnosis is usually made clinically; however, detailed electrodiagnosis and imaging can help confirm the diagnosis. In 97% of cases, the suprascapular nerve is involved. Therefore, the most frequently involved muscles are supraspinatus and infraspinatus followed by deltoid. Treatment is focused on pain management. Modalities such as TENS and acupuncture along with physical therapy have shown to improve functional outcomes.
Conclusions: Parsonage-Turner Syndrome should be considered in the differential for someone with acute onset of unilateral upper extremity pain and weakness when the diagnosis is unclear. Early diagnosis can help guide pain management and physical therapy to improve functional outcome.
Patellar Subluxation Following Below Knee Amputation
John R. Frampton, MD; Shanti M. Pinto, MD; Mary Ann Miknevich, MD
Case Diagnosis: Patellar subluxation following below knee amputation.
Case Description: Patient is a 48year-old female with history of right transtibial amputation (Syme’s procedure) performed when 5years-old due to neurofibromatosis who presented to our amputee clinic with knee pain associated with use of her patellar-tendon-bearing (PTB) endoskeletal prosthesis which she had used for the past two years. She was noted to have knee pain, patellar instability and patellar suluxation on physical exam likely as a result of years of prosthetic use. She had been seen by an orthopedic surgeon who recommended surgical correction, which she hoped to avoid. She was subsequently fitted with a new prosthesis with modified high supracondylar and suprapatellar trim lines which resolved her problems with patellar subluxation and knee pain while improving ambulation and forgoing surgical correction.
Discussions: Patellar instability and subsequent subluxation is the result of abnormalities in knee joint geometry, limb alignment, ligamentous stability and muscle strength. Individuals with below knee amputations and long-term use of PTB type prosthesis are at greater risk for developing patellar instability associated with patella alta, shallow trochlear notch and hypoplasia of the patella due to the added stress on the patellar tendon. This is particularly true when the amputation was performed in childhood. These is poor evidence guiding best practices in management of chronic patellar instability (Level –IV) in regards to conservative vs operative therapy, especially as it relates to below knee amputees. Only one similar case report was found describing successful outcomes in preventing chronic patellar dislocation by simple prosthesis modification rather than surgical intervention.
Conclusions: Chronic patellar instability is often seen in individuals with below knee amputations and evidence regarding management is lacking. Few case reports discuss prosthesis modification in relation to patellar instability indicating the need for increased awareness of this problem and potential solution.
Piriformis Syndrome Confirmed by NCS, with H Reflex Prolongation during the FAIR Maneuver
Reza Taher, MD; Wilson J. Chang, MD; Michael Fediw, MD; Michael Larson, MD; S. Kamal Fetouh, MD; Julie Larson, MD
Case Diagnosis: Piriformis Syndrome confirmed by NCS, with H reflex prolongation during the FAIR maneuver
Case Description: This is a sixty year old female who presented to the pain clinic with chief complaint of left buttocks pain, with radiation posteriorly into the left thigh. Buttocks pain was burning and intermittent in nature. Pain was exacerbated with prolonged sitting and ambulation, and made better with stretching exercises and analgesics. Physical examination included a positive FAIR and Mirkin tests. Workup included NCS which illustrated asymmetry in H-reflexes with abnormality in the left lower extremity while patient was in FAIR position.
Discussions: Following conservative management including NSAIDs, formal physical therapy which was followed by steroid injection into the left piriformis muscle, patient had improvement in her pain symptoms, function, quality of life, and increased ambulation distance without pain.
Conclusions: Piriformis syndrome was originally described by Dr. Robinson in 1947. Believed to be responsible for up to 8% of cases of low back and buttocks pain, with or without radiation down the ipsilateral lower limb. A common misconception is that piriformis syndrome is merely pain in the muscle itself, which from trauma or strain can happen in any muscle in the body. Piriformis syndrome is irritation or hypertrophy of the piriformis muscle that in turn can cause compression/irritation of the Sciatic nerve. Many prominent MSK doctors disagree on the existence of piriformis syndrome. This case sheds light on the importance of a good history and physical examination which can further be supported by NCS with objective findings and recording including H reflex prolongation during the FAIR test beyond 1.86 msec of the mean in the clinical diagnosis of Piriformis syndrome.
Point-of-Care Ultrasound in the Diagnosis and Management of Inflammatory Enthesitis in an Adult with Osgood-Schlatter Disease: A Case Report
Robert Diaz, MD; Minna J. Kohler, MD
Case Diagnosis: Inflammatory Enthesitis in Osgood-Schlatter Disease
Case Description: A 27 year-old female with an adolescent diagnosis of Osgood-Schlatter disease (OSD) presented to a tertiary musculoskeletal ultrasound clinic with a 2-month history of bilateral infrapatellar knee pain and swelling requiring intermittent cane use. Six months ago, she had a right fractured tibia managed conservatively. She recently experienced recurrent urinary tract infections (UTIs) prior to the onset of acute bilateral knee pain.
Physical exam revealed warmth over the right pre-tibial region and tenderness over bilateral tibial tuberosities/ patellar tendon insertions without joint effusions.
MRI of her right knee revealed subacute nondisplaced tibial fracture extending to the tibial spine and tibial tuberosity, and chronic patellar tendinopathy with fragmentation of the tibial tubercle. Per her orthopedic surgeon, MRI findings suggested healed fracture and did not explain her current symptoms.
Point-of-care ultrasound examination of her bilateral infrapatellar knees demonstrated bilateral infrapatellar enthesopathy; and hyperemia along her right bony ossicles correlating with patient’s maximal pain, consistent with inflammatory enthesitis. Differential diagnosis included reactive arthritis and reactivation of OSD.
Treatment included prednisone taper and aggressive bilateral knee physical therapy. She is now walking without assistive devices.
Discussions: OSD is a cause of knee pain in adolescence typically diagnosed clinically and confirmed on plain radiographs. Reactivation of OSD in adults is rarely reported. The use of ultrasound for evaluation of apophysitis, enthesopathy, and hyperemia has been described as a useful adjunct to confirm OSD in adolescents, however there are no studies describing the use of ultrasonography in adults with OSD; patient’s infectious history raises concern for possible inflammatory reactive arthritis.
Conclusions: OSD can lead to significant morbidity and disability in adolescence and early adulthood if management is sub-optimal. Ultrasound may be helpful in differentiating mechanical from inflammatory-associated pain, potentially changing treatment management. Further studies evaluating the value of ultrasound in these patients are needed.
Polymositis: A Case Report of the Interplay of Disease Severity and Iatrogenic Disability
Daniel A. Goodman, MS, MD; Toledo Santiago, MD
Case Diagnosis: 39-year-old female with polymyositis
Case Description: Patient is 39-year-old female with steroid-dependent polymyositis and pulmonary fibrosis who initially presented with proximal limb weakness, diffuse pain, and dyspnea leading to successive diagnoses of fibromyalgia, seronegative rheumatoid arthritis, and mixed connective tissue disorder. She was started on oral prednisone and ultimately diagnosed with polymyositis 1 year later after a muscle biopsy. Multiple steroid-sparing medication treatments failed over the course of the next 5 years and she remained on oral prednisone. Prolonged corticosteroid use and reduced mobility led to multiple side effects including obesity, osteoporosis, and bilateral cataracts. She was diagnosed with obesity-related obstructive sleep apnea requiring nocturnal CPAP and she underwent bilateral cataract surgeries. Her obesity and osteoporosis were implicated as the cause of multiple skeletal complications, including bilateral hip osteoarthritis, and 4 foot fractures as well as degenerative spine changes including cervical and thoracic spine disc protrusions with central and foraminal stenosis and L5-S1 spondylolisthesis with radiculopathy. She received corticosteroid injections in both hips, microdiscectomy at L5-S1, and multiple surgeries for right 3rd and 4th metatarsal fractures and 2 sequential left 5th metatarsal fractures. The patient has been non-weight bearing on the lower extremity for the majority of the last 2 years and unable to perform her real estate agent duties.
Discussions: Her chronic limitations due to poor mobility, poor endurance, and dyspnea are further complicated by additional impairments including weakness, non-weight bearing limb, and obesity, which are related to prolonged use of corticosteroids. Chronic corticosteroid side effects led to a cascade of complications and functional decline superimposed on accentuated functional deficits secondary to her primary disease process leading to compounded disability.
Conclusions: Iatrogenic adverse effects from chronic use of corticosteroids can lead to worsening disability in steroid-dependent inflammatory diseases and should be considered in refractory cases, such as this one of polymyositis.
Posterior Dislocation of a Total Knee Arthroplasty using Cruciate Retaining Prosthesis during Rehabilitation: A Case Report
Matthew G. Hadilaksono, DO; Ana M. Garcia, MD
Case Diagnosis: Posterior dislocation of a total knee arthroplasty
Case Description: This case presents a 75 year old obese female who underwent an elective left total knee arthroplasty due to severe tri-compartmental osteoarthritis with valgus deformity. Non-Constrained (cruciate retaining) design prosthesis was used in this procedure. By post-op day #2, patient was transferred to the inpatient rehabilitation floor and began a course of physical therapy. On post-op day #7, patient had developed spontaneous left lower extremity pain and swelling. Left knee x-ray revealed posterior total knee dislocation. Patient was immediately brought back to the OR for an emergent closed reduction under anesthesia. Post reduction, patient was placed in a knee immobilizer and was given non-weight bearing status to the left lower extremity. Patient continued to demonstrate some swelling of the left lower extremity and was eventually taken back to the operating room for a total knee revision.
Discussions: Total knee arthroplasty (TKA) dislocation is a relatively rare complication. The incidence has been estimated to be around 0.15–0.5%. TKA dislocations may occur with any of the prosthesis designs that are available, but usually it is more common in the posterior cruciate ligament (PCL) retaining design. Neurological and vascular compromise should be assessed in this situation. An immediate reduction of the dislocated knee is indicated. Patient should also be evaluated for possible further revision.
Conclusions: Rehabilitation of total knee replacement may occasionally be complicated with knee dislocation. Although it is a rare occurrence, awareness and recognition of this complication during rehabilitation process is crucial in order to avoid further neuro-vascular complications.
Posterior Interosseous Neuropathy Following Intravenous Line Placement
Aaron J. Yang, MD; Eric P. Sturos, MD
Case Diagnosis: Posterior Interosseous Neuropathy
Case Description: A 40 year old male with a past medical history of Type 1 Diabetes Mellitus presents to the electrodiagnostic clinic with a chief complain of a right wrist drop. States approximately 2 weeks prior, he was admitted to the hospital with elevated blood sugars and during hospitalization, he had an intravenous line placed into the ventral right forearm. Shortly after, he had swelling that involved his entire forearm and fingers that was followed by weakness with wrist and finger extension. He was soon discharged from the hospital with residual weakness and was advised that his symptoms would resolve within a few days. The swelling in the forearm and hands eventually resolved after few days after discharge. He continued to have persistent symptoms and went to his primary care clinic after 2 weeks and was urgently referred to the electrodiagnostic clinic for further work up. At the time of presentation, he continued to complain of right wrist and finger extension weakness with pain along the right forearm. He denied any associated numbness. He stated this situation was causing great distress in his life due to his job working customer service at a computer company and could not type or have full function of his right hand. In addition, he was taking classes at the university and was finding it difficult to complete his assignments. Regarding the remainder of his medical history, he was diagnosed with Diabetes 13 years ago and is currently taking Metformin. He denies any other significant medical or surgical history except hernia repair. Focused physical examination revealed a well nourished male in no apparent distress. Inspection was notable for symmetric muscle bulk in the forearm and hand. There was no tenderness to palpation along the bilateral upper extremities. Manual muscle testing was notable for full strength in the extremities except for right wrist extension of 4/5 and finger extension 2/5. Sensation was intact in the extremities and reflexes were symmetric and present. Electrodiagnostic testing confirmed the presence of a severe, axonal, posterior interosseous neuropathy on the right as well as a mild, large fiber polyneuropathy consistent with his prior history of Diabetes. Patient planned to follow up with his primary care provider and start physical and occupational therapy.
Discussions: Posterior Interosseous Neuropathy (PIN) is a pure motor branch of the radial nerve which supplies the extensor carpi ulnaris, abductor pollicis longus, and finger and thumb extensors of the hand. Entrapment neuropathy most often occurs at the radial tunnel or at the Arcade of Frohse. Other reported causes of PIN include fractures of the forearm, lipomas, hematomas, and ganglion cysts. Patients usually present with finger and thumb extension weakness with a mild wrist drop. Patients are able to extend their wrist with radial deviation due to weakness of the extensor carpi ulnaris muscle. Patient’s may have pain in their forearm as the nerve does have deep sensory fibers that supply the interosseous membrane. Diagnosis is usually made with electrodiagnostic studies in which radial motor studies may show reduced amplitude in the extensor indicis proprius muscle. Needle electromyography is the most helpful to demonstrate denervation in the muscles innervated by this nerve. Treatment consists of anti-inflammatories, splinting, and focuses exercises. With progressive weakness or failed treatment after 3–6 months, surgery should be considered. Kaplan found that 80% of patients with PIN had resolution of symptioms at 5 years when treated conservatively.
Conclusions: This was an unusual case in that due to IV infiltration and subsequent forearm swelling, the patient may have suffered a PIN due to compression of this nerve either at the Arcade of Froshe or the radial tunnel. As the swelling resolved, the patient continued to have residual deficits due to his PIN.
Post-Operative Hematoma Resulting in Airway Compromise after Anterior Cervical Spine Surgery
Janice Lau, BS; Tony C. T. Lo, DO, MS; Michelle Thai, MD
Case Diagnosis: Post-operative hematoma after cervical spine surgery
Case Description: A 76-year-old female with history of upper extremity DVT and metastatic breast cancer presented for rehabilitation after undergoing an uncomplicated anterior cervical decompression and fusion surgery for cervical stenosis. Three days after surgery, she was restarted on therapeutic anticoagulation for her history of DVT. A week later, she complained of dyspnea and imaging revealed a retroesophageal hematoma resulting in airway compression. The hematoma was immediately evacuated and the patient recovered successfully, making functional gains exceeding her initial evaluation.
Discussions: Post-op airway obstruction due to hematoma is serious complication of anterior cervical spine surgery with an incidence of 0.2–1.9%. Because of its rapid onset, narrow timeframe for intervention, and difficult location for airway control, cervical hematomas are potentially life-threatening. Chemoprophylaxis after spinal surgery is controversial because of the need to weigh the risks of a life-threatening pulmonary embolism against fatal hemorrhages. Spine surgeries done through an anterior approach have a higher incidence of VTE. Additionally, patients with malignancies are known to have increased risk for developing VTE. Thus, it becomes imperative to anticoagulate this population. However, there are no clear guidelines as to when therapeutic or prophylactic anticoagulation should be started. Although most surgeons begin chemoprophylaxis within three days, less is known about the timing for therapeutic anticoagulation. As noted in our case, one must be vigilant in monitoring hematoma formation after beginning anticoagulation treatment. Signs of hemorrhage include drainage, trachea deviation, and swelling of anterior neck and submandibular region. Alternatively, superior vena cava filters may be used, however, its benefit and safety remains questionable.
Conclusions: Post-operative hematoma resulting in airway compromise is a life-threatening complication of anterior cervical spine surgery. Anticoagulation should be started in high-risk patients with close monitoring for hematoma development in the rehabilitation setting. Further studies are needed to determine optimal periods for beginning anticoagulation in high-risk groups.
Prism Therapy for Pain and Distorted Body Awareness in an Orthopedic Patient: A Case Report
Pavli S. Demian, DO; Cristin McKenna, MD, PhD
Case Diagnosis: Left Hip Pian and Gait Dysfunction
Case Description: 57yo female presents with chronic left hip pain and gait dysfunction. She states, “Sometimes I don’t know where my left hip is.” She had multiple bilateral hip surgeries since childhood due to congenital hip dysplasia. She had bilateral hip replacement with several revisions. Her left hip at this time is a DuPuy hip which was found later to leach cobalt and chromium. Hip pain at presentation was described as aching, shooting, throbbing, sharp, burning, numb, continuous, worst: 9/10, best: 2/10, exacerbated by: standing, sitting, walking, carrying. Patient presented for management of pain on the left hip and desire to improve ambulation. She also wanted to minimize oral medication. Wearing goggles fitted with wedge prisms she performed repetitive upper and lower body line-bisection exercises. She experienced changes in both pain and body awareness immediately pre and post-treatment as measured by Likert scale. Changes in body awareness and pain lasted about 24 hours and were reproducible over a time period of months of daily prism treatment. She increased her community ambulation.
Discussions: Visual-spatial neglect is a failure to attend to or respond to stimuli on the side opposite of a brain lesion. The effect of chronic pain and change in anatomy secondary to multiple surgeries on brain remodeling in a developing brain compared to injury to an adult brain has not been explored. The patient’s description of remarkably “neglect-like” symptoms in her left hemibody along with a chronic pain condition in a limb and desire to avoid medication proided a confluence of medical conditions for which prism therapy, used in both neglect and pain, could have clinical benefit.
Conclusions: Use of prism for co-existing disorders of body perception and pain offers a low-risk intervention which may affect pain and increase body awareness.
Prognostic Indicators of Functional Recovery in Patients with Brain Tumors
Meghan E. Cochrane, DO; Eric Leung, MD; Heidi Fusco, MD
Objectives: In the US, 74,000 new cases of brain tumor are diagnosed annually and create barriers to functional independence and quality of life. Patients with brain injury from neoplasm undergoing acute rehabilitation have demonstrated equal improvements in recovery as traumatic brain injured patients. Few studies have evaluated prognostic indicators and modifiable risk factors for outcomes in brain tumor patients; however, several have shown that severity at presentation, tumor type, presence of pain, and radiation affect recovery and outcome. Objectives of our study: to evaluate rehabilitation outcomes for patients with brain injury from tumor in a tertiary rehabilitation center and to identify prognostic indicators for favorable rehabilitation outcomes based on initial presentation and tumor-related comorbidities.
Design: This is an IRB approved retrospective review of 93 patients admitted to an acute rehabilitation facility from 7/2012-7/2014. Demographics, admission and discharge FIM, discharge location, social demographics, tumor type, tumor location, treatment history, and various comorbidities were evaluated. 66 patients met inclusion criteria of admission to acute rehabilitation secondary to brain tumor.
Results: FIM data reflected positive gain in all areas, averaging 28.4 FIM gain per patient. Linear regression with FIM motor change demonstrated independent prognostic indicators for favorable rehabilitation outcome, including younger age (every increase in 20 years decreased FIM motor change by 5), surgical resection (no surgery decreased FIM by 12), and tumor type (primary brain tumors decreased FIM by 10). Although not statistically significant, bivariate analysis showed chemotherapy, radiation, antidepressants, and high relative risk were suggestive of unfavorable outcome. Initial presentation with high functionality, headache, and pain were suggestive of favorable outcome.
Conclusions: Acute inpatient rehabilitation for brain tumor patients yields functional improvement. Younger age, surgical resection, and metastatic tumors are independent prognostic indicators for favorable rehabilitation outcome. Future studies with larger sample size should ensue to identify other prognostic indicators predictive of favorable rehabilitation outcomes.
Prophylactic Ulnar Transposition Efficacy: A Case Report and Literature Review
Richard C. Swedarsky, DO; Matthew Miller, MD; Walter J. Faillace, MD
Case Diagnosis: Left ulnar neuropathy at the elbow secondary to a gunshot
Case Description: 30 year old male, shot in left arm in May 2014, had surgical repair of distal humeral fracture in Europe. After the repair, symptoms of ulnar neuropathy were present. Physical exam in October 2014 revealed an ulnar claw hand, decreased sensation in ulnar distribution and no finger abduction at ring and little finger. Electrodiagnostic findings showed severe left ulnar axonal injury and ultrasound evaluation showed focal flattening of the nerve around scar tissue and a subcutaneous transposition. The patient underwent an exploration of his ulnar nerve in December 2014, the ulnar nerve was freed from scar tissue and then placed in a new submuscular bed. An end-to-end anastomosis of the anterior interosseous nerve was also performed. Follow up in May 2015 showed improvement with increased motor activity in flexor digiti minimi and adductor digiti minimi; reinnervation of ADM was seen on a limited EMG study.
Discussions: This patient had a subcutaneous prophylactic transposition due to an orthopedic injury. He has had weakness and numbness since time of injury without any improvement. Scar formation was appreciated in Ultrasound and intraoperatively. The patient underwent neurolysis and a submuscular transposition. Current literature for submuscular vs. subcutaneous ulnar transposition for compression mediated ulnar neuropathy shows that the two are equivocal, however in more severe cases submuscular transposition is preferred as less strain on the nerve is generated during the procedure; however submuscular transposition has a higher tendency to lead to scar tissue formation. A more advantageous option would be an in-situ decompression as the risks are greatly decreased and efficacy of the procedure is not significantly different than transposition. Additionally, prophylactic transposition, when discussed in relation to elbow contracture release, a consensus is for the patient to be symptomatic or to have positive electrodiagnostic findings before considering a prophylactic ulnar decompression or transposition. Furthermore, ulnar transposition to prevent neuropathy has been suggested only for a severe deformity. Here we show ultrasound and electrodiagnostic studies proving scar tissue formation leading to ulnar neuropathy after a subcutaenous transposition, and intraoperative findings eliciting other adverse effects of the procedure.
Conclusions: Prophylactic ulnar transposition should only be entertained if severe deformity occurs due to trauma, tumor or other etiologies. If the procedure is being sought, the patient should be evaluated to see if either symptoms or electrodiagnostic findings are present. Submuscular transposition causes less stress on the nerve, however if the surgeon is not adequately trained scar tissue has a higher chance of forming.
Propranolol for the Treatment of Tacrolimus-Induced Tremors in a Rehab Patient: A Case Report
Joseph W. Frye, DO; Venerando Batas, MD
Case Diagnosis: Tacrolimus-induced tremors
Case Description: A 73 year old male 17 months status post bilateral orthotopic lung transplantation was admitted to acute inpatient rehab after a prolonged severe Clostridium Difficile infection. Upon admission the patient exhibited significant resting and intention tremors that worsened over the initial course of his rehab. His anti-rejection therapy included prednisone, azathioprine and tacrolimus. The patient’s tremors significantly impaired his rehab progress in activities of daily living. He required minimal assistance for feeding, grooming and bathing and maximal assistance for dressing. At that point, a literature search was completed for treatment options related to tacrolimus-induced tremors. A single case report was identified which successfully utilized propranolol at 10mg every eight hours for tacrolimus-induced tremors in a single lobe orthotopic lung transplantation patient in acute rehab. After obtaining consent from the patient, a trial of propranolol was instituted for possible improvement in tremors and subsequent optimization of rehab. At the time, the patient’s medication regimen included metoprolol 25mg every twelve hours for hypertension. This was discontinued and changed to equivalent dosing of propranolol 20mg twice daily. After approximately 36 hours, the patient reported subjective improvement in his tremors. Two weeks after initiating propranolol, the patient’s functional status had improved to stand by assistance for feeding and grooming, and minimal assistance for dressing and bathing. At discharge 1 week later, the patient was stand by assistance for feeding, grooming, dressing, and minimal assistance for bathing. Three months after discharge, a chart review revealed that the patient’s anti-regection regimen was changed by his transplant team and tacrolimus was discontinued. Subsequently, the patient’s tremors resolved and propranolol was discontinued.
Discussions: Tacrolimus is a macrolide antibiotic with immunosuppressive qualities via calcineurin inhibition. One of the most widely reported side effects of tacrolimus is tremor. Tacrolimus and calcineurin binding proteins have been identified in central and peripheral nerve tissue and it is believed that binding of these proteins causes sympathetic hyperactivity. Propranolol functions as a beta adrenergic receptor antagonist and is widely used for treatment of essential tremor. Research on the effects of propranolol has found that, in addition to blockage of peripheral beta receptors, it also likely functions as a central depressant and this may explain its tremor-mitigating effects. There are currently no studies that examine the efficacy of propranolol for tacrolimus-induced tremors, however, one case report identifying its utility does exist.
Conclusions: Tremors are a common side effect experienced by patients on immunosuppressant regimens that include tacrolimus. These tremors can significantly impair the recovery, and function of such patients. Propranolol appears to be an effective treatment option for tacrolimus-induced tremors in situations where tacrolimus must be utilized and cannot be discontinued. Continued research and potential clinical trials are warranted for further investigation into this treatment.
Prosthesis Use in a Patient with Osteogenesis Imperfecta and New Transfemoral Amputation
Bryndon B. Hatch, MD; Karen L. Andrews, MD
Case Diagnosis: Prosthetic fitting for patient with new transfemoral amputation and Osteogenesis Imperfecta (OI)
Case Description: 73 year old woman with peripheral vascular disease status post multiple revascularization procedures, osteoporosis, and OI with 13 fractures before age 4, but no further fractures until after menopause, presented with left lower extremity pain and fevers due to vascular graft infection spanning above to below the knee. TcPO2 levels at the popliteal artery and distal were < 30 mmHg two months prior, but at presentation had increased to 55 mmHg at the proximal foot with adequate healing for a distal amputation, but transfemoral amputation was indicated due to the graft infection. Physiatry was consulted by vascular surgery to evaluate whether she would be a candidate for use of a prosthesis safely due to OI and osteporosis. We reassured the patient and the surgeons that we anticipated she would be a successful prosthetic user and educated her about the postoperative recovery. She had delayed wound healing that prevented prosthetic fitting for five months. She underwent prosthesis fitting and training without fracture or other complications (more follow up data will be available by time of AAP conference) with an anticipated K2 ambulation level.
Discussions: OI is a congenital bone disorder caused by deficiency in or abnormal Type I Collagen, leading to abnormal bone formation, predisposing to pathologic fracture. The severity of the disease can be highly variable.
In this case, the patient was determined to have Type I (mild) OI due to her history of only having fractures in early childhood and after menopause. Although literature on lower limb prosthetic use in patients with OI is extremely limited, case reports showed good recovery for patients with OI undergoing joint replacement surgeries. Due to her milder form of OI, she was expected to be a successfully use a prosthesis.
Conclusions: Prostheses use is possible in patients with milder forms of Osteogenesis Imperfecta.
Rare Case of Flatbush Syndrome as a Cause of Critical Illness Polyneuropathy
Carrie McShane, MD; Clinton Faulk, MD; Joshua Brown, MD; Siena Ona, MD
Case Diagnosis: Flatbush Syndrome leading to Critical Illness Polyneuropathy.
Case Description: 21 year old female with a two month history of polyuria and polydipsia presented to the hospital with vomiting and loss of consciousness. She was found to have a blood glucose level of 961 and an anion gap of 37.2. She was treated for diabetic ketoacidosis (DKA), respiratory failure, septic shock requiring steroids and vasopressors, disseminated intravascular coagulation, and multiple organ dysfunction syndrome requiring hemodialysis. Blood cultures were positive for methicillin-sensitive staphylococcus aureus. Remaining work-up for the source of sepsis included lumbar puncture, abdominal ultrasound, computed tomography scan chest/abdomen/pelvis, and echocardiogram. All imaging was negative for infection. She was noted to have global weakness. After treatment in our Level One Trauma Center intensive care unit, she was admitted to inpatient rehabilitation for critical illness polyneuropathy (CIP). She was originally thought to have undiagnosed type 1 diabetes. However, anti-glutamic acid decarboxylase antibodies were negative. She did not require supplemental insulin. Endocrinology service was consulted again and diagnosed her with Flatbush Syndrome.
Discussions: Flatbush Syndrome, or ketosis-prone type 2 diabetes, is a rare disease that usually affects middle-aged patients. Patients with Flatbush Syndrome do not have a past medical history of diabetes. After a time of stress, they typically present to the hospital with a blood glucose level around 600 and require treatment for DKA. Only half of patients will require insulin after an episode of DKA.
Concussions: The patient’s proximal weakness improved with therapies and close monitoring for systemic inflammatory response syndrome. Her bilateral toe necrosis from peripheral vasopressors was treated with open-toed orthotics. At discharge, she was independent in ambulation and activities of daily living after completing inpatient rehabilitation. Physicians should be aware of Flatbush Syndrome as a source of sepsis that may result in CIP and subsequently require extensive rehabilitation.
Rare Case of Late Onset Central Hypoventilation Syndrome (Ondine’s Curse): A Case Report
Ana M. Garcia, MD; Matthew G. Hadilaksono, DO; Sanjeev Agarwal, MD; Tariq Hilal, DO; Tsai Chao, MD
Case Diagnosis: Late onset central hypoventilation syndrome (Ondine’s Curse).
Case Description: 57-year-old female with PMH of well controlled DM and HTN developed a sudden onset of respiratory failure. She was intubated and was treated in the ICU. After extubation she was able to breath with effort during the day and unable to breathe while sleeping. She was eventually discharged with a CPAP machine at home to assist breathing at night and was referred to rehab for pulmonary rehabilitation and diaphragm strengthening exercise program. After further examination and careful assessment the possibility of late onset central hypoventilation syndrome, previously known as Ondine’s curse, secondary autonomic dysfunction of the phrenic nerve was considered. After a course of pulmonary rehabilitation and diaphragm strengthening exercise program the patient showed improvement in her breathing patterns and ventilatory function.
Discussions: Congenital central hypoventilation syndrome, previously known as ‘Ondine’s Curse’, most commonly presents in neonates. Late onset cases are well described up to the age of 10 years with only two cases documented of adult onset central hypoventilation syndrome. This condition should be considered when adults present with unexplained respiratory failure and/or nocturnal hypoventilation. Current therapy focuses on achieving normal gas exchange, primarily through mechanical ventilation accompanied by a pulmonary rehabilitation program.
Conclusions: Early identification of central hypoventilation and initiation of appropriate ventilation strategies can help to improve outcomes associated with congenital central hypoventilation syndrome (“Ondine’s Curse”).
Raynaud’s Phenomenon Leading to Dry Gangrene
Kunj G. Patel, MD, MSC; Dale Strasser, MD
Case Diagnosis: Recurrent Discitis
Case Description: A 41 year old female was admitted to the acute rehabilitation hospital for autoimmune sensory ganglionopathy related to lupus. She had been diagnosed with lupus in 2004, and suffered from Raynaud’s phenomenon, for which she was taking amlodipine. She was also taking high dose prednisone (30mg daily) and hydroxychloroquine for her autoimmune conditions, as well as carvedilol for HTN. Social history was significant for smoking 1/2 packs daily. Her rehabilitation course was progressing as expected when she suddenly presented a beefy and erythematous distal tip of her left index finger which was cold and numb, suggestive of ischemia. Further questioning revealed that she had a history of developing felons and she experienced minor trauma to the finger the week before. Rheumatology consultation advised daily betadine and outpatient follow-up. However, over the next couple days, the patient continued to develop worsening of the digit until the distal portion ultimately turned black in color and began to emit a foul odor, suggesting necrosis and dry gangrene. Orthopedic consultation was obtained and eventually the digit was amputated.
Discussions: Raynaud’s phenomenon is a common condition which causes blood vessels to spasm, restricting blood flow to the fingers. When it is secondary to an autoimmune condition (e.g. lupus) it is associated with more severe restriction of blood supply and carries a higher risk of causing complications such as ulcers, scarring, and gangrene. Management of early ischemic changes consists of avoidance of cold temperatures, stress, caffeine, nicotine, beta blockers, and treatment with vasodilators and calcium channel blockers. Such approaches have been shown to avoid amputation in up to 86% of patients.
Conclusions: Raynaud’s phenomenon can lead to severe ischemia and dry gangrene, for which early conservative management is often successful. However, some cases still require partial amputation of the digit.
Real-World Walking Patterns Provide Unique Insight over Functional Walking Outcomes Following Lower Limb Amputation
Quinn Tate, Bart Gillespie, DPT; Krista O’Connor, PT, DPT; Teri Chou, PhD; Bradeigh Godfrey, DO
Case Diagnosis: Depression and cognitive deficits in transfemoral amputee with history of TBI.
Case Description: A 53 year old right handed man suffered a traumatic brain injury and multiple orthopedic injuries resulting in a staged right transfemoral amputation following a pedestrian versus automobile accident. He was admitted to inpatient rehabilitation for 8 weeks where he participated with physical, occupational, and speech therapy. Prior to discharge home he was prescribed Modus Trex System (MTS), a wearable device that tracks ambulation patterns. At the initial outpatient visit with PM&R the MTS was placed on his prosthesis. Regular outpatient therapy included ambulation training and decreasing assistive device use. At the one-week follow up, the patient independently recognized the need to be more active after seeing the MTS data. At three weeks he showed great improvement in activity levels. However, by week 6 the data revealed community ambulation had declined. In contrast, the therapists reported continued improvement in functional abilities and gait mechanics. When questioned, the patient reported symptoms of depression, insomnia, and difficulty concentrating. Changes were made to his treatment plan to address this. Without MTS demonstrating a drop in real-world activity, the patient’s worsening depressive symptoms may have gone unnoticed.
Discussions: Quantitative analysis of daily activity during the early phase of rehabilitation for new amputees provides insight into the patient’s transition to community life, and a tool for the patient to set personal goals. Potential limitations include the need to download the data to a computer with the necessary software. This patient will continue to utilize the Trex system during his outpatient rehabilitation process.
Conclusions: The utility of recording and analyzing daily ambulation data to verify progression early in the rehabilitation process deserves further evaluation.
Recurrent Discitis in the Acute Rehab Setting: A Case Report
Kunj G. Patel, MD; Lauren Hutts, BS; Chaz Fausel, MD; Dale Strasser, MD
Case Diagnosis: Recurrent Discitis
Case Description: A 67 year old female was admitted to the acute rehabilitation hospital for T4 Asia B spinal cord injury (SCI) secondary to spinal cord infarction. Prior to her SCI, she had T5-6 discitis due to methicillin sensitive staphylococcus aureus (MSSA), and a history of four failed left knee replacement surgeries, complicated by MSSA infection. She had completed a 16 week course of IV antibiotics prior to her arrival, and while at rehab initially demonstrated excellent participation in physical therapy and decreasing requirement of pain medications. However, after the first week, she suddenly began experiencing increasing back pain. She did not appear acutely ill, and her vitals and labs were unremarkable. Over the next couple days, her pain progressed despite aggressive medication adjustments, and she failed to tolerate physical therapy. A CRP and ESR were ordered, which returned >380 and 76, respectively—a significant increase from preadmission levels of 11 and 37, respectively. IV antibiotics were restarted, and blood cultures were obtained. Repeat imaging showed worsening discitis T3-T6 with 2 right paraspinal muscular abscesses and significant circumferential epidural phlegmon T2-T7. Blood cultures grew MSSA.
Discussions: Discitis is a serious and rare condition which can cause significant neurological injury. Frequently, discitis presents without any systemic signs, leukocytosis, or superficial signs of infection (present in only 10% of cases). Back pain and ESR/CRP elevation are the most consistent abnormalities seen in cases of diskitis. Blood cultures are positive in only one third to one half of cases, and recurrence of infection occurs in 2-8% of patients.
Conclusions: Clinicians should have a low threshold to test for inflammatory markers (ESR, CRP) in patients with a history of discitis who have sudden unexplained back pain—even in the absence of the usual physical or laboratory signs of infection.
Rehab of Fluctuating Cerebellar Ataxia and Dementia in the Setting of Non-Vasculitic Autoimmune Inflammatory Meningoencephalitis
Justin Choi, MD; Martin Wice, MD
Case Diagnosis: Nonvasculitic Autoimmune Meningioencephalitis (NAIM)
Case Description: A previously healthy 65-year-old man developed progressive ataxia for a year before developing a cognitive decline for three months. After a fall, he was hospitalized for left frontal and left posterior parafalcine subdural hematomas, along with facial fractures. He was admitted to rehabilitation for encephalopathy until he could tolerate further workup. After an extensive workup including EMG and brain biopsy, the patient was diagnosed with NAIM.
He returned to rehabilitation, and his second hospitalization was punctuated by fluctuant periods of functional gains relative to pulsed steroid infusions. At his worst, he could not sit unsupported, feed himself, and was minimally verbal. After infusions, he was able to transfer with minimal assistance, ambulate with a wheeled walker, feed himself, and speak in simple sentences. Collaboration between the rehabilitation team and the neurology team guided immunomodulatory treatment and a transition to high dose oral steroids. This made it possible to advance the patient’s functional progress despite his devastating pathology.
Eight months later, he is a household ambulator and has increasing awareness of his deficits.
Discussions: NAIM’s progressive presentation can mimic such clinical entities as Creutzfeldt-Jakob Disease, Hashimoto’s encephalopathy, and Sjogren’s encephalopathy. Its treatable and reversible nature makes diagnosis especially important in the rehabilitation setting should patients arrive with otherwise inconclusive etiologies.
Conclusions: Nonvasculitic autoimmune meningioencephalitis is a rare clinical entity. A Pubmed query for this diagnosis yields seven results. It remains a diagnosis of exclusion, presenting as progressive ataxia and dementia that is responsive to immunomodulatory agents. If diagnosed early, symptoms can be reversible. If diagnosed late, as in this case, symptoms can plateau at a relatively low functional level. Early diagnosis of NAIM can facilitate efficient use of healthcare resources in rehabilitation as well as improve clinical outcomes.
Rehabilitation and Spasticity Management of Tropical Spastic Paraparesis
Frank Jackson, DO; Venessa Lee, MD; Alexandra Flis, MD
Case Diagnosis: This case report describes the rehabilitation and spasticity management of a patient with tropical spastic paraparesis.
Case Description: A 71 year-old male with a history of tropical spastic parapareis (TSP) was admitted to an academic acute inpatient rehabilitation unit with significant spasticity and deficits in transfers, endurance, activities of daily living, and mobility. He was infected with Human T-cell lympotrophic virus type 1 (HTLV-1) in Guatemala in 1976. He began developing symptoms of TSP in 1999. This progressed to difficulties rising from a chair, climbing stairs and carrying heavy objects while walking. In 2007 he presented to Neurology clinic where he was diagnosed with TSP.
On admission to acute inpatient rehabilitation, nighttime oral baclofen was trialed for significant lower extremity spasticity but caused sedation. Due to oral baclofen failure, he underwent an intrathecal baclofen (ITB) trial with significant improvement in spasticity. During an interruption in his acute inpatient rehabilitation admission, an ITB pump was placed by Neurosurgery. The dose was further titrated on acute inpatient rehabilitation.
Discussions: HTLV-1 infection is typically encountered in Central and South America as well as in Japan and Africa. There is limited literature describing the rehabilitation of TSP and to the authors knowledge nowhere has described the management of spasticity in this population. The patient in our case twice failed oral baclofen treatment for spasticity but did tolerate ITB therapy. He demonstrated significant improvement in function with ITB therapy and provides evidence for the efficacy of this modality in the spasticity management of patients with TSP.
Conclusions: TSP affects the function of patients in worldwide locations typically underserved with acute inpatient rehabilitation and ITB therapy. In this case we described the benefits of acute inpatient rehabilitation and ITB therapy in a patient with TSP.
Rehabilitation in the Intensive Care Unit after Total Artificial Heart Placement: A Case Report
Ann H. Lichtenstein, DO; Miguel Escalon, MD, MPH
Case Diagnosis: 58 year old male with a history of familial non-ischemic cardiomyopathy status post total artificial heart placement. Post operative course complicated by respiratory failure with tracheostomy and ventilator dependence, renal failure requiring hemodialysis, and sepsis awaiting heart and kidney transplant.
Case Description: Rehabilitation was consulted to manage patient’s mobilization while on the ventilator. Upon initial assessment, patient had an arterial line, central venous catheter, and chest tube. Muscle strength testing revealed 4/5 strength in the bilateral upper and lower extremities except for absent ankle dorsiflexors and extensor hallicus longus bilaterally. Electromyography showed decreased anterior tibial activation and gastrocnemius activity most likely secondary to critical illness myopathy. Serial casting was implemented for plantar flexion contractures. While in the ICU, the patient was able to ambulate 80 feet utilizing a thoracic walker with sitting breaks and moderate to maximum assistance of two persons.
Discussions: Patients in the ICU for prolonged periods may develop long-term physical and functional impairments due to immobility. Early intervention rehabilitation programs focusing on prevention of deconditioning, muscle loss, and contractures as well as improving respiratory status are vital for a patient’s recovery. ICU rehabilitation requires a well-coordinated team composed of physicians, nurses, respiratory and physical therapists. This team working together can effectively mobilize critically ill patients, which may decrease length of stay in the ICU and improve patient’s quality of life after discharge.
Conclusions: The implementation of rehabilitation in the ICU setting is vital for the prevention of deconditioning. Mobilization of critically ill patients is possible by coordination of medical and rehabilitation teams. This collaboration is crucial as early rehabilitation as an intervention may speed a patient’s recovery.
Rehabilitation of a New Bilateral Amputee after Frostbite Injury: A Case Report
Katherine Power, MD; Se Won Lee, MD; Jeremy Roberts, BS
Case Diagnosis: Bilateral below-the-knee amputation (BKA) secondary to frostbite injury
Case Description: A 45 year old male with no significant past medical history was brought to an emergency room with cold painful lower extremities after falling asleep in a work truck the night before when the outside temperature was below freezing. After rewarming and allowing enough time for the tissue to demarcate the areas of non-viable tissue, he underwent bilateral BKAs. The below knee level was chosen due to the area of tissue injury and to allow for functional ambulation thereafter. After unremarkable post-operative course he was discharged to rehab to learn how to care for his residual limbs, perform transfers, and use a wheelchair for transportation. He was then discharged home to continue healing and to allow reduction of limb edema.
Social issues interfered with his ability to get proper prosthetic limbs at first but after some time he was able to quality for prostheses. Thanks to his years of playing soccer and his employment in manual labor, his body was fairly strong and fit. These factors and his need to continue to work in construction helped classify him as a K-3 level prosthetic candidate. As he was a bilateral amputee, his energy expenditure while ambulating would need to be higher. Furthermore, his prosthetic legs would require features such as exactly matching feet to allow for more natural ambulation.
Discussions: While bilateral amputations are sometimes seen secondary to trauma, frostbite is an uncommon cause offering unique challenges. This case demonstrates the importance of individualizing one’s treatment and rehabilitation plan.
Conclusions: Sustaining bilateral below-the-knee amputations due to frostbite is uncommon in this country but offers a unique rehabilitation scenario for a patient who is otherwise in good health to now be rehabilitated.
Rehabilitation of Anti-NMDA Receptor Encephalitis
Dara Jones, MD; Ryan Ramsook, MD; Anne Felicia Ambrose, MD, MS
Case Diagnosis: anti-NMDA receptor encephalitis
Case Description: A 31 year old woman with 2 month history of headache and progressive altered mental status was brought in with catatonia. Head CT and brain MRI were negative. An infectious workup revealed significant lymphocytosis both in the serum and CSF, but was negative for bacterial, viral and fungal etiology. CSF anti-NMDA receptor antibodies was positive. Whole body PET scan was negative for tumors. She was diagnosed as Anti-NMDAR Encephalitis and treated with IV acyclovir, IVIG, plasmapheresis and Rituximab. She regained consciousness but was severely agitated, confused and paranoid. She was admitted to the rehabilitation service where she was started on propranolol and olanzapine and steroids were tapered off. This, in combination with cognitive and behavioral remediation helped her make sufficient improvement to be discharged home 2 weeks later, oriented, appropriate, with improved judgment and at a modified independent level. Her antipsychotics were tapered off prior to discharge.
Discussions: Anti-NMDAR encephalitis is a relatively new condition which is characterized by prominent psychiatric manifestations of anxiety, agitation, delusions and neurologic manifestations of memory deficits, seizures, and dyskinesias. Infectious work-up, brain imaging, and EEG are often negative. CSF typically demonstrates lymphocytic pleocytosis or oligoclonal bands. Diagnosis is confirmed by the presence of IgG antibodies to N1 subunit of NMDAR in serum or CSF. Tumor resection and immunosuppression can improve outcomes but rehabilitation efforts are often thwarted by psychiatric symptoms. However, careful and limited use of anti-psychotics can improve patient’s mood, behavior and cognitive functioning, giving the patient a chance to be rehabilitated successfully.
Conclusions: Anti-NMDAR encephalitis is a serious life threatening condition with psychiatric, neurologic and cardiovascular manifestations with a prolonged, often difficult course. However, it can respond to rehabilitation efforts if managed appropriately.
Rehabilitation of Concurrent Transverse Myelitis and Acute Inflammatory Demyelinating Polyradiculoneuropathy
Frank Jackson, DO; Suleiman Lapalme, MD; Jeffrey Rosenbluth, MD
Case Diagnosis: This case report describes the diagnosis, treatment, and rehabilitation of a patient with concurrent transverse myelitis and acute inflammatory demyelinating polyradiculoneuropathy (AIDP).
Case Description: A 30 year-old man was admitted to an academic acute inpatient rehabilitation unit with tetraplegia and deficits in transfers, mobility, and activities of daily living. Prior to this, he had been admitted to two community hospitals. He initially presented to the first hospital with complaints of left lower extremity weakness, was diagnosed with transverse myelitis, and received a course of steroids. However his weakness progressed to include all four extremities so he was transferred to the second hospital where he was diagnosed with AIDP. He was administered additional steroids as well as a course of intravenous immunoglobulin. On admission to acute inpatient rehabilitation Neurology was consulted due to his nebulous diagnosis. Electrodiagnostic studies were performed demonstrating nerve conduction abnormalities of the nerve roots and peripheral nerves. Imaging from the outside hospitals was reviewed, and in conjunction with the nerve conduction study results he was diagnosed with concurrent transverse myelitis and AIDP.
His admission functional independence measure (FIM) score was 47. While admitted to acute inpatient rehabilitation, he was given additional intravenous immunoglobulin as it was felt his prior course was insufficient; he was monitored and tolerated treatment. He made functional gains during a 43-day admission and his discharge FIM score was 63.
Discussions: Tetraplegia may be the consequence of either central or peripheral nervous system dysfunction. Demyelination of the central and peripheral nervous systems are generally thought to occur as separate disease processes. Scant literature describes co-occurring transverse myelitis and AIDP, and to the authors knowledge nowhere has detailed the rehabilitation course.
Conclusions: Transverse myelitis and AIDP are generally considered to be separately occurring disease processes. Here we describe the diagnosis, treatment, and rehabilitation of co-occurring disease.
Rehabilitation of Guillain-Barre Syndrome Tetraplegia Complicating Pre-Existing Congenital Deaf Mutism: A Case Report
Svetlana Abrams, DO; Lisanne C. Cruz, MD, MSC; Jeffrey Fine, MD
Case Diagnosis: Guillain-Barre Syndrome Tetraplegia Complicating Pre-existing Congenital Deaf Mutism
Case Description: 57 year old male with childhood sensorineuronal hearing loss and mutism, communicating via American Sign Language (ASL), lip reading and limited writing in Spanish. The patient developed tetraplegia due to Guillain-Barre Syndrome that prevented ASL communication and resulted in gluteal pressure ulcers. He was admitted to our hospital based Inpatient Rehabilitation Facility (IRF) for interdisciplinary rehabilitative treatments, evaluations for appropriate DME and environmental control devices, wound management, therapeutic counseling for adaptation to new impairments and family education. OT manufactured custom head pointing device and mounted icon based communication boards at the bedside within his functional pointer envelope. Head switch call bell permitted prompt contact with nursing staff. This provided respite for ASL speaking family members who previously remained nearly continuously at bedside for interpretation. Pressure ulcers healed, toileting schedule prevented functional incontinence. Family members learned ergonomic techniques for bed mobility and transfers and were instructed regarding appropriate use of DME. Appropriate custom wheelchair and cushion were provided. Patient was successfully and safely discharged home to family.
Discussions: Our patient had an unusual combination of congenital and acquired impairments that produced unique challenges for him and his family. He was previously able to communicate his needs by utilizing his hands but after developing tetraplegia this communication option was no longer possible. This clinical presentation coupled with limited family financial resources created additional challenges that were creatively overcome.
Conclusions: Individualized patient care provided by resourceful interdisciplinary inpatient Rehabilitation team, particularly in the setting of profound impairments, can have a significant positive impact on patient and caregiver quality of life.
Rehabilitation of Severe Bilateral Leg Lymphedema
Naveed H. Butt, MD; Muhammad Danish Saleem, MD; Rummana Aslam, MD
Case Diagnosis: A case with lymphedema and chronic leg ulcers treated successfully in our clinic
Case Description: 59 y/o obese man with h/o bilateral leg swelling since adolescence which progressively got worse. He presented with grade 3 lymphedema, pachydermia and large weeping foul smelling ulcers despite 7 months of 3x/week hydrotherapy with wound care. We devised a management plan to treat symptoms by treating the underlying problem- namely the lymphedema. A dressing for ulcers with a 4 layer short stretch compression bandage covered with self-adhering wrap to secure the bandage was used. This was changed daily initially and then thrice weekly. As the patient demonstrated improvement (calf circumference 52cm), a weekly zinc based non elastic layer of compression was added. The pachydermia was treated with lymph pads. Effective edema control was demonstrated by dry bandages, no drainage and no odor between consecutive dressings. He was educated throughout on his condition, treatment and exercise plan. Ulcers healed in 2 months and edema improved in 4.5 months (circumference 42 cms) and a compression pump once daily was added to the treatment. Patient’s behavior has changed from hopelessness and despair to happy, compliant and motivated. He walks daily and has started consultation for weight loss surgery.
Discussions: Patients with lymphedema and ulcers require a multidisciplinary plan including physical medicine, wound care and medical care. Main aim is to correct underlying disorder i.e. lymphedema while at the same time managing secondaryproblems including chronic ulcers, difficulty walking, cellulitis and sepsis. A common mistake made is management of ulcers and cellulitis without addressing the primary underlying cause which is lymphedema.
Conclusions: Chronic ulcers with lymphedema impart an enormous psychological, physical and financial burden on patients. Patient tailored management for lymphedema, exercise, weight loss, education and rehabilitation will ensure a successful outcome in ulcer healing, restoring function, patient satisfaction and quality of life.
Reliability of Two Novel Metrics to Assess Function in the Acute Care Hospital Setting by Nurses and Physical Therapists in Adult Neurosciences Patients
Kara Shumock, DPT; Erik H. Hoyer, MD; Julie Kreif, PT, MBA; Michael Friedman, PT, MBA
Objectives: Bed-rest and immobility in the acute hospital setting has been associated with hospital-acquired complications and there is growing research to support the benefits of early mobility to improve patient outcomes. Towards this goal is it necessary to have outcome measures that assess functional impairments and mobility status, determine patients’ progress during hospitalization and help to develop a multidisciplinary plan of care. Although physical therapists (PT) specialize in functional mobility, the majority of mobilization in acute care is nurse (RN) driven. Currently there are no functional metrics that are routinely used by both PTs and RNs in daily inpatient care that are reliable, feasible and valid. Our goal in this study was to investigate the inter-rater and test-retest reliability of two novel mobility assessment tools currently used by nurses and physical therapists at the Johns Hopkins Hospital, the Johns Hopkins Highest Level of Mobility (JH-HLM) and the inpatient short-form of the Activity Measure for Post Acute Care (AM-PAC). Here we studied these metrics in a neurosciences inpatient population because they are frequently admitted for evaluation of falls, dizziness, abnormal gait and/or weakness or are status-post neurosurgical procedures that may result in impaired mobility as a post-operative sequelae.
Design: This study was conducted over 5 study-sessions between May 29 and June 26, 2015 on two 34-bed inpatient neurosciences units in a large teaching hospital. A mobility-event consisted of one RN (mobility RN) assessing the patients mobility potential and mobilizing the patient to the highest level on the JH-HLM scale they felt comfortable with. During the mobility-event an observer RN and observer PT were also present. After the mobility-event, the 3 study participants independently scored the patient on the JH-HLM and AM-PAC scales and served to measure the inter-rater reliability. Each study-session consisted of a morning and afternoon mobility-event and served to measure test-retest reliability. The JH-HLM is an ordinal scale to record achievement of mobility milestones and ranges from bed rest (score=1) to ambulating ≥250 feet (score=8). The AM-PAC is a 6-question functional assessment tool to measure the burden presented by mobility limitations in activities such as sitting down and standing from a chair or walking in the hospital room. Inter-rater and test-retest reliability was calculated with Intra Class Correlations (ICC), where an ICC of ≥0.6 was considered good and an ICC ≥0.7 was considered excellent.
Results: 118 neurosciences patients participated in 213 total mobility-events and in 68 patient study-sessions consisting of both morning and afternoon mobility-events. Patients had a mean (SD) age of 56.6 (15.5) years, 55% were female, 59% were Caucasian, mean LOS was 10.9 (11.8) days, and 40% were medicare beneficiaries. The most common diagnosis categories were patients after spinal surgery (25%), after craniotomy (24%), with stroke/brain injury (9%), with nervous system infection (7%), and patients with multiple sclerosis or a degenerative nervous system disorder (6%). For inter-rater reliability, the ICCs between mobility RN and observe RN and observe PT was 0.86 (95% CI, 0.83-0.89) and 0.90 (95% CI, 0.88-0.92) for the AM-PAC and JH-HLM scales, respectively. For test-retest reliability, the ICCs between the morning and afternoon mobility-events as scored by the mobility RN were 0.88 (95% CI, 0.82-0.93) and 0.68 (95% CI, 0.56-0.80) for the AM-PAC and JH-HLM scales, respectively.
Conclusions: The JH-HLM and AM-PAC are reliable assessment tools of mobility milestones and mobility impairments for an adult inpatient neurosciences population. Establishing the psychometric properties of multi-disciplinary functional assessment tools has the potential to have a broad impact in direct patient care. Future studies should investigate whether these results are generalizable to other patient populations.
Renal Cell Carcinoma and Paraneoplastic Weakness
Ingrid Yang, MD; Danny Bega, MD, MSCI; Steven Nussbaum, MD
Case Diagnosis: Weakness as a Paraneoplastic Syndrome in Renal Cell Carcinoma
Case Description: A 61-year-old female with Type II Diabetes presented with several days of urinary retention and inability to ambulate in the setting of one-year of progressive lower extremity weakness and 100-pound weight loss. She described weakness in the proximal left leg, then right leg, and bilateral hands, and numbness and tingling in her feet. On exam, she had weakness and atrophy throughout the proximal lower extremities and intrinsic hand muscles. Sensation was diminished in her feet. Lower extremity reflexes were absent. Catheterization revealed 2 liters of retained urine. Spinal tap revealed total protein 175 and 1 WBC. Cytology and paraneoplastic panel were negative. EMG/NCS demonstrated a chronic length-dependent sensorimotor polyneuropathy with demyelinating features with diffuse fibrillations in the lower extremities, possible CIDP or lumbar plexopathy. CT demonstrated a 1.2 cm right renal parenchymal mass. Partial nephrectomy confirmed clear cell renal cell carcinoma. She was placed on steroids and then once-weekly IVIG treatment and discharged to a skilled nursing facility for rehabilitation. One month following resection, she still required intermittent catheterization, but with improving urinary urge and was modified independent with rolling walker for household distances.
Discussions: Paraneoplastic symptoms are estimated to occur with RCC in 10-40% of patients, but these are often endocrine or neuroendocrine abnormalities rather than neurologic symptoms. Paraneoplastic neuropathy with RCC has been described in case reports, although the pathological basis is unknown and the electrophysiologic features are not well described. In this case, demyelinating features and albuminocytologic dissociation pointed toward CIDP, but autonomic involvement raised suspicion for painless diabetic amyotrophy, and some features on EMG resembled a plexopathy.
Conclusions: Paraneoplastic weakness in RCC is rare and electrophysiologic features are variable. This case considers the possibility of RCC causing a paraneoplastic weakness with features of CIDP as well as lumbosacral plexopathy.
Resident Quality Improvement Project: Urgent Unplanned Discharges from an Inpatient Rehabilitation Facility (IRF)
Dmitriy Dvoskin, MD; Liju John, MD; Deanna Holtman, NP; Margaret A. Turk, MD
Objectives: IRFs admitting patients with high medical acuity and case mix indices must manage unplanned patient discharges to higher levels of care. These discharges are unsurprising, but they disrupt patient flow and routine unit activities. The goal of a resident-driven Quality Improvement Project is to determine risk factors that can prospectively identify these patients, and to develop a monitoring strategy to protect patients at risk.
Design: A retrospective cohort (unexpected discharge from the IRF to acute care September 2014 through July 2015) had their Electronic Medical Record abstracted. Multiple variables were identified from published articles evaluating urgent discharges and 30-day readmissions. Scores of functional comorbidity index (FCI), Charlson comorbidity index (CCI), and Braden scale were determined. Reasons for discharge and discharge destinations were noted.
Results: There were 29 subjects with an average age of 65 years (38yr-88yr old). The most common Rehabilitation Impairment Category was Orthopedic Disorders. Proxies for increased complexity included previous acute length of stay (LOS) (17.4 days), average number standing medications (11.10), and IRF LOS (13.14 days). Average FCI was 5.2; most common identified comorbidities were Neurological Disease (18) and CHF/Heart Disease (18). Average CCI was 7.10; most common identified comorbidities were Solid Tumor non-metastatic (22), Cerebrovascular Disease (13), and Peptic Ulcer Disease (12). Reasons for discharge were surgical (12), higher medical (12), neurological change (3), psychiatric (1) and miscellaneous (1). Most common discharge destinations were telemetry/ICU (13), Orthopedic Floor (5), Pre-Op awaiting emergency surgery (4).
Conclusions: Common factors for patients at high risk for unplanned discharge from an IRF are high complexity of care, especially related to neurologic conditions, cancer, and cardiac disease. Further additional patient data collection and analysis using a case control approach will be used to identify patients at higher risk for potentially preventable unplanned discharge and to develop an intervention and monitoring plan.
Return to Play Post-Operative Rehabilitation Program for a Professional Football Athlete with Lumbar Radiculopathy
Laura M. Pilgram, BA; Matthew Matava, MD; Reggie Scott, BS, MS; Jacob Buchowski, MD, MS; Heidi Prather, DO
Case Diagnosis: Return to play post-operative rehabilitation program for a professional football athlete with lumbar radiculopathy
Case Description: A 24 year-old professional football athlete presented with LBP during preseason. Symptoms progressed despite conservative treatment. An MRI showed disc extrusion at L4-L5 and congenital central stenosis from L2 to L5. He elected to undergo microscopic discectomy and decompression. Immediately following surgery he reported reduced intensity in LBP and thigh pain. He had a new lumbar shift. Post-operative day 5 the athlete began rehabilitation by walking on an altered gravity treadmill at 50% body weight while self-correcting the shift using a mirror for guidance. Active neural glides designed to reproduce “stretch” sensation but avoid pain were performed. His lumbar shift corrected within 3 days and 2 weeks after surgery LBP and positive neural tension signs were eliminated. He progressed to full weight-bearing treadmill walking and biking and lumbar stabilization in frontal and sagittal planes. Retesting active range of motion provocation and neural tension signs before and after sessions was used to decide when to advance activities. This provided a mechanism to guide milestone achievement with the athlete as an active decision maker. Weeks 6–7 he sprinted at 60% progressing to 80% of bodyweight. Trunk rotation activities were introduced. Weeks 8–9 he began position-specific drills. He returned to play 10 weeks following surgery, completed the season and remains symptom free now one year following surgery.
Discussions: Post-operative rehabilitation for athletes with spine disorders with intent of return to play has not been well investigated or described. This case is one example of a rehabilitation protocol that allowed for successful return to play and maintenance of absence of symptoms one year following surgery.
Conclusions: This report provides a template for post-operative lumbar spine rehabilitation for athletes with milestones for return to play. Supported by AAP RREMS(LP).
Revision of Major Lower Extremity Amputation and Independent Ambulation at 12 Months
Rebecca A. Speckman, MD, PhD; Daniel C. Norvell, PhD; Joseph Czerniecki, MD
Objectives: To determine if amputation revision at the same or higher level is associated with independent ambulation 12 months after initial major dysvascular lower extremity amputation, and if the results depend on the initial amputation level.
Design: Two multisite prospective cohort studies were combined. Eligibility criteria included: 18 years or older, initial dysvascular lower extremity amputation (transmetatarsal (TM), transtibial (TT), or transfemoral (TF)). 12-month ambulation independence was self-reported and defined as ambulation without standby or physical assistance but allowing use of assistive devices to ambulate indoors, or outdoors on even or uneven surfaces. Adjusted relative risks were obtained using Poisson regression with robust standard errors. Models included amputation level, demographic characteristics, comorbidities, premorbid ambulation status, and interaction of amputation revision with level of initial amputation.
Results: 334 patients met study criteria, and 200 were subsequently enrolled. At follow-up 9 had withdrawn, eight were lost, one declined, and 25 died, leaving 157 participants. Twenty-two (14.0%) underwent an amputation revision at the same level, (5 TM, 13 TT, 4 TF), and 10 (6.4%) underwent a revision at a higher level (4 TM, 6 TT, 0 TF). 97 (62%) were independent in ambulation at 12 months (34 TM, 52 TT, 11 TF). Revision at the same or higher level was not associated with ambulation independence (unadjusted RR=0.86, 95% CI 0.58—1.29; adjusted RR=0.82, 95% CI 0.45—1.48 and unadjusted RR=0.95, 95% CI 0.56—1.60; adjusted RR=0.73, 95% CI 0.42—1.26, respectively). Any revision was also not associated with ambulation independence (unadjusted RR=0.89, 95% CI 0.64—1.24; adjusted RR=0.77, 95% CI 0.51—1.16). The effect of revision on ambulation independence did not depend on initial amputation level.
Conclusions: Amputation revision at the same or higher level is not associated with likelihood of future independence in ambulation. Studies with larger sample sizes are needed to explore this relationship further.
Rheumatoid Vasculitis Presenting with Numbness, Dysesthsias and an Inability to Ambulate
Emily A. Robbins, DO; Brian D. McMichael, MD; Jeffrey D. Lemberg, MD; Gerald Nora, MD, PhD
Case Diagnosis: Rheumatoid vasculitis presenting as sensory predominant polyneuropathy.
Case Description: MB is a 38 year-old independent woman with a history of poorly controlled rheumatoid arthritis who presented to the hospital unable to ambulate after suffering progressive numbness and dysesthesias in her extremities. Physical exam revealed left facial weakness, diminished sensation in left V2, V3, lower worse than upper extremity weakness, areflexia, dysmetria, profoundly impaired proprioception and diminished light touch and vibratory sensation in all four extremities. There was bruising over all four extremities due to bumping into objects at home.
Diagnostic work-up revealed positive RF, anti-cyclic citrullinated protein antibodies and borderline thiamine deficiency. Cerebrospinal fluid, paraneoplastic markers, Lyme, SS-A/SS-B antibodies, cryoglobulins and hepatitis panel were unremarkable. Sural nerve biopsy showed chronic degeneration and loss of myelinated axons with areas of perivascular reactivity containing mononuclear cells and T-cells, but no overt vasculitis. Serial NCS/EMG revealed absence of all SNAPs, motor conduction velocity and F-wave preservation, and decreasing CMAP amplitudes with development of fibrillations and sharp waves in 4/5 muscle groups.
MB was initially treated with IV thiamine and prednisone with slight improvement in sensation and strength but continued deficits in proprioception and ambulation. She was later given one dose of cyclophosphamide while inpatient for rheumatoid vasculitis. She was lost to follow-up.
Discussions: This case describes an atypical presentation of rheumatoid vasculitis. Classic findings for vasculitis on biopsy include necrotizing vasculitis with fibrinoid necrosis and a mononuclear inflammatory cell infiltrate. Despite the lack of necrosis in this biopsy, the serial EMGs are most concordant with a vasculitis as opposed to another diagnosis (e.g. dorsal root ganglionopathy).
Conclusions: The diagnosis of rheumatoid vasculitis should be considered in patients who have a history of rheumatoid arthritis and physical exam and NCS/EMG evidence of polyneuropathy, even if the histopathologic findings do not entirely meet the classic definition of the disease.
Rimabotulinum Toxin B (Myobloc) Injection for Focal Abdominal Skeletal Muscle Pain
Susan J. Kim, DO
Case Diagnosis: Right upper quadrant abdominal pain secondary to diabetic associated right thoracic radiculopathy vs. secondary to direct injury to the abdominal skeletal muscle itself
Case Description: 51 year old obese male with Hypertension, Diabetes Mellitus type 2, Hyperlipidemia and Lower Back Pain was referred to my clinic for right upper quadrant (RUQ) abdominal pain which started after the sigmoidectomy surgery for diverticulitis in 2008. He reports that the surgical abdominal wound was infected requiring several wash outs and the wound was eventually closed by secondary intention.
He underwent extensive work-ups by a Gastroenterologist. During the workup, choledocholithiasis was found and cholecystectomy was done in December 2010 which did not improve his RUQ abdominal pain. MRI of abdomen showed pancreatic divisum but without any evidence of pancreatitis.
Prior to coming to my clinic, he tried nonsteroidal anti-inflammatory drugs, opioid analgesics, antispasmodics and neuropathic pain medications such as tramadol and gabapentin without much improvement in RUQ abdominal pain. Also, local anesthetic injections with and without corticosteroid into RUQ abdominal scar and muscle tissues did not improve his pain.
10,000 units of Rimabotulinum toxin B (Myobloc) diluted in local anesthetics (total volume of 20ml) was injected at 15 to 20 different sites (1.5ml to 1ml at each site) throughout RUQ abdominal scar and skeletal muscle tissues under electromyography and ultrasound guidance (EMG/US). Patient was able to localize his most severe abdominal pain in the region where Complex Repetitive Discharges (CRDs) were heard on EMG during the injections. No other abnormal findings (i.e. Positive Sharp Waves or Fibrillation Potentials) were noted on EMG.
As he has diabetic distal symmetrical polyneuropathy affecting his bilateral lower extremities from 2011 Nerve Conduction Study (NCS), needle EMG testing was done in bilateral thoracic paraspinal muscles in October 2013 which did not show any abnormal spontaneous electrical potentials.
The Myobloc injections done in my clinic resulted in 50 to 70% abdominal pain reduction for 2 to 3 months from 2011 to 2012. The dose was cut down to 5,000 units in 2013 as there was carry over benefit from subsequent injections. Even with reduced dosage, he experienced 50 to 70% pain reduction. In addition, the benefit lasted longer from 3 months initially to 6 to 8 months after 3 years of receiving Myobloc injections. Thus, he now receives maintenance Myobloc injection twice per year.
His most painful region still correlates to the location where CRDs are heard on EMG during injections; however, CRDs are less frequently heard now than when Myobloc injection was first started in December 2011.
Discussions: The Complex Repetitive Discharges (CRDs) are bursts of recurrently firing complex muscle action potentials which start and end abruptly. It can be seen in chronic conditions of both myopathy and neuropathy.
Thus, the CRDs indicate that there were some injury to muscle fibers as CRDs originate from muscle fibers to muscle fibers and time linked (i.e. activated ephaptically) whether it be secondary to direct trauma or neuropathy affecting the muscle fibers.
In this particular patient, the past direct trauma/injury to right abdominal skeletal muscle itself is more likely based on history of infection in the region rather than as a consequence of right thoracic radiculopathy or rather right thoracic ventral rami involvement (focal neuropathy) from his diabetic associated condition.
In animal studies Botulinum toxins are shown to block substance P release (a neuropeptide involved with pain transmission) and reduce calcitonin gene-related peptide release, both of which can result in pain reduction. This is an independent mechanism than the pain reduction from the decreased muscle hyperactivity by blocking the presynaptic Acetylcholine neurotransmitter release at the Neuromuscular Junctions (NMJs).
Rimabotulinum toxin B (Myobloc) injections have been quite effective in reducing RUQ abdominal skeletal muscle pain in this particular patient.
Conclusions: Rimabotulinum toxin B (Myobloc) injection under EMG/US guidance is a clinically sound treatment option in patients with abdominal skeletal muscle pain who has failed oral pain medications (i.e. NSAIDs, opioids, neuropathic pain medication, etc.).
Myobloc is thought to have greater affinity for sympathetic nerve endings than Onabotulinum toxin A (Botox) and this can account for better pain control with Myobloc than Botox if the pain is sympathetic driven.
In future, it would be great to do comparison study of Myobloc vs. Botox injections to determine which particular toxin provides a greater benefit in this particular set of patient populations.
In addition, it would be nice to further explore the utility of Botulinum toxin injections for abdominal visceral associated pain control.
Role of Blink Reflex Study in Multiphasic Acute Demyelinating Encephalomyelitis: A Case Report
Juan Carlos. Perez, MD; Joanne M. Delgado, MD; Carmen Lopez, MD
Case Diagnosis: Acute Demyelinating Encephalomyelitis (ADEM) is an immune mediated inflammatory demyelinating disease of the central nervous system, affecting children usually in a monophasic multifocal manner. Multifocal ADEM stands at the juxtaposition of ADEM and multiple sclerosis (MS), making its diagnosis controversial. Currently MRI studies are considered important diagnostic tool in differentiating MS from ADEM, however iterature reports have proven the usefulness of electrodiagnostic (EDX) studies in helping with MS diagnosis, which raised the question of the utility of such studies in diagnosis correlation and prognosis in patients with multiphasic ADEM.
Case Description: 12 year old female previously diagnosed with ADEM nine months ago with no residual functional deficits presents with new onset neurological findings, including left hemiparesis and left facial paralysis. MRI studies showed interval development of demyelinating lesions of left hemipons and central pons/medulla oblongata. Patient was treated with high dose IV steroids and IVIG with clinical improvement of facial paralyisis and in lesser degree of left hemiparesis. Blink reflex studies performed three weeks after treatment demonstrated no abnormalities in both ipsilateral and contralateral R1 or R2 latencies as well as no facial nerve latency or amplitude abnormalities.
Discussions: As reported in literature regarding MS, electrodiagnostic studies such as blink reflex studies have been used to correlate neuroimaging studies with clinical findings and to support the diagnosis in time and space when brainstem is involved. In our case with pontine and medulla oblongata demyelinating lesions and clinical facial paralysis we would have expected abnormal blink reflex results (R1/R2 latencies). However given resolving presentation upon study, normal results could indicate improvement following treatment.
Conclusions: Given its cost efficiency and accessibility, neurophysiological tests such as the blink reflex study should be considered as an adjunct method for establishing prognosis and recovery in Multiphasic ADEM.
Saphenous Nerve Entrapment Case Series
Thomas J. Malbrough, MD, MA; Jessica M. Hasak, MPH, RN; Heidi Prather, DO; Susan Mackinnon, MD; Andrew Yee, BS
Case Diagnosis: We describe the clinical symptom complex of seven patients with compressive saphenous neuropathy confirmed by successful saphenous nerve release.
Case Description: In a retrospective chart review we obtained data on seven patients referred to plastic surgery for saphenous nerve release. Our population of subjects primarily developed onset of pain either following surgery (3) or trauma (3). They presented with a variable distribution of pain but predominantly it was focused either over the medial aspect of the knee or along the medial aspect of the leg from the extending from the distal thigh to the ankle. Three subjects had undergone knee surgeries prior to our evaluation attempting to improve their symptoms. All subjects underwent a saphenous nerve release while some underwent additional procedures typically involving other nerve decompressions.
Discussions: The saphenous nerve is the largest sensory nerve branching from the femoral nerve. It travels medially through the adductor canal, or Hunter’s canal, bordered by the vastus medialis, abductor longus, and adductor magnus muscles. Entrapment of the saphenous nerve most commonly occurs at the outlet of the adductor canal as the nerve pierces the fascia between the sartorius, vastus medialis, and adductor magnus muscles. While injury to the saphenous nerve from surgery is reported as high as 50-70%, it is reported that less than 1% of adults presenting with lower extremity pain have saphenous neuropathy. Our case series demonstrates successful treatment compressive saphenous neuropathy from saphenous nerve release. Three patients had complete symptom resolution while another three had modest improvement following surgery.
Conclusions: Saphenous nerve entrapment is likely an unrecognized cause of medial knee and lower extremity pain. A history of surgery involving the knee prior to symptom onset or persistent symptoms in spite of surgery likely contributes to the diagnosis of saphenous neuropathy.
Satisfaction with a Formal Mentorship Program in Physical Medicine & Rehabilitation
Mithra Maneyapanda, MD; Leslie Rydberg, MD
Objectives: To assess the satisfaction with a formal mentorship program in a Physical Medicine and Rehabilitation residency program.
Design: Prospective survey-based study. Anonymous surveys with Likert items were distributed to all participants in the program. Surveys were completed at the beginning and end of one academic year. Responses were scored with rating of 1 through 10, with 10 being the most valuable/satisfied. Participants met with their assigned mentor/mentee 4 times during the year.
Results: The response rate for attending physicians was 25 of 25 (100%) for the initial survey and 20 of 25 (80%) at follow-up. The response rate for residents was 28 of 36 (77.8%) for the initial survey and 25 of 36 (69.4%) at follow-up. The most important goals of the program for residents were career planning (mean 9.37, standard deviation 0.84), support/resident well-being (8.00, 1.71), and networking (7.77, 2.27). The most important goals for attending physicians were career planning (8.48, 1.06), support/resident well-being (8.08, 1.35), and networking (7.00, 1.77). At follow-up, residents were most satisfied with support/resident well-being (7.80, 2.21), knowledge about the organization (7.71, 2.29), and career planning (7.56, 2.58). Attending physicians were most satisfied with support/resident well-being (8.15, 1.75), career planning (8.10, 1.55), and knowledge about the organization (7.85, 1.63). At follow-up, residents felt that individuals were more available to address their concerns (p = 0.0121).
Conclusions: Resident and attending physicians in a Physical Medicine and Rehabilitation residency program feel that career planning, support, and networking are important goals for a mentorship program. After a year in the program, residents felt that individuals were more available for addressing concerns. These results demonstrate that a formal mentorship program can address goals that are important to the participants. These results can help tailor mentorship programs to improve their efficacy.
Seronegative Neuromyelitis Optica (NMO) after L5-S1 Laminectomy: A Case Report
Sean A. Lacey, BSC; Alcinto Steven. Guirand, MD; Douglas Sohn, MD
Case Diagnosis: Seronegative Neuromyelitis Optica (NMO)
Case Description: A 54 year old male of mixed Native American and Caucasian descent was admitted to a tertiary care inpatient hospital two weeks status post L5-S1 laminectomy with discectomy with a chief complaint of sacral and lower extremity paresthesias associated with lower extremity weakness. His hospital course was complicated by progressive weakness, left eye optic neuritis, bowel and bladder incontinence, somnolence, and intractable vomiting.
MRI of the cranium revealed hydrocephalus. MRI of total spine revealed a T2 weighted hyperintensity from obex to T9 level along with an incidental 5 mm mass along the first lumbar nerve. Lumbar nerve biopsy was consistent with schwannoma. Frontal leptomeningeal biopsy revealed no malignant cells. IV dexamethasone was started and a ventriculoperitoneal (VP) shunt was placed. After VP shunt placement there was exacerbation of prior symptoms and new weakness of his right upper extremity. Autoimmune workup including serum anti-AQP4 antibody were negative, however CSF anti-AQP4 returned positive. Treatment with rituximab and five courses of plasmapheresis were performed over the following two weeks, with improvement in optic neuritis, weakness and constitutional symptoms.
Discussions: AQP4 expression is known to increase in the setting of tumors and trauma. This patient’s history of recent spine instrumentation associated with initial development of symptoms and discovery of an incidental schwannoma, lends to the possibility of disease triggering via tumor and/or surgery.
Conclusions: In patients with NMO, symptoms may present after spine surgery or in the presence of nervous system tumors.
Severe Statin-Induced Necrotizing Autoimmune Myopathy (SINAM) Resulting in Functional Tetraplegia
Marissa L. Dombovy-Johnson, BA; Erin M. Conlee, MD; Jeffrey A. Strommen, MD
Case Diagnosis: Severe Statin-Induced Necrotizing Autoimmune Myopathy (SINAM)
Case Description: A 62 year old female with hyperlipidemia developed rapidly-progressive, axial and proximal limb weakness over a 6 week period 11 months after initiation of statin therapy. Evaluation revealed creatine kinase (CK) levels greater than 10,000, electromyography (EMG) showed a diffuse myopathy and on muscle biopsy necrotic and regenerating fibers without prominent inflammation were found.
EMG and muscle biopsy were consistent with SINAM and diagnosis was confirmed with positive anti-3-hydroxy-3-methyglutaryl-coenzyme A reductase auto-antibodies (anti-HMGCR). Aggressive immunosuppressive therapy consisting of prednisone, rituximab, methotrexate, and IVIG were initiated. Hospital course was complicated by pneumonia in the setting of respiratory muscle weakness and severe dysphagia.
Serum CK levels declined but debilitating muscle weakness persisted and the patient was admitted to inpatient rehabilitation to optimize functional status. Currently, the patient operates a power wheelchair.
Discussions: Statins are commonly prescribed, lipid lowering agents used in prevention of cardiovascular disease. Despite being well-tolerated, musculoskeletal complications range from asymptomatic rise in CK to rhabdomyolysis and debilitating muscle weakness. SINAM, a rare and more severe form of myopathy that persists after statin discontinuation, is treated with immunosuppressive therapy. Characteristics of SINAM include rapid onset proximal muscle weakness, elevated CK, irritable pattern on EMG and myonecrosis with minimal inflammation on biopsy. The recently discovered anti-HMGCR antibody is very specific for the diagnosis. Various immunosuppressive agents have been used with favorable responses in functional improvement. Antibody levels correlate with CK levels and clinical severity; therefore trending anti-HMGCR levels may impart treatment recommendations. The current literature suggests recovery can be prolonged, taking 9–12 months to regain functional strength.
Conclusions: This case illustrates the debilitating consequences of this severe disease. Awareness of this condition is vital as these patients are optimally served by physiatry and the multi-disciplinary rehabilitation team.
Short Term Bisphosphonates Induced Atypical Femur Fracture
Saiyun Hou, MD, PhD; Monica Verduzco-Gutierrez, MD
Case Diagnosis: Short term bisphosphonates induced atypical femur fracture
Case Description: A 73 year old woman was admitted following a femur shaft fracture in her left thigh. She reported that she tripped and fell from a curb in a parking lot. She had severe pain and limited movement in her left thigh. She denies injury, pain and loss of range of motion in her right lower extremity. X-ray showed that left displaced oblique femur shaft fracture and right atypical femur shaft fracture. Her past history revealed osteoporosis for which she was taking alendronate for 10 months and discontinued following 2–3 years prior to this fracture. She underwent bilateral femur closed reduction and internal fixation with cephalomedullary nailing. The patient started ambulation the day after surgery and is able to walk with a walker without any issues.
Discussions: Bisphosphonates reduce the overall risk of fractures among patients with osteoporosis. However, since bisphosphonates inhibit bone remodeling, they may enhance the formation and propagation of micro-cracks over time and patients may therefore be prone to atypical fatigue fractures. The risk of atypical fracture among women increased progressively with the duration of use. Also, for each year since the last use, the risk was 70% less. The consensus now is to take into consideration the increased risk of atypical fractures when continuing bisphosphonates beyond 5 years. To date, few reports describe short term use (<1year) bisphosphonates induced atypical femur fracture. Our data showed that an atypical femoral shaft fracture occurred 2–3 years after receiving bisphosphonates for 10 months. We recommend that patient who is taking bisphosphonates should require regular interval bone scan for fracture screening.
Conclusions: Despite the overall beneficial effect of bisphosphonates, routinely bone scan is recommended for atypical fracture screening. Also, further research is required to prevent this significant complication.
Significant Truncal/Abdominal Lymphedema with Minimal Extremity Involvement in a Breast Cancer Patient
Jessica Engle, DO; Jack Fu, MD
Case Diagnosis: Significant Truncal/Abdominal Lymphedema with Minimal Extremity Involvement in a Breast Cancer Patient
Case Description: A 60 year old female with history of type II diabetes and left breast carcinoma (status post resection and chemoradiation) who is currently disease-free, presented to the PM&R Oncology Clinic complaining of new onset left asymmetric abdominal wall swelling. She underwent left breast segmental mastectomy with left axillary sentinel lymph node dissection and right breast reduction mastopexy for symmetry 1.5 years earlier. Pathology showed stage IIa T2 N0 M0 invasive ductal left breast carcinoma. After beginning left breast and tumor boost radiation 6 months later, she complained of left upper extremity decreased range of motion and lymphedema. The patient received left upper extremity lymphedema therapy with improvement. At follow-up clinic, she had a 4–5 pound weight gain in the last 3 months despite lifestyle changes. The patient reported a remote history of hysterectomy and bladder suspension surgeries. She denied changes in bowel or bladder function. On exam, the patient was found to have significantly larger left-sided abdominal pannus and lymphedema as compared to right. Left breast and left lateral trunk were significant for lymphedema. Her arm involvement was minimal. Ultrasound revealed benign post-surgical and post-radiation changes in left breast. CT was negative for hernia and showed diffuse thickening of skin on left breast. She failed conservative treatments and was referred to plastic surgery for possible liposuction.
Discussions: Lymphedema is typically seen in the ipsilateral upper extremity in a breast cancer patient. Literature regarding truncal and abdominal lymphedema in breast cancer patients who have not undergone reconstruction involving abdominal donor tissue is lacking. To our knowledge, this is the first case report of a breast cancer patient with this type of presentation.
Conclusions: Early lymphedema identification and treatment increases quality of life in cancer survivors. Unusual presentations should not be overlooked.
Smoking and Cervical Degenerative Disc Disease as Seen on Computed Tomography
Mitchel Leavitt, MD; William Beckworth, MD
Objectives: This study seeks to evaluate the association between cigarette smoking and cervical degenerative disc disease (DDD) via advanced imaging using computed tomography (CT). This has been reported in the lumbar spine but not in the cervical spine except for an x-ray study suggesting that smoking had no effect.
Design: A radiologist with subspecialty training in neuroradiology along with a physiatrist reviewed 182 consecutive CT scans which had been completed at a university hospital for various reasons. Documentation was done in regards to severity of the cervical DDD. Each disc was rated as normal, mild (0-33% loss of disc height), moderate (33-66% loss of disc height), or severe (>66% loss of disc height or vacuum disc). Scores of 0 (normal) to 3 (severe) were given for each disc. A cumulative cervical DDD score was given for the entire cervical spine (C2-7), with a range of 0–15. Other health information was collected including age, smoking status, pack years smoked, BMI, hypertension, dyslipidemia and diabetes. A linear regression model was used to evaluate for a correlation with cervical DDD while accounting for age.
Results: Of the 182 patients there were 61 smokers (34%) and 103 females (57%). Age correlated with worsening cervical DDD (correlation coefficient 0.636, p < 0.0001). Current smokers were found to have more severe cervical DDD after controlling for age (p=0.0203). Active smokers had a worse cumulative cervical DDD score by one point on average. There was no statistical significance for pack years (p=0.164). Comorbidities including diabetes, hypertension, hyperlipidemia and BMI did not correlate with worsening cervical DDD.
Conclusions: There is a positive correlation between active smoking and cervical DDD after controlling for age, although the effect was small. This has not been previously described in the cervical spine.
Spinal Headache and Intracranial Hypotension following Bilateral Hip Arthroplasty
Diana Barayeva, DO; Yu-Jen Lai, MD
Case Diagnosis: 50 year old male with Spinal Headache Secondary to Intracranial Hypotension Following Spinal Anesthesia for Bilateral Hip Arthroplasties.
Case Description: A 50 year old male underwent bilateral total hip arthroplasties under spinal anesthesia. Upon admission for acute rehabilitation on post-operative day 2, he reported a severe headache with nausea which was aggravated by upright posture. Head CT scan revealed a hypodense area in the posterior parasagittal convexity suspicious for subarachnoid hemorrhage. Anticoagulation was discontinued. Intravenous fluids, caffeine, and bed rest were ordered. Contrast enhanced brain MRI revealed diffuse dural parenchymal enhancement over both cerebral convexities and cerebral sinus vein thrombosis. The patient’s headache was deemed to be secondary to cerebrospinal fluid leak which resulted in intracranial hypotension .The diffuse parenchymal enhancement and the cerebral sinus vein thrombosis noted on MRI developed secondary to intracranial hypotension. He was started on methylprednisolone. By post-operative day seven, the patient’s headaches abated and his FIM score improved 33 points over ten days.
Discussions: Spinal anesthesia may be indicated for surgeries of the pelvis and lower limbs. Lidocaine is injected into intrathecal space at L2-L3, providing sensory and motor blockade. Post spinal anesthetic headache and intracranial hypotension are more commonly seen when large diameter spinal needles are used resulting in CSF leak and decreased CSF pressure. Initial treatment includes bed rest, fluids, caffeine, and steroids. An epidural blood patch may be used to treat this condition with 80% efficacy when initial treatment fails.
Conclusions: Severe intracranial hypotension following spinal anesthesia is relatively uncommon and is more commonly seen in women. When severe, intracranial hypotension can lead to debilitating headaches with possible cranial nerve involvement, stroke, subdural hematoma formation, and cerebral venous thrombosis due to venous stasis. This case warrants review as it describes a rare and severe neurological complication of a commonly employed anesthetic procedure which must be promptly recognized by rehabilitation professionals in order to administer timely and effective treatment.
Stretching of Connective Tissue: Do Porcine Fibroblasts Increase in Cross Sectional Area in Response to Shear Stretch?
Mairin A. Jerome, MD; Nicole A. Bouffard, BS; Rhonda L. Maple, AS, BS; Gary J. Badger, MS; Helene M. Langevin, MD
Objectives: In mouse areolar connective tissue, fibroblasts respond to shear tissue stretch by actively remodeling their cytoskeletons and increasing in size. This response has been linked to purinergic signaling and may be important for local sensory modulation, in addition to affecting viscoelastic properties of connective tissue. As the architecture of porcine tissue is more similar to humans than that of a mouse, we sought to determine 1) whether or not a similar fibroblastic response to stretch occurs in porcine tissue and 2) whether this response is altered when movement of the animal is impaired in vivo. We hypothesized that mean fibroblast cross-sectional area would be increased in stretched versus unstretched tissue and that this difference would be diminished in pigs with movement restriction (hobble) compared to controls.
Design: Post-mortem porcine tissue was collected from three hobbled and three control animals. Bilateral samples spanning the dermis to skeletal muscle were collected, half of which were stretched in shear for 2 hours, fixed with paraformaldehyde, micro-dissected, stained with phalloidin, and visualized under confocal microscopy. Measurements of cell body area were obtained through MetaMorph analysis. An analysis of variance was performed comparing mean areas of stretched versus unstretched tissue and differences between control and hobbled pigs.
Results: There was an overall significantly greater mean cell area in stretched tissue compared to unstretched tissue (F=31, p < 0.01). There was also a significant interaction between the effect of stretch and treatment group (F=8.4, p < 0.05) with a greater increase in cell cross-sectional area in the hobbled pigs.
Conclusions: This preliminary data demonstrates that ex-vivo porcine connective tissue responds to shear stretch with a significant increase in mean fibroblastic cell area. This is consistent with what has previously been observed in mice, but has never before been seen in pigs. We found a surprising increase in responsiveness to stretch in the hobbled pigs, which is so far unexplained and needs to be confirmed with a larger group of animals.
Study on the Effects of Onabotulinum Toxin a Injection on Needle Electromyography of the Lumbar Paraspinal Muscles
Adam J. Susmarski, DO; Kevin F. Fitzpatrick, MD; Min Ho Chang, MD
Objectives: The injection of Onabotulinum toxin A into the lumbar paraspinal muscles has been shown to have beneficial effects on pain in patients with chronic low back pain. The injection of Onabotulinum toxin A into muscle may result in abnormal spontaneous activity on needle EMG, independent of denervation.
Design: Patients with chronic mechanical low back pain of greater than six months were evaluated by EMG using the MiniPM technique. They were subsequently treated with Onabotulinum toxin A injections into the lumbar paraspinal muscles followed by reevaluation of paraspinal musculature 1 month later using the same MiniPM technique.
Results: At 1 month follow-up all three patients exhibited a significant increase in EMG MiniPM scoring representing abnormal spontaneous activity in the treated lumbar paraspinal muscles.
Conclusions: The injection of Onabotulinum Toxin A into the lumbar paraspinal muscles does result in abnormal spontaneous activity, creating a confounding variable in the evaluation of lumbosacral radiculopathy.
Subacute Onset Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) with CNS Involvement Diagnosed Initially as Guillan-Barre Syndrome
Anand M. Navarasala, DO; Vasilios Stambolis, MD
Case Diagnosis: Subacute onset chronic inflammatory demyelinating polyneuropathy (CIDP) with CNS involvement diagnosed as Guillan-Barre syndrome
Case Description: 50 y/o male with medical history of hypertension and diabetes presented to the ED with balance problems, diffuse burning sensations, and tightness in the legs and arms. Symptoms progressed over 12 hours after the patient fell asleep and awoke with worsening symptoms. MRI showed moderate areas of scattered T2 and FLAIR signal hyperintensity throughout periventricular and subcortical white matter suspicious of a demyelinating process. CSF fluid analysis showed ambuminocytologic dissociation, elevated IgG, and the absence of oligoclonal bands. Patient was diagnosed with Guillan-Barre syndrome and a five day course of IVIG was administered followed by plasma exchange. Patient was stabilized and transferred to acute inpatient rehabilitation hospital. Examination finding included horizontal nystagmus, unilateral tongue atrophy, weak phonation, tetraparesis, and symmetrical patellar hyperreflexia. Patient made minimal progress over the course of a month and was discharged to subacute rehabilitation as total assist. After three months in subacute the patient was readmitted to acute inpatient rehabilitation and remained total assist.
Discussions: Approximately 15% of patients diagnosed with CIDP present with subacute onset that are often initially diagnosed as Guillan-Barre syndrome. The diagnosis CIDP is given to patients following eight weeks of continued symptoms which are refractory to treatment. Although this patient continued therapy at subacute rehabilitation the patient may have benefited from pulsed steroids once weekly for one to three months followed by IVIG if ineffective.
Conclusions: Patients affected by CIDP require close follow up due to the neuronal demyelination along with axonal degeneration associated with the disease. If not treated aggressively throughout the disease course axonal degeneration may lead to irreversible damage. Guillan-Barre and subacute onset CIDP have similar presentations and both treatment duration and frequency change based on the transition from acute to chronic inflammatory demyelinating polyneuropathy.
Superior Gluteal Neuropathy Following Superior Gluteal Artery Perforator (SGAP) Flap Breast Reconstruction: A Case Report
Alan Schleier, DO; Eric Wisotzky, MD
Case Diagnosis: Superior Gluteal Neuropathy Following Superior Gluteal Artery Perforator (SGAP) Flap Breast Reconstruction
Case Description: We describe a case of a 53 year old female who presented for outpatient rehabilitative services related to her history of breast cancer. She had undergone a right mastectomy 11 months prior to presentation and had a superior gluteal artery perforator (SGAP) flap reconstruction 4 months prior to presentation. On her first visit, she described right lateral buttock pain which had started immediately following her reconstruction. She noted “tight” pain which was worse with walking and at times progressed to numbness, tingling and burning. A clinical diagnosis of sciatica was initially made, however further workup was pursued. MRI of the lumbar spine did not reveal significant central canal or neuroforaminal narrowing, but did demonstrate asymmetric fatty denervation of the right gluteus medius muscle. Further examination of the right gluteus medius with EMG revealed decreased insertional activity, increased spontaneous activity, and increased motor unit duration. These findings were consistent with an incomplete axonal injury to the superior gluteal nerve.
Discussions: An increasing number of breast cancer survivors who undergo mastectomy are opting for SGAP reconstruction due to the positive outcomes associated with this method. Given the history and clinical findings related to this patient, it is most likely the case that her superior gluteal neuropathy was a direct result of her SGAP flap procedure. Although this surgical approach tends to spare major neurovasculature, this case identifies the possibility for damage to significant structures.
Conclusions: This case demonstrates that although donor site morbidity is considered very low inSGAP flap reconstructions, a superior gluteal neuropathy may result. This case holds great importance in highlighting this potential adverse affect, and physiatrists treating breast cancer survivors who have undergone SGAP reconstruction will benefit from knowing this possible complication.
The Case of Mr. K.: Electrodiagnostic Studies Spared Patient Unnecessary Neurosurgery
Rupali Kumar, MD; Lauren Eichenbaum, MD; Richard Keyme, MD; Min Kim, DO; Roger Klima, MD
Case Diagnosis: Lumbosacral radiculoplexopathy
Case Description: Mr. K. is a 53 year-old man with prior C3 AIS C TSCI from a diving accident in 1984, who presented to our facility with progressively worsening right lower extremity (RLE) weakness over the past four years.
He was initially evaluated by neurosurgery, who noted RLE weakness as well as bilateral triceps weakness. MRI findings were suggestive of cervical spondylitic myelopathy, though unchanged from three years prior. Considering cervical spondylitic myelopathy to be the potential source of his problems, they planned for anterior corpectomy with C6-7 ACDF. However, several days before the planned surgery, electrodiagnostics were sought to clarify the RLE weakness.
EMG/NCS revealed electrodiagnostic evidence of acute denervation in the right L2-S2 myotomes, with no abnormalities in right paraspinal muscles. There was evidence of recent reinnervation in the right gluteus medius, in contrast to evidence of chronic reinnervation (very high amplitude motor unit action potentials ∼16-20 mV) in the bilateral triceps brachii and pronator teres.
Discussions: These findings raised suspicion for right lumbosacral radiculoplexopathy, suggesting a more distal cause for the patient’s symptoms. EMG demonstrated that the changes in the triceps and pronator teres were chronic, likely stemming from his original SCI.
As a direct result of these electrodiagnostic findings and discussion with our neurosurgical colleagues, the decision was made not to pursue the cervical spine surgery that was scheduled for later in the week, in favor of further workup of the lumbosacral radiculoplexopathy, which to date is of unclear etiology.
Conclusions: Electrodiagnostic tests are often difficult to draw meaningful conclusions from, unless being utilized to support a strong clinical suspicion. This was a case of electrodiagnostics playing a pivotal role in influencing management decisions and sparing the patient an invasive and unneccesary surgery.
The Effect of a Mirror on Preferential Loading of the Lower Extremities during a Double Legged Squat: A Pilot Study
Monica Rho, MD; Franz Nigl, MS; Steven Makovitch, DO
Objectives: The double legged squat is a regularly used exercise and rehabilitation tool. Although common practice is to perform squat exercises in front of a mirror for feedback on form and positioning, some believe this has detrimental effects. There are no studies that evaluate performance of a squat based on mirror use. The purpose of this study was to examine the effect of a mirror on preferential loading of the lower extremities during a double legged squat exercise in multiple foot positions (fixed, mixed, self-selected) and during a deep squat.
Design: Ten healthy subjects (5 male, 5 female) performed 5 squats to the fixed height of a chair in 3 different foot positions and 5 deep squats both with and without a mirror. Mean preferential load shift to the dominant leg along with maximum knee and hip flexion angles during deep squat were analyzed (α = 0.003).
Results: There was no significant difference in mean preferential load shift between the mirror versus no mirror conditions in any of the squat types.
Comparison between the fixed and mixed foot positions in the no mirror condition demonstrated a statistical difference (p = 0.001), whereas in the mirror condition no difference was found (p = 0.247). All maximum knee and hip flexion angle comparisons were non-significant.
Conclusions: The presence of a mirror during a double legged squat exercise did not change preferential loading of the lower extremities. Athletes should self-select a comfortable foot position during a squat exercise for equal loading.
The Effect of BNP Testing on Cardiac Rehabilitation Outcomes in Patients after Cardiothoracic Surgery
Adeepa D. Singh, MD; ShaEssa L. Wright, DO, MBS; Iqbal Jafri, MD; Lei Lin, MD; Sara Cuccurrullo, MD
Objectives: Brain Natriuretic Peptide (BNP) is a cardiac hormone secreted by myocytes within the ventricles in response to changes in pressure due to volume expansion and overload. Serum BNP levels correlate to the severity of cardiac decompensation. In comparison to an echocardiogram as an evaluation method for management of cardiac function, BNP testing as a diagnostic tool provides rapid results, is non-operator dependent and decreases the likelihood of missed therapy time. Studies show that elevated levels of BNP during the first several days after coronary artery bypass graft (CABG) surgery has been associated with increased mortality. The purpose of this study is to examine the effect of obtaining admission Brain Natriuretic Peptide levels on functional outcomes in patients after cardiothoracic surgery admitted to acute inpatient telemetry monitored cardiac rehabilitation.
Design: This case controlled study was conducted at an acute inpatient telemetry monitored cardiac rehabilitation program in an academic setting. The 47 subjects were inpatient cardiac rehabilitation patients who underwent CABG and valvuloplasty involving aortic, mitral or tricuspid valves. The experimental group (16 patients) had serum BNP testing within the first twenty-four hours of admission and the control group (31 patients) did not. Patients with elevated BNP levels received immediate interventions including diuretic administration and or medication dose adjustments and those levels were followed closely for the first two to five days of admission. This protocol was performed in conjunction with close monitoring and medical management lead by cardiology consultants.
Both groups were assessed on Functional Independence Measure Scores (FIM) and Length of stay (LOS). Each group received EKG, chest X-ray and cardiology consultation within twenty-four hours of admission as part of routine care. All patients in this study underwent a comprehensive acute inpatient rehabilitation program for three hours daily for five days per week in a telemetry monitored cardiac rehabilitation program.
Results: This study reveals reduced length of stay by 2.11 days and greater daily FIM score gains in the BNP group when compared to the control group. This suggests reduction in overall healthcare cost due to shorter LOS. Greater FIM gains were attributed to more efficient and effective therapy time and less time missed due to complications after surgery.
Conclusions: Existing literature demonstrates that increased postoperative BNP levels are associated with poor physical function six months to two years after CABG. In this study, BNP testing for patients who recently underwent cardiac surgery results in rapid recovery and greater daily FIM gains as a result of early intervention to prevent post-operative complications. There is a dearth of literature that describes correlations between biomarker levels with clinical and functional outcomes of patients status post CABG or valvular repair in acute inpatient telemetry monitored cardiac rehabilitation programs, further investigation is needed. This study identifies the utility of BNP testing in the field of Physiatry as a method of improving overall medical care and functional outcomes of cardiac patients in acute inpatient rehabilitation programs.
The Effectiveness of Online Learning with PMR Graduate Medical Education for Dysphagia Evaluation
Noel Rao, MD; Susan Brady, MS, CCC-SLP, CCC-SLP; Letha Williams, PhD, FACHE; Mark Hakel, PhD, CCC-SLP; Theresa Pape, DRPH, MA
Objectives: To develop, implement, and evaluate the effectiveness of an inter-professional, online, interactive course designed to increase the ability of medical residents in PMR and speech language pathologists (SLPs) to accurately interpret the findings of the fiberoptic endoscopic exam of the swallow (FEES) procedure.
Design: This educational intervention was developed with the underlying theoretical concepts of adult learning theory and social cognitive theory (SCT). In SCT, self-efficacy and how it relates to the interpretation of the FEES procedure was evaluated. A quantitative, non-randomized research study design was utilized to evaluate the effectiveness of this course. Main outcome measures include the FEES Interpretation Knowledge Test (40 points) and the FEES Self-Efficacy Questionnaire.
Results: Participants who completed the online FEES training course (N=30) demonstrated significant improvements with their ability to interpret the findings of the FEES procedure based upon the pre-course (28.47, SD=3.92) and post-course (35.47, SD=2.40) knowledge test scores (t=−9.37, df=29, pt=3.849, df=28, p=.001); however, both groups had similar post-course scores (PMR=35.67; SLP=35.27; t=−.450, df=28, p=.657). The PMR group (n=15) demonstrated significantly greater change in knowledge (9.46, SD=4.06) as compared to the SLP group (n=15) (4.53, SD=2.26), suggesting this online course is an effective educational intervention for PMR residents. Self-efficacy ratings related to interpreting the FEES procedure on a 5-point Likert scale for the entire study sample increased from 2.28 at pre-course to 4.133 post course (p=.0001).
Conclusions: PMR residents gained significant knowledge in an unfamiliar area following participation with this theory driven educational intervention for swallowing disorders. Since dysphagia is best managed by an interdisciplinary team, it is essential for the PMR residents to receive dysphagia training as it poses a significant health care concern and is often seen with patients who have rehabilitation needs.
The Impact of Routine Lower Extremity Deep Vein Thrombosis Screening on Acute Rehabilitation Admissions
Cynthia C. Hung, MD; Anne Felicia Ambrose, MD, MS
Objectives: Brain injury patients are at increased risk for deep vein thrombosis (DVT) due to immobility, steroids, prolonged surgery time, and cancer. Prior studies report an incidence of 8.5% to 18% for asymptomatic DVT’s in the neurorehabilitation population. Despite increased mechanical and/or chemical DVT prophylaxis in the acute hospitalization phase, we hypothesize that screening for lower extremity DVT’s on admission to acute rehabilitation will detect asymptomatic DVT’s which will impact management and outcomes.
Design: In this retrospective chart review, we included patients with any intracranial pathology on imaging including demyelination, intracranial hemorrhage, stroke, and cancer necessitating rehabilitation. We excluded patients already on anticoagulation, and those who had signs of DVT prior to screening. Patients underwent femoral popliteal venous duplex ultrasound (VDU) screening at least 7 days from admission (mean 1.94 days).
Results: 67 patients admitted from February to March of 2015 were included. 6 patients were excluded because they were already on anticoagulation. 2 patients were excluded for having signs of DVT prior to screening. 10 patients did not get a VDU. 49 patients, with an average age of 65.22 years old admitted an average of 13.14 days from inciting event, remained in the study. 18 patients had brain hemorrhages, 15 patients had ischemic strokes, 6 patients had tumors, 3 patients had demyelinating lesions, 1 patient had a combination (tumor, ischemic stroke, and brain hemorrhage), and 6 patients were classified as miscellaneous. 4 patients were not on chemical prophylaxis or anticoagulation. Of the 49 patients screened with VDU, 3(6.12%) were found to have asymptomatic DVT’s.
Conclusions: Screening for lower extremity DVT’s in our brain injury population altered management and can prevent complications such as post-thrombotic syndrome and pulmonary embolism. Larger prospective randomized controlled studies are needed to further understand these long term benefits of detecting asymptomatic DVT’s.
The Outcomes and Cost of Comprehensive Outpatient Therapies in Patients with Malignant Brain Tumors
Stacy McCarty, MD; Susan Keeshin, MD; Samman Shahpar, MD; Patrick Semik, BA; Alex Wong, PhD, DPHIL; Sarah Eickmeyer, MD
Objectives: There is a paucity of literature to support the role of comprehensive outpatient rehabilitation in malignant brain tumor (MBT) patients although much therapy is shifting to the outpatient setting. This study is aimed to evaluate the function, quality of life, pain, depression, and cost in adults with MBT in a comprehensive outpatient program.
Design: A prospective, longitudinal cohort study of patients with MBT attending a comprehensive outpatient program. The control group was 50 brain injury and 50 stroke patients, with similar characteristics to the study group. Function (DayROS) was studied at admission and discharge. Quality of life (QOL; FactBr), pain (PROMIS pain), depression (PROMIS depression), and caregiver burden (Zarit burden inventory) were studied at admission, discharge, and one and three months after discharge. The cost of the day rehabilitation program, demographic and treatment characteristics were evaluated.
Results: 49 patients with MBT were studied over 35 months. There was a significant improvement in total function (t (33) =−7.524, p < .01), mobility (t (36)=−8.636, p < .01), activities of daily living (t(35)=−5.418, p < .01), and communication (t (34)=−5.224, p < .01). Those who received chemotherapy or radiation therapy had worse mobility gains (t(35)=2.208, p=.034). Younger patients had better mobility gains (r=−.339, p=.040). Women had larger functional gains (t(31)=−3.203, p=.003). Those in less pain from discharge to one month had better social/family well being (r=.494, p=.027) and significant gains in total function (r=.556, p=.039) and mobility (r=.561, p=.024). Total QOL from admission to discharge was correlated with total functional (r=.418, p=.05) and mobility gains (r=.487, p=.013). Physical well being at admission was correlated with depression at all time points (r=−.368, −.480,-.513, all p.013). Total QOL on admission correlated with depression at all time points (r=−.638, −.478, −.623, all p .006.) There was not any significance between functional gains and caregiver burden. The total cost (t (141) =−2.971, p=.003), and cost per day (t(105)=−2646, p=.009) were significantly less than the control group.
Conclusions: Comprehensive outpatient therapies improve function in individuals with malignant brain tumors, and it is less expensive than similar therapy in individuals with brain injury or stroke. QOL also improves, with there being correlations with depression, pain, and function.
The State of Disability Awareness Education in American Medical Schools
Erica Seidel, MD; Scott Crowe, MD
Objectives: The purpose of this research study was to: 1) determine how many U.S. medical schools include disability awareness in their curriculum, 2) explore the format of disability awareness programs in existence 3) understand why some schools do not include disability awareness in their curriculum.
Design: An online survey was sent to deans of medical education at all American medical schools (n=167). The questionnaire asked if they had an awareness program. Schools with a program were asked for additional details about the characteristics of their program. Schools without a program were asked about barriers to having a program and about their interest in potentially adopting a curriculum if one was provided.
Results: 75 schools completed surveys. 52% (39/75) reported having a disability awareness program. The most common format was people with disabilities or caregivers speaking in a large group setting. Programs were most likely to focus on adults with physical disabilities. Among schools without a program, the top barriers were no one advocating for inclusion in the curriculum and time constraints. Nearly half of schools without a program expressed interest in adopting an awareness curriculum if one was provided.
Conclusions: 52% of medical schools surveyed have a disability awareness program. The actual rate across all American medical schools may be as low as 23% if we assume there was a selection bias with schools without programs being less likely to respond. Efforts should be made to increase this number through increased advocacy or providing additional resources to schools without a curriculum. It is encouraging that nearly half of schools would be willing to adopt a curriculum if one was provided. Programs described by other respondents could be used as a starting point for curriculum development.
The Use of a Submaximal Exercise Program in the Rehabilitation of Normal Pressure Hydrocephalus Complicated by Type 2 Myotonic Dystrophy
Franz Jones, DO; Noel Rao, MD
Case Diagnosis: 62 year old female with prior diagnosis of Type 2 Myotonic Dystrophy who presented with Normal Pressure Hydrocephalus 9 months after mechanical fall
Case Description: 62 year old female with prior diagnosis of Type 2 Myotonic Dystrophy, who presented to her primary care physician in August 2013 with complaints of confusion, progressive memory loss, urinary incontinence and increase in gait problems over the past 9 months since a fall in December 2012. Etiology of the fall was deemed mechanical, since the patient had been suffering from slowly progressively worsening weakness, muscle fatigue and soreness since the diagnosis of Type 2 Myotonic Dystrophy in 2005. Imaging of the brain revealed ultimate diagnosis of Normal pressure hydrocephalus. A ventriculoperitoneal shunt was placed in September 2013 by Neurosurgery and the patient was discharged to an Acute Rehabilitation facility. On admission, the patient had complaints of moderate to severe muscle pain, stiffness, weakness and fatigue during the first physical therapy evaluation and the initial subsequent physical therapy sessions. A submaximal exercise program combined with daily muscle stretching and Range of Motion exercises was implemented to help the patient achieve pain relief and work towards discharge goals. Patient reported significant decrease in daily pain levels and muscle soreness with subjective increase in physical endurance.
Discussions: Type 2 Myotonic Dystrophy is a rare, multisystem progressive neuromuscular disease with limited evidence supporting the use of specific physical therapy exercises or specific therapeutic modalities in the management of the disease. Although the primary diagnosis here is Normal pressure hydrocephalus, this case report highlights the use of a submaximal exercise program combined with daily muscle stretching and ROM exercises in the rehabilitation of this patient complicated by the comorbid diagnosis of Type 2 Myotonic Dystrophy.
Conclusions: In patients with Type 2 Myotonic dystrophy, clinicians should consider using a submaximal exercise program prescription combined with daily muscle stretching and ROM exercises for decreased pain, decreased stiffness and improved outcomes. Further studies and evidence is needed to evaluate the efficacy of such an exercise prescription for use in both the acute inpatient rehabilitation as well as in the outpatient setting.
The Utility of Ultrasound in Diagnosing CAM-type Femoracetabular Impingement
Raisa Bakshiyev, MD
Case Diagnosis: Femoracetabular Impingement - CAM type
Case Description: A 34 year-old male with past medical history only significant for a self-resolved and painless childhood limp, was informed that his left lower extremity was longer than his ri