Abstracts of Scientific Articles and Posters Presented at... : American Journal of Physical Medicine & Rehabilitation (2023)

Faculty Category Award Winner

The influence of force on the biomechanics of jumping landings during maturation in women: implications for ACL injury risk and prevention.

Dr. Daniel C. Herman, MD; Giorgio Negron, BS; Kyle Fallgatter, Bachelor of Science; Heather K. Vincent, PhD

Purpose:Anterior cruciate ligament (ACL) tears are potentially devastating injuries that have a significant detrimental impact on short- and long-term musculoskeletal health and physical function [1]. Impaired neuromuscular control during relatively high-risk athletic tasks, such as landing with a jump, has been shown to be a compelling risk factor for ACL injury. Groups at high risk of injury have neuromuscular characteristics such as high frontal plane movement of the knee and trunk and low sagittal plane movement of the knee and trunk during the jump landing [1]. Furthermore, such neuromuscular features have the ability to predict ACL injury [2], and improvements in neuromuscular control have been shown to reduce the risk of ACL injury [3].

There is a well-known gender bias in the risk of ACL injury, with women having up to eight times the risk of injury than men [1]. This difference in risk arises during maturation and is partly due to sex-based changes in neuromuscular control that also occur during maturation [4]. 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 [5]. Compensatory neuromuscular control strategies to accommodate this relative lack of strength may result in increased risk of injury. These altered patterns of neuromuscular control will persist even after engaging in resistance training in adulthood [6]. Therefore, resistance training during maturation may represent an opportunity for injury prevention by preventing the development of altered patterns of neuromuscular control. But although these different aspects of development have been previously studied, neuromuscular control and strength have not been explicitly associated in mature populations, nor have specific measures of strength related to the development of neuromuscular control been identified.

The objectives of this study were to examine neuromuscular strength and control at maturational stages in females and to identify measures of strength associated with poor neuromuscular control. We hypothesized that 1) females would not show differences in measures of knee and hip strength throughout maturation; 2) females would show worse neuromuscular control at the end of maturation; and 3) neuromuscular control would correlate with measures of knee and hip strength after puberty.

Project:Healthy high school participants (N=56; 1.56±0.1 m, 45.3±9.6 kg) were grouped into Prepubertal (PRE; N=18 Age=11.7±0.6), Pubertal (PBL; N=21 Age=12.3±1.3) and postpubertal (POST; N=17 Age=13.7±1.3) using the Observational Puberty Maturation Scale. This scale has high reliability and can be used to differentiate the stages of puberty based on indicators such as growth, breast development, menstrual status, body hair, acne, and sweating during physical activity [7]. . Neuromuscular control during a jump landing was assessed using two-dimensional videography and a scoring tool called the Landing Error Scoring System (LESS) [8]. The LESS has high validity for categorizing neuromuscular control using an eighteen-item checklist to assess movement in the frontal and sagittal planes (higher LESS = worse neuromuscular control) and has the ability to predict ACL injuries in adolescents [9 ]. The maximal voluntary isometric contraction (MVIC) strength test of knee extension, knee flexion, hip extension, and hip abduction was assessed using portable dynamometry, which has also been shown to be accurate and reliable [10]. Comparisons between groups were made using independent samples t-tests, and correlations between LESS and measures of strength were assessed using Pearson's r (alpha = 0.05).

Results:The POST group demonstrated greater knee flexion compared to the PRE group (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 measures of strength. LESS scores were higher in the POST maturation groups compared to 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). Strong negative correlations were found between knee extension and LESS (r=−0.555, p=0.021) and hip abduction and LESS (r=−0.521, p=0.032) for the POST group.

Conclusions:Our findings of 1) little difference in strength between maturation groups; 2) reduced neuromuscular control in the post-maturation group; and 3) the strong negative correlations between LESS and the strength of knee extension and hip abduction largely confirm the hypotheses of our study. 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 that the critical period for the development of neuromuscular control patterns occurs during the PBL stage before the transition to the POST stage of maturation.

These results provide evidential support for the concept of implementing resistance training programs in high school. This strength training would be particularly emphasized in the early grades of secondary school, to reach the PRE and PBL stages of maturation in order to prevent the development of altered patterns of neuromuscular control observed in the POST maturation stage. This injury prevention model would have the advantage of being able to be implemented in a mandatory or systematic way through existing networks (for example, physical education classes), which could be carried out on a large scale. Furthermore, strength training is a very basic and easy-to-understand concept for physical education teachers to incorporate into their curricula with low-cost equipment [11] and can avoid documented compliance and knowledge issues demonstrated with coaches. in many sports [12].

Given the significant impact that ACL injuries have on musculoskeletal health and function, and the opportunity that may be present to engage in true large-scale primary injury prevention, more research is needed using prospective cohort and intervention designs. randomized by groups.

REFERENCES:

1. Dai B et al. RSM, 2012, 20(3–4):180–197

2. Hewett TE, et.al. AJSM, 2005, 33(4):492–501

3. Dai B and other RSMs, 2012, 20(3–4):198–222

4. DiStefano L, et.al. JSCR, 2015, 29(9):2465–2473

5. Croix, MS JSSM, 2007, 6(3):292–304

6. Herman D, et al. AJSM, 2008, 36(4):733–40

7. Davies PL, et al. POTP, 2000, 20(1):19–42.

[ PubMed ] 8. Padua DA, et al. JSM, 2009, 37(10):1996–2002

9. Padua DA, et al. JAT, 2015, 50(6):589–95

10. Beutler, A., et.al. JSSM, 2009, 8:663–671

11. Herman D., et al. MSSE, 2014, Suppl.

12. Norcross M, et al. JSMS, 2015, not available

Thanks:

This study was supported by a Richard S. Materson New Investigator Grant through the Foundation for Physical Medicine and Rehabilitation, and the Training Program for Rehabilitation Medical Scientists.

Fellow Category Award Winner

Neuromotor block by transcutaneous direct current block

Fustaf M. Van Acker, III., MD, PhD; Nilov Bhadra, MD, PhD; Tina L. Vrabec, BS; Narendra Bhadra, MD, PhD; dr. John Chae; dr. Kevin L. Kilgore

Spasticity is a major cause of functional limitation and pain after upper motor neuron injury or disease. Treatment of existing spasticity primarily involves systemic or local administration of neuromuscular blocking pharmacological agents. These agents are associated with negative side effects and significant cost, limiting the desirability of long-term treatment. Alternatively, neuromuscular blockade with electrical current can be applied to an anatomically targeted area with minimal or no systemic side effects, can be turned on and off almost instantaneously, and can be dose-modified through a stable partial block that can be applied to preserve muscle tone for functional purposes. However, to date, a true nerve conduction block has not been achieved using a non-invasive electrical methodology.

Here we have developed a new means to block peripheral nerve transmission using electrodes placed on the skin surface. This non-invasive transcutaneous direct current block (tDCB) applies a constant current, rendering cells refractory to repeated depolarization. By doing so, tDCB may be purely inhibitory, depending on the characteristics of the waveform. This is fundamentally different in principle from clinically available non-invasive electrical stimulation-based approaches using 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 inhibitory or competitive circuits within the nervous system. tDCB produces a direct nerve conduction block at the delivery site. It is analogous to a local neuromuscular blocking agent, except that it is produced electrically and has the unique ability to titrate and decrease almost instantly and reversibly for optimal efficacy. DC has a good safety profile and has been widely used for clinical and research applications in transcranial direct current stimulation (tDCS) and transspinal stimulation (tsDCS). However, to our knowledge, transcutaneous DC has never been investigated for blocking action potential conduction in the peripheral nerve.

Data was collected from adult Sprague Dawley rats. General anesthesia with isoflurane was maintained for each procedure. Surgical exposure of the sciatic nerve was performed, from one centimeter lateral to the midline to the bifurcation of the tibial and peroneal nerves. The sural ramus was crushed to eliminate the conduction to the gastrocnemius, leaving intact the conduction through the tibial and common peroneal nerves. A platinum bipolar J-cuff electrode was placed circumferentially to span approximately 270° of the proximally exposed sciatic nerve. This proximal stimulating electrode delivered cathode or anode biphasic stimulus pulses at 1 Hz and 20 µs per phase to evoke muscle activity and dorsiflexion of the foot. Force production was monitored using a force transducer attached to the foot. The stimulus amplitude at which maximum sciatic nerve activation occurred was delineated by monitoring force output while gradually increasing the stimulus current until force output stabilized. This stimulus amplitude was subsequently applied concomitantly with tDCB. With the proximal stimulating electrode in place, the muscle and skin were sutured closed.

tDCB was applied to the skin over the tibial and common peroneal nerves distal to the proximal stimulating electrode, through Ag/AgCl ring electrodes with internal and external diameters of 0.6 and 1.2 cm, respectively (EL-TP-RNG Sintered; Stens Biofeedback Inc, San Rafael, California). Conductive gel (Signa, Parker Laboratories Inc., Fairfield, NJ) was placed in a thin layer between the electrode and the skin surface. Four general geometric configurations of electrodes in relation to the nerve were investigated: 1) active and return electrodes placed on opposite sides of the leg/nerve, oriented perpendicular to the target nerve; 2) active and return electrodes placed on opposite sides of the leg/nerve, at acute or obtuse angles relative to the target nerve; 3) active and return electrodes on the same side in relation to the leg/nerve, oriented parallel to and directly superimposed on the target nerve; and 4) active and return electrodes on the same side in relation to the leg/nerve, oriented perpendicular to the target nerve.

Each tDCB waveform consisted of 1) a 2 second acceleration phase from zero current to 2) a 4 to 10 second phase at constant current, followed by 3) a 2 second deceleration phase. The ramp prevented the generation of action potentials in the nerve at the initiation/compensation of the current. The maximum current intensity applied was 20 mA.

Complete neuromotor blockade, manifested by complete removal of the force evoked by the stimulus, was routinely achieved with stimulus amplitudes equal to or less than 20 mA and as low as 5.5 mA. A direct relationship was found between the amplitude of the tDCB stimulus and the percentage of motor block. These partial blocks were consistent during tDCB. The maximum force evoked by the stimulus returned as soon as the tDCB was discontinued. No evidence of action potential generation was observed when ramping up and down was applied.

The #1 electrode geometry, with the active and return electrodes placed on opposite sides and perpendicular to the leg/nerve, had the greatest blocking effect. Blockade was achieved, albeit less robustly, in configuration #2, in which the active and return electrodes were placed on opposite sides of, but not directly perpendicular to, the leg/nerve. Configurations #3 and #4, in which the active and return electrodes were placed on the same side of the leg/nerve, produced no nerve conduction block up to current intensities of 20 mA. Effective nerve conduction blockade may depend on the geometric configuration that directs current flow from one side of the nerve to the other, thus 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 observed at the end of each study.

Successful blockade of neuromuscular activity in the periphery using tDCB may provide a non-pharmacological and inexpensive alternative for the treatment of spasticity. The ability to provide a stable incomplete block may provide the ability to modulate the optimal amount of spasticity block, allowing residual muscle tone to preserve functionality. Delineating the factors that affect the success of transcutaneous nerve block, such as stimulus parameters, electrode placement, and design, is important for future nerve block applications.

Resident Category Award Winner

Ten-Year Trends in Pediatric Inpatient Rehabilitation: Prediction of Length of Stay and Rehabilitation Outcomes Using WeeFIM Data

Dra. Tracy Knippel; Amy Houtrow, MD, PhD, MPH

Goals.With the changing landscape of healthcare, it is important to determine how to make rehabilitation as effective as possible in an efficient and cost-effective manner. There is no consensus on the optimal provision of rehabilitation care, especially in pediatrics. Recent studies have highlighted discrepancies in pediatric rehabilitation care structures and processes within and between different rehabilitation centers. Other investigators have attempted to define the determinants of outcomes and length of hospital stay (LOS) for children admitted to inpatient rehabilitation programs. Taken together, these showed that age, diagnosis, and functional status at admission predict LOS and functional outcomes. However, national data trends are not available. This project aims to help fill the gaps in our knowledge and has several objectives. First, we sought to assess overall trends in pediatric inpatient rehabilitation over a ten-year period to examine how care is changing in relation to patient demographics, health, and functional characteristics, as well as facility characteristics in which care is provided. It is provided. Second, we sought to identify patient and facility characteristics that predict length of stay and efficiency of rehabilitation. Finally, we characterize regional variations in rehabilitation care.

Project:We used a retrospective analysis of existing Uniform Data Systems (UDS) WeeFIM data collected from all participating pediatric rehabilitation programs in the United States from 2004 to 2104. Descriptive statistics were calculated for admissions to pediatric rehabilitation centers and patients during the period. to study. Variability in LOS throughout the 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 ANOVA and Tukey HSD post hoc comparisons. We examined the effects of patient age and diagnosis on outcome variables (LOS, admission WeeFIM scores, WeeFIM gain, and WeeFIM efficiency) using one-way ANOVA and Tukey HSD post hoc comparisons. A hierarchical linear model 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, region of facility (Northeast, Midwest, South, West), insurance type (public, private), WeeFIM admission score, facility type (freestanding, hospital facility-based ), facility size (based on number of beds), and year of discharge]. At the facility level, we examined the growth of inpatient rehabilitation units versus freestanding inpatient rehabilitation facilities over time. Next, specific disability groups were assessed. We looked at how each disability group changed as a percentage of total inpatient rehabilitation admissions over time. For all study analyses, missing data were excluded from the models.

Results:Between 2004 and 2014, 67 facilities reported WeeFIM data to the UDS, representing 42,702 inpatient rehabilitation admissions during the study period. At the individual level, LOS varied widely. The mean length of stay was 28 days, the median 19 days, with a range of 1 to 944 days. Slightly more than 10% of the children had a hospital stay of 60 days or more. From 2004 to 2014, the average stay decreased significantly (F = 27.6, p < 0.0001). The average LOS in 2014 was 24 days compared to 31 days in the previous decade.

The mean total WeeFIM score at admission was relatively stable over the 10-year period (range 49.62 to 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 an almost linear increase over the study period.

Using hierarchical linear models, length of stay, age, region, insurance type, WeeFIM admission score, facility type, number of comorbidities, facility size, and year of high were significant predictors of WeeFIM efficiency (R2 = 0.22) . The strongest correlations with higher WeeFIM efficiency were older age, private insurance, shorter stay, and facilities in the Northeast.

At the facility level, the total number of free-standing units has remained stable over time, but has decreased as a percentage of total facilities providing pediatric rehabilitation services (from 26% in 2004 to 20% in 2014). Most freestanding pediatric rehabilitation units are located in the northeastern United States.

Certain disability groups are becoming more or less admitted to inpatient rehabilitation over time. In 2004, disability accounted for 0% of admissions for rehabilitation and increased to 5% in 2014. In 2004, musculoskeletal disorders accounted for 15% of admissions and decreased to 8.6% in 2014. By comparison, injuries Acquired brain disorders accounted for 49% of admissions. admissions for rehabilitation in 2004 and 47.7% in 2014.

Conclusions:The way inpatient pediatric rehabilitation services are delivered is changing over time. In our study period, we found that although the LOS is quite individually variable, the overall LOS is decreasing. There is a trend to provide rehabilitation care in a hospital setting as opposed to a free-standing facility. Although children have shorter stays, they do not necessarily enter with higher functional levels, as evidenced by relatively stable WeeFIM admission scores over time. WeeFIM efficiency is improving over time, but this rate of change is not keeping pace with the decrease in LOS, as evidenced by the decrease in WeeFIM gains over time. This means that the children were being discharged home with more functional limitations, transferring recovery to the outpatient sector.

In our hierarchical model, nine of the eleven input variables 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 the variables that affect length of stay in pediatric rehabilitation and the efficiency of rehabilitation. Understanding how the various factors that affect the efficiency of WeeFIM can provide a starting point for intervention measures aimed at reducing length of stay and improving efficiency in pediatric rehabilitation units across the country. We believe this is important because healthcare as a whole is moving towards standardization of care processes.

Award Winner in the Medical Student Category

Ryan Sankovic, Bachelor of Science; Ameya Nanivadekar, MSE; Ahmed Kashkoush, Bachelor of Science; William F. Cusack, PhD; Lee Fisher, PhD; Robert A. Gaunt, PhD

People with spinal cord injury (SCI) face significant challenges with urinary tract function as a result of loss of supraspinal control. These complications have led to the development of several clinical devices focused on improving bladder management, with the goal of decreasing urinary tract infections and healthcare costs and improving the quality of life for people with IBS. However, many of the clinical methods and devices for monitoring and managing bladder function are imperfect. Electrical microstimulation can be an effective method to solve these problems, but there is currently no device available. A potential site for microstimulation of afferent fibers involved in the lower urinary tract (LUT) is the dorsal root ganglion (DRG). Feline LUT reflex pathways travel primarily 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 penile nerve (pudendal nerve branch). Sensory input from the pelvic nerve is important in completely emptying the bladder via LUT reflexes. The primary goal of these experiments was to identify recruitment patterns of LUT afferents in response to DRG microstimulation. A second goal of these experiments was to combine single channels with the same physiological function and stimulate them to try to elicit greater physiological responses (both urination and continence).

All experimental protocols were approved by the University of Pittsburgh Institutional Animal Care and Use Committee. Detailed surgical procedures and experimental methods common to the targets have been previously described (Bruns et al. 2015) and are briefly summarized here. Surgical procedures were performed under isoflurane anesthesia and animals received mechanical ventilation. The abdomen was opened, and a double-lumen catheter was placed in the bladder to monitor bladder pressure and 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 the prone position, and the pudendal nerve and its branches were dissected. Customized nerve cuff electrodes were placed on the pudendal, rectal, perineal, sensory, caudal rectal, and deep perineal nerves. Following a sacral laminectomy, microelectrode arrays (Utah arrays, 32 channels per device, 400 µm electrode spacing) were implanted into the DRG S1 and S2 unilaterally. Microstimulation was delivered through individual DRG electrodes with stimulus amplitudes ranging from 3 to 50 μA. Electroneurogram (ENG) signals from the nerve cuffs were recorded and stimulus-triggered averaging was used to examine peripheral nerve activity for the presence of compound action potentials. Functional tests to determine bladder responses and EUS were performed under alpha-chloralose anesthesia to avoid suppression of spinal reflexes. Functional tests involved stimulation of a single channel from each of the electrodes on the arrays at S1 and S2 with different stimulus parameters from 2 to 50 Hz and 3 to 50 μA. In addition, channel combinations that elicited similar physiological responses were tested to observe changes in the physiological response.

ENG data showed selective recruitment of the pelvic nerve by 8 electrodes at a mean threshold of 9.6 μA +/− 3.0 μA. The pudendal nerve was selectively stimulated by 5 electrodes at a mean threshold of 18.7 μA +/- 10.0 μA. Pudendal branches that were selectively stimulated include the sensory nerve, with 12 selective electrodes at a mean threshold of 17.1 μA +/− 8.5 μA, and the deep perineal branch, with 1 selective electrode at a threshold of 15, 6 μA. No selective response was observed in the caudal rectal and rectal perineal nerves.

The results of the functional tests of the two animals showed that single channel stimulation elicited bladder contractions without simultaneous EUS contraction at 45/128 electrodes of S1 and S2 of both animals. Amplitudes of at least 20 μA were required for 97% of bladder contractions to occur. The mean magnitude of bladder contraction was 6.3 mmHg +/− 2.4 mmHg. The highest observed bladder contraction was 14 mm Hg. Combining two channels that individually displayed large bladder contractions at 10 µA and 30 Hz for a duration of 30 seconds showed a sustained bladder contraction of 8 mmHg. 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 at any electrode. We have also found that, in some cases, simultaneous stimulation of multiple channels in subthreshold currents can elicit a physiological response similar to stimulation of suprathreshold currents in individual channels.

Several limitations occurred in this study. In the second experiment, it was difficult to record reliable intraurethral pressures due to challenges in transducer placement. Instrumentation of the various nerve branches was also difficult, leading to poor recording performance in several cases. It is also possible that the difficulties in obtaining large functional responses could have been caused by compression of the nerves from the nerve cuffs themselves. One possible way to improve this research in the future would be to include the L7 DRG in the study, as we found some evidence in our study that L7 stimulation could elicit EUS contractions.

PRESENTATIONS OF SCIENTIFIC WORKS Friday, February 19, 2016

Analysis and Management of the Incidence of Diabetic Hypoglycemia in an Acute Rehabilitation Unit

Xiaoli Wang, MD, PhD; Rachel Levihaiem, Doctor of Pharmacy; Adrian Cristian, MD

Goals.Untreated diabetic hypoglycemia can cause medical emergencies such as seizures and loss of consciousness, leading to discontinuation of rehabilitation treatment. The objective of this study is to monitor hypoglycemic events in the KJMC acute rehabilitation unit and to evaluate the effectiveness of the hypoglycemic treatment protocol in the management of diabetic hypoglycemic events.

Project:Hypoglycemic events of diabetic patients admitted to an acute rehabilitation unit were documented from February 2015 to May 2015. According to the KJMC Hospital-Wide Hypoglycemia Treatment Protocol, hypoglycemia is defined as a level of Glucose less than 70 mg/dL detected with a glucometer. Patients with different glucose levels were treated, respectively, with oral glucose supplementation, IV dextrose supplementation, IM glucagon, or combination therapy. Related information was collected, including symptoms, glucose level before and after treatment, treatment strategies, time the treatment protocol was repeated, related events including PT/OT treatment discontinuation, CODE doctor, acute patient transfer. All the information was reviewed and analyzed at the end of the investigation.

Results:Over a period of 4 months, 99 diabetic patients were admitted to the KJMC acute rehabilitation clinic, and 28 cases of hypoglycemia were recorded. Among the 28 cases, 24 cases were asymptomatic; 11 cases repeated the treatment protocol; 3 cases were symptomatic and received combined treatment. The 28 repeat cases of finger glucose were optimized to normal after treatment and no PT/OT treatment was interrupted. There was no initiation of medical CODE or related acute transfers.

Conclusions:Hypoglycemia in diabetic patients is a common phenomenon with a high incidence in KJMC acute rehabilitation clinic. Hypoglycemic events were optimally managed with the KJMC Hypoglycemic Treatment Protocol. The protocol is a good tool for quality improvement in patient safety and health care.

Association between rehabilitation time and outcomes after traumatic spinal cord injury

Kurt Herzer, MSC; Yu-Ying Chen, MD, PhD; Allen Heinemann, PhD; Marlis González-Fernández, MD, PhD

Goals.The benefits of early rehabilitation after traumatic spinal cord injury (SCI) remain unclear. The aim of this study was to examine the relationship between rehabilitation time (TTR) after SCI and rehabilitation outcomes, measured at discharge and 1 year post-injury.

Project:We conducted a retrospective study using data from 23 spinal cord injury model systems in the United States. Patients who suffered a traumatic SCI between 2000 and 2014, older than 18 years, and who were admitted to a Model System within 24 hours of the injury made up our study population (N = 3937). TTR was measured as the number of days between injury and admission to hospital rehabilitation. Pre-specified outcome measures included Functional Independence Measure (FIM) motor score at discharge and 1 year post-injury (Rasch transform), a dichotomous measure of discharge to private home, and the Assessment and Reporting Technique of Craig's disability (CHART). Physical independence and mobility scores (0-100 scale) 1 year after injury. Instrumental variables regression was used to reduce confounding of disease severity/unobserved comorbidities. All models controlled for sociodemographic and injury characteristics (including injury severity), FIM motor score at admission, and length of rehabilitation 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 CHART physical independence score of 3.92 a year later. -lesion (95% CI, -7.66 to -0.19; P = 0.04). Compared with the mean FIM motor score (37.5) and the CHART physical independence score (74.7), they represent relative decreases of 4.0% and 5.3%, respectively. There was no association between longer TTR and the probability of discharge to a particular home, 1-year FIM motor score, or CHART mobility score.

Conclusions:Efforts to promote early rehabilitation after traumatic SCI may improve patients' functional status at discharge.

Altered use of the upper extremities and motor coordination in children with hemiplegic cerebral palsy after the combination of botulinum toxin-A and restraint-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; Julia Steiner, MA

Goals.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. The objectives of this study were to examine possible post-BoNT-A as well as post-CIMT changes in: 1) subjective reporting of use of the affected arm (Pediatric Motor Activity Log [PMAL]); and 2) coordination of the reaching and grasping movement (three-dimensional kinematic analysis). The relationship between changes in PMAL scores and kinematic measures was also explored.

Project:Eight children with hemiplegic cerebral palsy (4 boys, 4 girls, 6.5-12 years) were recruited from a pediatric rehabilitation clinic. Inclusion criteria: need for BoNT-A in upper limbs, grasp and release, and good cognition. Exclusion criteria: contractures or surgery of the upper limbs and BoNT-A of the upper limbs in the last 6 months. Participants received upper limb BoNT-A followed by a 3-week CIMT program. Measurements included PMAL and three-dimensional kinematic analysis of the thorax and arm segments during reaching to grasp a kaleidoscope. Measurements were taken at baseline, 4 weeks after BoNT-A, and 3 weeks after CIMT.

Results:There were no significant differences between groups between baseline and post-BoNT-A mean scores in the frequency (HO) or well-being (HW) domains of PMAL. There were statistically significant improvements in PMAL means between post-BoNT-A and post-CIMT (p = 0.008 HO and p = 0.02 HW) and at baseline and after CIMT (p = 0.008 HO and p = 0.008 HW). Kinematic analysis revealed individual patterns of impaired motor coordination with relatively greater improvement after CIMT. Moderate associations were identified between changes in specific coordination patterns and changes in PMAL scores.

Conclusions:Subjective reports of arm use indicated a significant improvement in the cumulative effects of BoNT-A and CIMT, but not only with BoNT-A. Although generalizability is limited by the small sample size and individual change patterns, the findings support further study of the combination of BoNT-A and CIMT, as well as the association between upper extremity kinematic changes and fitness. daily function.

Combined non-invasive direct current stimulation of the brain and spine in the recovery of upper limbs in chronic iSCI: a case series

Jessica M. Beardsley; Dr. Zafer Keser; Gerard E. Francisco, MD; Dra. Nuray Yozbatiran

Goals.The aim of this study is to evaluate the effects of non-invasive transcranial anodal direct current stimulation (tDCS) and non-invasive transcutaneous anodal spinal current stimulation (tsDCS) combined with robot-assisted training (R-A training) on ​​the motor of the Superior limbs. in adults with chronic tetraplegia due to incomplete spinal cord injury (iSCI). Preliminary literature and data suggest that non-invasive brain and spinal cord stimulation with R-A training will significantly improve arm and hand function compared with combined treatment of brain stimulation and R-A training.

Project:This study uses a combined case-control design. Four adults with chronic cervical iSCI (AIS levels C and D) are assigned to receive tDCS and tsDCS combined with R-A training or tDCS combined with R-A training. The treatment is given five sessions a week for two weeks. The evaluation of the motor behavior of the upper extremities for the training arm is carried out at the beginning and at the end of ten sessions. The main clinical measure of 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 measures.

Results:Two people were included in the study and are undergoing treatment. Subject 1 is a 59-year-old man with a history of C3-C4 ASIA D SCI trauma. The time since the injury is 84 months. Subject 2 is a 64-year-old man with a history of C3-C6 ASIA D SCI trauma. The time since the injury is 60 months. Baseline assessment of upper extremity motor and sensory behavior in the training arm was measured for both subjects.

Conclusions:This study is ongoing. Data will continue to be collected to see if non-invasive brain stimulation combined with non-invasive spinal cord stimulation and R-A training will improve upper extremity motor function compared to brain stimulation and R-A training.

Effect of AbobotulinumtoxinA (Dysport®) injections on function in children with dynamic clubfoot deformity due to cerebral palsy: analysis of treatment goals, gait, and quality of life from a phase 3 study

Maurice R. Delgado, M.D.; Barry Russman, MD; Mark Gormley, MD; Jorge Carranza, MD; Leader Nigar, MD; Marcin Bonikowski, MD; Resa Aydin, MD; Umit dining room; Dr Ozlen Peker; Zbigniew J. Lipczyk, M.D., Orthopedic Surgery; Anissa Tse, BM, BS; Philippe Picaut, PhD in Pharmacy/PhD

Goals.To assess the effectiveness of AbobotulinumtoxinA (ABO, Dysport®) ABO in improving functional capacity and quality of life of focal/segmental spasticity in patients with cerebral palsy (CP).

Project:An international, double-blind, placebo-controlled study was conducted in children (2 to 17 years of age) with dynamic clubfoot deformity due to cerebral palsy. Patients were randomized (1:1:1) to receive injections of ABO 10U/kg/leg, ABO 15U/kg/leg, or placebo in the gastrocnemius-soleus complex (injected into 1 or 2 legs).

Functional outcomes included the Goal Achievement Scale (GAS) at Week 4, change from baseline to Week 4 on the Observational Gait Scale (OGS; initial foot contact), and change from baseline to Week 12 on the Pediatric 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 to improve gait pattern (70.2% of patients), improve balance (32.3%), and reduce falls (31.1%). While patients in the ABO groups achieved the goal better than expected (GAS score 50.9 for ABO 15U/kg/leg, 51.5 for ABO10 U/kg/leg; score of 50 represents goal achieved as described). expected), patients in the placebo group did not achieve the expected level (score 46.2). Treatment effects for GAS were significant for both ABO groups versus placebo (p = 0.0031 and p = 0.0006, respectively). Improvements in gait were also observed with doses of 15U/kg/leg (difference between treatment and placebo: 1.1 [0.3, 1.9]; p=0.01) and 10U/kg/leg (1, 5 [0.7, 2.2], p=0.0003). Significantly more ABO-treated patients had a ≥1 grade improvement in baseline OGS foot contact scores than placebo (odds ratio 9.8 and 7.8 vs. placebo, respectively, both p = 0.0001). The fatigue subscale in the PedsQL CP module showed a statistically significant improvement at week 12 for both ABO groups versus placebo (p = 0.037 and p = 0.030, respectively).

Conclusions:This large placebo-controlled study in pediatric CP patients demonstrated that the improvement in muscle tone/decrease in spasticity provided by ABO treatment directly translated into functional benefits and reduced fatigue.

Efficacy and safety of repeated injections of botulinum toxin A for upper extremity spasticity after stroke

Ziyad Ayyoub, MD; Angélica Hanschmann, MSC; Reinhard Hiersemenzel, MD; Dr. Michael C. Munin

Goals.To investigate the efficacy and safety of repeated injections of botulinum toxin A (Xeomin®) for post-stroke spasticity in the upper extremities.

Project:This 36-week open-label extension (OLEX) evaluated subjects (18 to 80 years of age) with post-stroke spasticity of the upper extremities who completed the 12-week, randomized, double-blind, placebo-controlled (PM ) from a phase III study (NCT01392300). Subjects received 3 treatments of incobotulinumtoxinA (400U), injected into the affected muscles of one upper extremity at fixed injection intervals of 12 weeks. The main outcome measures included: assessment of muscle tone [Ashworth Scale (AS)]; Disability Rating Scale (DAS); Caregiver Burden Scale; and the incidence of adverse events (AEs).

Results:Nearly all subjects (296/299) who completed the MP received incobotulinumtoxinA on the OLEX; 248 subjects completed the OLEX. The proportion of subjects with a ≥1 point improvement in AS score from each incobotulinumtoxinA treatment at the respective 4-week post-injection visit ranged from 52.3% to 59.2% for wrist flexors, 49.1% to 52.3% for elbow flexors, 59.8% to 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 primary objective domain improved significantly from each incobotulinumtoxinA treatment to the respective 4-week assessment (p < 0.0001 for all). From the onset of PM to the final study visit (week 48), significant improvements were observed in caregiver burden scale scores for "palm wiping" (58/108 subjects, 53.7% ; p < 0.0001), "cutting your nails". ' (65/125 subjects, 52.0%; p < 0.0001), 'wiping armpit' (50/112 subjects, 44.6%; p=0.0023), and 'putting arm into sleeve' (59/116 subjects, 50.9%; p < 0.0001). 'Apply 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 extremities (n=2, 0.7%) and constipation (n=2, 0.7%). Severe AEs were reported by 22 individuals (7.4%); none were related to treatment.

Conclusions:Repeated treatment with incobotulinumtoxinA is well tolerated, significantly reduces upper extremity spasticity, and leads to significant improvements in muscle tone that translate into clinically significant improvements in disability and caregiver burden.

Imaging, Behavioral, and Electrophysiological Analysis of Neuromuscular Function in Aged C57BL/6J Mice

W. David Arnold, MD; Kajri A. Sheth; Vicki L. McGovern, PhD; Arthur H. Burghes, doctorado

Goals.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 interplay between motor unit function, grip strength, and muscle mass. We are also testing whether overexpression of a specific protein can prevent age-related deficits.

Project:Electrophysiological measurements of motor unit function (compound muscle action potential amplitude, CMAP, and estimated number of motor units, 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 analyzed with grip strength and hindlimb MRI and electrical impedance myography (EIM) for muscle size/quality. Protection against loss of motor units will be evaluated in mice with overexpression of a specific protein.

Results:The CMAPs at 10 m (50.7 ± 12.4 mV), 13 m (43.6 ± 11.2 mV), 15 m (47.5 ± 6.7 mV), and 17 m (45.3 ± 5 .7 mV) remained unchanged, but at 20 m the CMAPs are reduced (36.1 ± 6.1 mV) (p <0.05). Likewise, MUNE is stable at 10m (341±93), 13m (302±98) and 15m (314±51), but at 17m MUNE shows a slight but not significant reduction (271±51). At 20m the MUNE is reduced (225±77) (p < 0.05). Forelimb and all-limb footprints normalized for body weight at 20 m (3.11 ± 1.10 g and 5.7 ± 0.86 g, respectively) were unchanged relative to 11-m mice. (3.06 ± 0.69 g and 5.62 ± 0.92 g). Overexpression of a specific protein shows protection against motor unit loss after nerve injury, presenting a way to treat sarcopenia.

Conclusions:Preliminary data show motor unit loss before grip strength deficits, suggesting that motor unit loss may be an early and important determinant of age-related sarcopenia. Further longitudinal evaluations and analyzes of muscle size/quality are ongoing. We identified an enhanced nerve regeneration effect after overexpression of a specific protein. We are testing overexpression of this protein as a potential treatment due to the presumed role of motor unit loss in age-related loss of muscle mass and function.

Elevated serum estrone levels predict 6-month mortality in patients with traumatic brain injury

Milap Rakholia, BA; Byung-Mo Oh, MD, PhD; Raj Kumar, MPH; Dr. Amy Wagner

Goals.Recent clinical trials on the use of progesterone to improve long-term outcomes in patients who have sustained traumatic brain injury (TBI) have been unsuccessful, despite preclinical evidence suggesting its ability to mitigate secondary damage after a TBI. The aim of this study was to extend the findings on how changes in the progesterone downstream steroidogenesis pathway affect long-term prognosis by characterizing the effect of estrone (E1), a precursor to estradiol, on mortality. at 6 months after a TBI.

Project:A prospective cohort study was conducted in patients 18 to 75 years of age receiving treatment for TBI at a level 1 trauma center. Demographic data were collected on age, gender, Glasgow Coma Scale Best Score ( GCS) during a 24-hour period, length of stay, mechanism of injury, and type of injury on a CT scan. Blood samples were collected daily for up to 7 days, centrifuged, aliquoted, and stored at -80 °C. For the study, 101 patients and eight healthy controls, aged between 21 and 62 years, were selected. Competitive ELISA kits were used to measure E1 levels in serum. Results from days 0-3 were calculated for analysis.

Results:Mean E1 levels in the TBI cohort were more than 3-fold higher than in the control (359.9 pg/mL vs 99.2 pg/mL, p < 0.001). There were no significant differences in the demographic variables, neither for the E1 quartile nor for the 6-month survival. The covariates of age, sex, and best 24-hour GCS were controlled for by determining the association between 6-month mortality and the E1 quartile. We found that for any increase in the E1 quartile, there was a 1.7-fold increase in the odds of mortality (odds ratio, 1.695 [95% CI, 1.197 to 2.193]; p = 0.034).

Conclusions:Serum E1 levels are elevated in TBI compared to controls. Furthermore, elevation in the TBI cohort is associated with an increase in 6-month mortality. Acute serum E1 serves as a predictor of long-term mortality and may provide information to guide future hormone-directed therapies for TBI.

Improving motor learning with a cable-actuated lightweight three-dimensional arm exoskeleton (CAREX)

Syed Z. Ali, BS; Viswanath Aluru, MD; Xin Jin; Raj K. Dalsania, BS; Sunil K. Agrawal, PhD; Dr. Preeti Raghavan

Goals.CAREX is a new lightweight robotic upper limb exoskeleton with a wired design that can eliminate gravity and provide roadside assistance using a force field. The objectives of this study were to determine the extent of motor learning in a CAREX circle-drawing task in healthy controls and in chronic stroke subjects in the early and late stages of post-stroke recovery, as defined by their limb. superior Fugl- Meyer (FM) scores.

Project:Seven healthy subjects and nineteen subjects with right hemiparesis following chronic stroke performed 3 sets of 3D circular drawings with CAREX under 3 randomly assigned conditions: (a) gravity removal only, (b) trajectory assist only, and (c) trajectory assist and gravity removal together. subjects did a total of 20 circles, 10 clockwise and 10 counterclockwise, under each of the 3 experimental conditions during a single session.

Results:Path deviation in the circle-drawing task was significantly greater in stroke subjects in all conditions compared with 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) subgroups (61.6 ± 1.32). The high FM subgroup had less trajectory deviation (0.11 ± 0.04) with trajectory assist and severity removal together comparable to controls (0.08 ± 0.04, p > 0.1). In contrast, the low FM subgroup showed a greater deviation from trajectory in this condition compared to controls (0.26 ± 0.11, p2 = −0.53). Control subjects showed no difference in path deviation under the three conditions.

Conclusions:The results suggest that robotic training strategies to control movement trajectory are best provided when sufficient movement recovery occurs. Stratification of people with stroke based on stage of recovery may determine optimal robotic treatment strategies to improve performance and improve motor learning after stroke.

Examining the psychological effect among physiatrists treating traumatic injury patients: the role of secondary traumatic stress

Ann Marie Warren, PhD; Megan C. Reynolds, MS; Simon Driver, PhD; Jacob Christiansen, Bachelor of Science; Monica Bennett, PhD; rita hamilton

Goals.Studies have shown that secondary traumatic stress disorder (STS), an indirect form of post-traumatic stress disorder (PTSD), can occur in physicians as a result of caring for patients who have suffered a traumatic injury. However, STS remains unexplored among physiatrists in the rehabilitation setting. Therefore, the aim of the present analysis was to examine the relationship between STS, personality traits, and resilience among physiatrists.

Project:The surveys were distributed to the membership list of the Academic Physiatric Association, as well as to a local private group of physiatrists, between January and June 2015. Eligibility included physiatrists who provide direct care to traumatic injury patients. Surveys included: (1) 21-item Secondary Traumatic Stress Scale (STSS), (2) Conner Davidson Resilience Scale (10 items), and (3) 10-item Personality Inventory (TIPI). Demographic and career-related information was also collected.

Results:Of the 102 returned questionnaires, 89 were fully completed and included for analysis. The mean age of the participants was 41.7 ± 11.2 years, including 44 men (49%) and 45 women (51%). With a cutoff score ≥47 to indicate moderate or severe STS, 18 (20.2%) participants tested positive. Physiatrists with STS symptoms had significantly lower TIPI scores on 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 differences were found in demographic and career-related variables.

Conclusions:A substantial number of physiatrists endorsed moderate to severe STS symptoms, consistent with previous surveys among physicians working in a trauma setting, with both groups reporting significantly higher STS symptoms than the general population. Additionally, resilience and personality traits may be useful in identifying physiatrists at risk for STS. These findings provide a basis for developing STS preventive measures and treatments to improve physiatrists' well-being (eg, quality of life) and are also likely to improve patient care and satisfaction.

Type of establishment and functional results during the rehabilitation of hospitalized pediatric patients

Molly M. Fountains, MD; Nathalia Jimenez, MD, MPH; Frederick P. Rivara, MD, MPH; Dra. Susan Apkon

Goals.To compare functional scores among children who received rehabilitation at a children's hospital versus other centers.

Project:Retrospective cohort study using the national database Uniform Data System for Medical Rehabilitation of the Functional Independence Measure for Children (WeeFIM®) instrument for the years 2004-2014. Outcomes were motor, cognitive, and total developmental quotient (DQS, WeeFIM® scores/age-based normative score] x 100) and WeeFIM® efficiency scores (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 unloading efficiency DQS and WeeFIM. Regression models used robust variance estimates to account for within-facility correlation and adjusted for age, gender, race, insurance status, region, referral role, type of disability, year of discharge, and (except for the WeeFIM efficiency model) duration of Stay.

Results:A total of 28,793 children from 6 months to 18 years of age were included; 12,732 received rehabilitation in children's hospitals and 16,061 in other establishments. Brain dysfunction (traumatic and non-traumatic) accounted for a higher proportion of patients in children's hospitals compared to other institutions (54.0% versus 43.6%). Patients in pediatric hospitals had lower functional scores on admission (total DQS 43.5 vs 47.3, motor DQS 38.5 vs 42.2, cognitive DQS 56.7 vs 60.7, all hospital stays (median 16 days vs 22 days, efficiency (1.9 vs 1.2, pRehabilitation to a children's hospital was independently associated with high 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 receiving inpatient rehabilitation at children's hospitals show small but significantly better improvement in cognitive function and more efficient rehabilitation hospital admissions than children in other types of facilities.

Factors associated with hospital readmission six months after stroke rehabilitation

Katherine Yao, MD, BS; Joan Toglia, PhD, OTR/L, FAOTA; Michael Taub, MA; Dr. Michael O'Dell

Goals.Identify predictors of readmission 6 months (m) of post-stroke rehabilitation

Project: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 6-month follow-up were analyzed (with no differences based on follow-up status). The 83 subjects were 42% female, 59% white, and 80% with ischemic stroke with (standard deviation) acute length of stay (LOS) of 13.3 (16.5) and rehabilitation LOS of 15.8 (8, 3) d. The dependent variable was "hospital readmission - yes or no" evaluated by telephone interview with an average of 6.4m post discharge. Based on sample size and clinical applicability, 4 independent variables (IV) were chosen: age, National Institute of Health (NIHSS) stroke score via emergency department or neurology, Charlson Comorbidity Index score modified (mCCI) on admission to the URI and total functional independence measured (FIM-D) on discharge from the IRU. Logistic regression evaluated the ability of IV to predict hospital readmission (p < 0.05 considered statistically significant).

Results:25/83 (30%) patients were readmitted 6m after 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 = 0.29, SE 0.12, Wald X²=5.5, p=0.02; odds ratio = 1.33; 95% CI (1.0, 1.7). The model including these 4 variables demonstrated a predictive accuracy of readmission of only 20%, but a predictive accuracy of non-readmission of 93%, with an overall predictive accuracy of 71%.

Conclusions:In terms of age, functional status, and stroke severity, medical complications better predict hospital readmission 6 months after post-stroke rehabilitation. These 4 factors, all potentially available at rehabilitation discharge, accurately identified patients at low risk for readmission. Our readmission rate is higher than in other reports, but otherwise the findings are consistent with previous studies after acute stroke and discharge for stroke rehabilitation. Our study is limited by a small sample size. Future studies should include more participants and predictor variables.

Restoration of Functional Independence for Pediatric Chronic Pain in an Inpatient Rehabilitation Unit

Sara E. Williams, PhD; Andrew Collins, MD; David W. Pruitt, MD; Dr. John B. Rose

Goals.Research in pediatric chronic pain shows that function improves before pain. However, children with high levels of pain and disability struggle to make functional gains in ambulatory care. Inpatient pain rehabilitation allows for greater intensity and frequency of therapies in a specialized setting. This abstract examines the initial results of the Functional Independence Restoration Program (FIRST) for the rehabilitation of hospitalized pediatric chronic pain.

Project:Fourteen patients admitted with a diagnosis of amplified chronic musculoskeletal pain conditions entered the pediatric inpatient rehabilitation unit in the first year of the program. The patients were between 10 and 17 years old; 79% of the sample were women. The average stay was 2 weeks. Inpatients received daily therapies from experts in nine disciplines: physicians, nurses, psychologists, physical/occupational/recreational therapists, schoolteachers, and holistic health and child life specialists. Clinical outcomes were measured at baseline (Day 1) and discharge (usually Day 12). The children rated their mean pain levels on the Numerical Rating Scale (NRS) on a scale of 0 to 10; higher scores indicate more pain. The Functional Disability Inventory (FDI) measured the children's physical limitations secondary to pain; higher scores indicate more disability. The Children's Functional Independence Measure (WeeFIM) assessed performance in the domains of self-care, toilet training, transfers, mobility, communication, and cognition. WeeFIM scores range from 18 (full assistance required in all domains) to 126 (full independence in all domains).

Results:In general, the pain and functional capacity of the patients improved. Pain decreased from baseline (M = 7.36, SD = 1.86) to discharge (M = 5.86, SD = 2.68), t = 3.22, p < 0.01. FDI scores decreased significantly from baseline (M = 36.21, SD = 7.32) to discharge (M = 17.5, SD = 10.33), t = 7.51, p < 0.001. WeeFIM scores increased significantly from baseline (M = 103.29, SD = 7.26) to discharge (M = 119.5, SD = 5.03), t = 11.89, p < 0.001.

Conclusions:A focus on improving function was successful in helping children overcome significant deficits associated with chronic pain in the context of an inpatient pediatric pain rehabilitation program.

Impact of distraction on the control of the brain-computer interface of a robotic arm during a motor task

Lucas Brane; John Downey, Bachelor of Science; Michael Boninger, MD; Jennifer Collinger, PhD

Goals.Our aim was to examine how distractions affect the performance of a brain-computer interface (BCI)-powered prosthetic arm and whether any neural correlates of distraction could be observed. Our hypothesis is that, with increased distraction, there would be a decrease in performance and an increase in the rate of neural activation.

Project:The subject had two arrays of intracortical microelectrodes (MEAs) implanted in his primary motor cortex. The 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 subtraction, counting down from 3, use of a toothpick on the chin, and response to questions. Title performance (number of targets/minute), perceived difficulty rating, and neural and kinematic data were recorded.

Results:The number of successful targets, as well as the perceived difficulty score of the title, did not show statistically significant differences between the distraction variables. Subject reported that the joystick operation distraction variable was the most difficult overall, although this rating was not statistically significant relative to other variables when compared between days. A significant decrease in firing velocity was observed while Subject counted backward by 3s during the motor task. (p < 0.005) Without motor task, a decrease in shooting velocity was observed during background noise, count and subtraction, and chin stick movement compared to baseline (p < 0.005).

Conclusions:Contrary to our hypotheses, no changes in performance were observed and the only changes in neural firing showed a decrease during distraction. The distractions may not have been strong enough to affect performance on a fairly simple BCI task. In some cases, the Subject may have become more relaxed during the distraction. Overall, this is encouraging, as it appears that the BCI control is resilient to these types of distractions.

Impaired memory performance in endothelial nitric oxide synthase knockout mice after ischemic stroke

Shanshan Li, BS; Yao Wang, MD, MS; Yaping Huai, MD, PhD; Ze Jiang, MD;

Goals.Introduction: 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 whether eNOS is involved in memory recall after stroke.

Project:Method: We used eNOS knockout mice (eNOS-/-) to study the role of eNOS during stroke recovery. Fifteen adult c57 BL/6 wild-type (WT) mice and 17 eNOS -/- mice received 60 minutes of transient middle cerebral artery occlusion (MCAO). Functional outcomes including neurological score, limb asymmetry (cylinder test), sensory motor function (sticker removal test), and spatial memory (Morris water maze test) were measured over 4 weeks. The level of microglia was measured by immunohistochemical staining.

Results:eNOS-/- MCAO mice had a significantly higher number of non-performing mice compared to WT MCAO mice during MWM (p = 0.014). Furthermore, eNOS-/- MCAO mice had a significantly longer time to complete the MWM spatial memory test compared to WT MCAO mice (p = 0.0042). However, decreased MWM performance in eNOS-/-MCAO mice was not associated with neurological or motor deficits. 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 the MWM test was performed, although eNOS-/-MCAO mice had a greater motor deficit during the first week after stroke. career. Furthermore, the number of microglia in the striatum on the injured side was significantly higher than on the normal side in the WT MCAO (p = 0.020); however, this elevation was attenuated in eNOS-/-MCAO mice (p=0.38).

Conclusions:Data suggest that eNOS may play an important role in memory recovery after stroke. This discovery could lead to the development of new interventions to improve memory.

Results of the rehabilitation of hospitalized patients diagnosed with venous thromboembolism

Shanti M. Pinto, MD; Dr. Dear Gary

Goals.To investigate the impact of venous thromboembolism (VTE) on inpatient rehabilitation (IPR) transfer for acute rate, length of stay, and change in FIM score.

Project:This is a retrospective case-control study. Patients discharged from a single IPR center at an academic medical center between January 1, 2013 and June 30, 2014 were included. Those admitted for less than 24 hours were excluded. Main outcome measures included carryover to acute hospitalization rate, IPR length of stay, and change in FIM scores. Initial univariate analysis was performed using Chi-square for nominal variables. Continuous variables were analyzed with the Mann-Whitney u test for nonparametric data and the t test for parametric data. All variables were entered into multivariate analyses, and non-predictive variables were removed by backward elimination if p value > 0.200.

Results:During the study period, 2,312 patients were discharged from the IPR, of which 113 were diagnosed with VTE before admission to the IPR and 145 were diagnosed with VTE during admission to the IPR. Controlling for FIM scores for gender and admission, patients with VTE were almost twice as likely to be transferred to the acute hospital than those without VTE. The length of stay in the IPR was more than 4 days longer for those diagnosed with VTE before admission to the IPR and more than 1.5 days longer for those diagnosed with VTE during admission to the IPR. There was a trend of decreasing change in the FIM mobility score 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 intensive care hospital and had a longer stay in the IPR, regardless of admission FIM scores. There was no difference in the change in FIM scores based on VTE diagnosis.

New approach to understanding the contribution of the brain to neurological impairment in patients with cervical spondylotic myelopathy

Carmen M. Cirstea, MD, PhD; José Burris, MD; Sorin C. Craciunas, MD, PhD

Goals.Cervical spondylotic myelopathy (CSM) is the most common spinal cord dysfunction in adults older than 50 years, 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, unexplained variability in recovery remains. As this variability appears to be influenced, at least in part, by remote brain injury or dysfunction, we investigated whether the neurochemical integrity (as measured by proton magnetic resonance spectroscopy, 1H-MRS) of remote primary motor cortices (M1) is altered. and correlated neurological impairment in patients with MSC.

Project:Twenty-one CSM patients and 16 age- and sex-matched healthy controls underwent 1H-MRS imaging assessments (15x15x15 mm3 volume of interest placed in the hand representation in each M1). Three neurochemicals considered most likely to be involved in brain injury/dysfunction were quantified and compared: N-acetylaspartate (a marker of mitochondrial neuronal integrity), myo-inositol (a glial marker), and choline (a marker of cell membrane integrity/inflammation). at the controls. Relationships between neurochemical concentrations and neurological impairment (9-Hole Peg Test, Modified Japanese Orthopedic Association Scale) were also evaluated.

Results:MSC patients generally had significantly lower N-acetylaspartate and significantly higher choline in left and right M1 compared with control (p≈0.1-0.3; p = 0.009 and p = 0.005, respectively). Variable changes in myo-inositol concentrations were observed, although 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 a significant inflammatory reaction and moderate neuronal changes in remote M1, with changes in the left M1 associated with neurological impairment. Therefore, 1H-MRS may be a sensitive method to quantify relevant remote neurochemical changes in the MSC and consequently increase our knowledge of the factors that lead from these remote motor cortex changes to clinical deficits in these patients.

Personalized prevention of pressure ulcers in spinal cord injuries: development of a multivariate biomarker approach

Kath Bogie, DPHIL; John McDaniel, PhD; Jennifer Graebert, Licenciada en Ciencias; Tykie Theofilos, BS; M. Kristi Henzel, MD, PhD

Goals.The development of pressure ulcers (PU) remains a very important source of morbidity for many people with spinal cord injury (SCI). Essentially, the development of PU is prevented by keeping the tissue healthy under the applied load. Pressure relief regimens are prescribed based on standardized thresholds. However, the continued high incidence of pressure ulcers in SCI indicates that these regimens are inadequate.

Alterations in muscle composition and functional response to applied load may provide the clue to personalized risk status that the clinician can use to determine an individual's optimal PU prevention regimen. The central hypothesis to be tested is that muscle quality is a critical objective indicator of increased susceptibility to PU after SCI.

Project:Contrast-enhanced pelvic CT scans are obtained with the subject supine with a pillow under the legs to minimize soft tissue compression. Gluteal muscle composition is determined along with tissue health outcomes, including transcutaneous oxygen (T_CAFTER₂) and laser Doppler blood flow (LDF). T downloaded_CAFTER₂and blood flow are monitored with the subject lying on their side for 10 min to obtain T_CAFTER₂levels and blood flow bilaterally over the discharged IT.

Results:Muscle composition was found to vary across the gluteal muscle in the current cohort of 17 subjects with spinal cord injury. The region below the ischial tuberosities had less lean muscle and more intramuscular fat infiltration (IMAT) than the proximal muscle (p < 0.05). Those with more than 20% of IMAT below the ischial tuberosities likely had a history of severe or recurrent pressure ulcers. He wanted to say_CAFTER₂decreased as IMAT increased (p < 0.05, r²=0.84). Spectral analysis showed that muscle composition mainly impacted the metabolic component of blood flow, with significant correlations between the percentage of IMAT (p < 0.01.r²=0.87) and percentage of lean mass (p < 0.01, r²=0,81).

Conclusions:Changes in muscle quality affect tissue health even when the tissues are unloaded. People with a history of severe or recurrent pressure ulcers have a higher IMAT. Detailed analysis of muscle characteristics and tissue health responses can provide a personalized indication of risk status. A better assessment of the risk for the development of PU will have a positive impact on the health status and quality of life of each individual. Current work in progress includes evaluation of biomarkers for muscle quality, inflammatory status, and damage, along with tissue response under load. Longitudinal follow-up will provide the basis for developing a personalized predictive model of pressure ulcer risk.

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

Goals.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) in a level 1 trauma center with an acute care stay of at 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 physical medicine and rehabilitation (PMR) consultation.

Project:A retrospective clinical study of acute trauma patients admitted to the STICU in a level 1 trauma center with days of stay in acute care of at least 14 days was conducted. Patients admitted from January 1, 2013 to December 31, 2013 who were 16 years of age or older and who remained in the ICU for at least 14 days were included in this study. General demographics, characteristics, and disposition of the 126 patients included in this study were then recorded and analyzed.

Results:The general demographics of the 126 acute trauma patients included in this study are as follows: mean age: 42 years; 97 men, 29 women, average Glasgow Coma Scale (GCS) from the emergency department: 9.4; injury severity scale – 31.8; Mean ICU stay: 23.6 days; Days out of the ICU – 13.9 days; Length of stay: 37.5 days; Ventilation days - 18.3 days.

The disposition pattern for the 126 acute trauma patients included in this study is as follows: Rehabilitation: 33%, Long Term Acute Care (LTAC): 27%, Home: 23%, Skilled Nursing Facility (SNF): 10 %, Death: 4%, Psychiatry/Hospital/Asylum – 0.7%.

Characteristics of patients with PMR consultation (64%): Severity scale of injury - 33.4, Mean ICU stay - 24 days, Ventilation days - 19 days, Mean length of stay - 39 days.

Conclusions:Polytrauma patients make up a significant portion of the population admitted to trauma intensive care units, and PMR consultations are generally indicated for these patients. More than 50% of these patients who are discharged from a STICU level 1 trauma center go on to rehab or LTAC. More than 80% of patients present to Rehabilitation, LTAC, or at home, highlighting the importance of the PMR consultation in determining where to send acute trauma patients upon discharge from the critical care hospital.

Second, patients in the STICU with PMR consultation had a worse injury severity scale and were on the ventilator for 2 more days compared with those without PMR consultation (19 vs 17 days). Although the average length of stay was longer for those with a PMR visit (39 versus 36 days), the average ICU stay was 24 days for both groups. This retrospective study shows that patients with a PMR visit have worse injuries but have an equal acute NICU stay.

The presence of spillover movements in children with traumatic brain injury correlates with the size of the corpus callosum segment.

Jamie A. Schub, BA, MS; Dra. Stacy Suskauer; Deana Crocetti, BS

Goals.Children with traumatic brain injury (TBI) often have grossly normal physical examinations despite persistent cognitive and behavioral problems. The main objectives of this study were to characterize fine motor movements in children with TBI and to assess the relationship between spillover movements and corpus callosum (CC) morphology.

Project:Data were collected from 24 children at least one year after mild to severe TBI and 19 age- and sex-matched controls (ages 9.93-18.65 years). Overflow movements were assessed using Physical and Neurological Examination for Subtle Signs (PANESS). Using MPRAGE images, the CC was divided into five segments using an automated algorithm and the areas of the segments were calculated. Independent t-tests assessed differences between groups for PANESS scores and CC areas. Age-controlled partial correlations assessed relationships between PANESS scores and a) CC segment areas, and second, performance on accelerated cognitive tasks.

Results:Children with TBI showed more proximal overflow movements than controls (p= 0.011). Children with TBI had smaller areas for four of the five CC segments (rostral body p=0.018, median body p=0.009, isthmus p=0.043, splenium p=0.044). In children with TBI, there was a negative correlation between proximal overflow and the 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 a significant correlation between proximal spillover and accelerated cognitive tasks (r=−0.481 to −0.663, p=0.001-0.027).

Conclusions:Children with TBI have subtle motor findings in the chronic phase of recovery that are associated with CC size in regions that project to the primary premotor and sensorimotor cortex and also correlate with cognitive performance. This provides an opportunity to increase the sensitivity of the physical exam to both the milder motor effects of TBI and a screen to determine which children might benefit from more extensive cognitive/behavioral assessments.

Rectal temperature: an effective infection screening tool on admissions to traumatic brain injury units

Yuriy Shepelyak, MD; Dr. Sara Cucurullo

Goals.Improve detection of febrile patients admitted to the head trauma unit (BTU).

Project:Improve fever screening among patients admitted to the BTU by performing rectal temperature measurements in patients with oral temperatures greater than 99.0. In addition, all admitted patients had a complete metabolic panel (CMP) and complete blood count (CBC) performed as soon as they arrived at the unit, rather than waiting until the morning after admission. This study evaluated 44 BTU admissions with 29 traumatic brain injuries, 10 strokes, 2 brain tumors, 2 anoxic encephalopathies, and 1 normal pressure hydrocephalus.

Results:The oral thermometer had a fever detection rate of 1/44, while the rectal thermometer had a fever detection rate of 6/44. Of these 6 patients, 1 had negative tests and 5 positive tests: 2 pneumonia, 2 urinary tract infections, and 1 soft tissue infection. In addition, the performance of a 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 along with ALT/AST was found in 8/44 patients (18%). Subdivision of patients into febrile and non-febrile groups revealed that these metabolic abnormalities occurred more frequently in the febrile group compared to the non-febrile 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 tests of function hepatic (OR=3.3).

Conclusions:This is the first reported quality improvement study of admissions laboratory statistics combined with rectal temperatures in BTU patients. The value of rectal temperature in the detection of early signs of infection stands out. This early detection of infections allows early treatment of these BTU patients and results in avoiding interruption of therapies as well as avoiding transfer of these patients to the Acute Care Hospital. In addition, patients with fever were more likely to have associated metabolic abnormalities, leading to more severe prognoses, a finding corroborated by the medical and surgical literature; thus opening the door for further research on these markers in BTU settings. Rectal temperature is a low-cost screening tool that could potentially affect acute inpatient care on a large scale.

Safety and efficacy of increasing doses of botulinum toxin A (400U-800U) for spasticity of the upper and lower limbs: results of the phase III TOWER trial

Jörg Wissel, MD, FRCP; Dr. John R. McGuire; Olivier Simon, MD, PhD; Dr. David Simpson

Goals.Patients with severe multifocal spasticity may benefit from higher-dose botulinum toxin treatment. This study evaluated the safety and efficacy of increasing doses of incobotulinumtoxinA (Xeomin®) (400U-800U) for patients with spasticity.

Project:This prospective single-arm dose titration study (NCT01603459) enrolled adult patients (18 to 80 years of age) with spastic hemiparesis due to cerebral causes, who were expected to require a total body dose of 800U of botulinum toxin A. received 3 consecutive injection (IC) cycles with 400U, 600U and 600-800U of botulinum toxin A, respectively, each followed by 12-16 weeks of observation. Outcome measures included: adverse events (AE), Resistance to Passive Movement Scale (REPAS, based on the Ashworth Scale), Goal Achievement Scale (GAS), and 5-dimensional EuroQoL questionnaire (EQ-5D).

Results:In total, 155 patients were enrolled. IncobotulinumtoxinA dose escalation did not lead to an increase in the incidence of AEs (CI1: 36.1%; CI2: 37.5%; CI3: 25.7%). The most frequent AEs were falls (7.7%), nasopharyngitis, arthralgia, and diarrhea (6.5% each). There were no treatment-related serious adverse events; 5 patients (3.2%) dropped out due to AE.

The mean (standard deviation [SD]) change in REPAS score from each injection up to 4 weeks post-injection increased throughout the study (CI1: -4.6[3.9]; CI2: -5.9[ 4.2]; CI3:-7.1[4.8] ; p < 0.0001 for all). The proportion of patients achieving at least 3 of the 4 treatment goals increased from 25.2% for CI1, to 50.7% for CI2, and 68.6% for CI3. Mean (SD) EQ-5D quality of life scores improved from 59.9 (18.9) at baseline to 69.7 (17.6) at the end of the study visit (p < 0, 0001).

Conclusions:Increasing doses of incobotulinumtoxinA (400U up to 800U) allowed treatment in a greater number of muscles, leading to greater treatment efficacy, resulting in improved muscle tone, achievement of individual goals, and quality of life, without compromising the quality of life or patient safety. tolerability

Safety of the use of botulinum toxin injections in children under one year of age

Supreet Deshpande, MD; Nikhil Deshpande; Dr. Mark Gormley

Goals.Children with cerebral palsy may have hypertonia, and infants with brachial plexus injuries may have contractures due to imbalances in muscle strength that can interfere with nurturing, comfort, and development. Treatment of these muscles with botulinum toxin before one year of age can improve function and minimize adverse impact on development and care. However, in children under 1 year of age due to their small size, there is concern that botulinum toxin injections may lead to adverse effects from the toxin spreading to non-target muscles, which could affect breathing, swallowing and overall strength. This study seeks to demonstrate that botulinum toxin treatment in children under 1 year of age may be safe.

Project:Retrospective review of medical records

Results:23 patients (11 male, 12 female) received botulinum toxin injections before 1 year of age (3 to 12 months) at a mean dose of 6 units/kg, with a range of 3 to 15 units/kg. One patient received botulinum toxin at a concentration of 50 units/cc, the rest received a concentration of 100 units/cc. Ten patients were treated in the lower limbs, 7 in the upper limbs, 11 in the pectorals, 11 in the subscapularis muscles, 2 in the sternocleidomastoid, 1 in the trapezius, and 3 in the suboccipital muscles. Five of the 23 patients had only one muscle treated at the time of treatment, the remaining patients received treatment for a combination of muscles, and 6 received multiple rounds of injections within one year.

Conclusions:22 patients did not report complications. 1 patient experienced fever, vomiting and diarrhea for 1 week after the injections, but a subsequent injection had no adverse effects. Patients who received injections near the throat and chest had no complications. One child treated with a more dilute dose in the neck had no complications. Botulinum toxin injections in children younger than 1 year appear to be safe, although further studies with a larger sample of patients are needed.

The effect of traumatic brain injury on circulating female reproductive hormones: are hormone levels prognostic markers for outcomes?

Maria E. McClanahan, MD; Benjamin Brusch, MD; Justin J. Gilbert, MD; Janet P. Niemeier, PhD; Jonathan Silverman, M.D.

Goals.1) Determine the expression levels of reproductive hormones (progesterone, estradiol, luteinizing hormone, follicular-stimulating hormone, and serum cortisol of 21 women aged 18-35 years with mild to severe TBI and 21 age-matched healthy controls. 2) To obtain evidence of the neuroprotective role of progesterone in women after traumatic brain injury.

Project:prospective case-control design with repeated serum measurements (within 24 hours post-injury and 72 hours post-injury) cognitive, functional, and community engagement scores (baseline and 3-month follow-up) Follow-up was made over the phone. Measures: Minimum Status 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 the women's outcomes after TBI. Controls had significantly higher estradiol levels than patients. Higher Glasgow coma scores were significantly related to higher FSH and LH levels in the lesion. Progesterone had a substantial but not significant positive correlation with social integration. Cortisol was significantly (p = 0.0001) higher for women with TBI than for healthy controls.

Conclusions:The findings reflect the mixed results in the brain injury literature related to gender differences in outcomes after TBI. The findings are also similar to those of Wunderle et al. (2013) in which progesterone did not affect TBI recovery for women in this current sample. Disruptions in menstrual cycles in women who have had TBI may be due to a stress response in the body, as reflected in the high cortisol levels of our TBI participants. More research, with a larger sample size, is needed to shed light on the complex factors underlying the effects of TBI on women's reproductive hormones and ovulatory cycle.

The hip-spine connection: physical examination findings in adolescents and young adults with low back pain

Laura M. Pilgram, BA; Linda Van Dillen, PT, PhD; Heidi Prather

Goals.The objective is to describe the physical examination findings of the hip in adolescents and young adults presenting for evaluation for low back pain (LBP) and to compare pain and function in those with findings of a hip and spine disorder with those with findings of a spinal disorder. only.

Project:This is a prospective observational cohort study of consecutive patients (ages 10 to 23 years) presenting for evaluation by a physiatrist for evaluation of low back pain. Validated patient-reported pain, hip, and lumbar spine questionnaires were obtained, including: pain diagram, Numerical 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 single examiner performed a musculoskeletal and neurological examination and the results were recorded. Specific hip tests were performed, including goniometer measurement of hip range of motion and hip challenge tests. Patient characteristics, pain, and function were compared between those with and without positive hip findings.

Results:Twenty-four consecutive patients (18 women, 6 men) with a mean age of 18.9 years (SD±3 years) and a mean BMI of 23.7 kg/m2 (SD±5 kg/m2) were included. On physical examination, 1) 3 (12.5%) had analgesic 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 hip provocative tests. Those with <20° hip internal rotation had worse hip functional scores (p=0.02) as measured by the mHSS.

Conclusions:This is the first data to describe the connections between the hip and the spine in adolescent and young adult populations with low back pain. Further studies are needed to define how hip disorders impact and contribute to low back pain. Acknowledgements: This study was funded by the Rehabilitation Research Experience for Medical Students (RREMS) program.

The visual performance of non-native versus native English speakers on a lateral concussion screen: an objective view of eye movement recordings

Joel Birkemeier, MD, MBA; Janet Rucker; Todd Hudson, PhD; Weiwei Dai, MS; John Ross Rizzo, MD; Katie Dempsey; Jan Verstraete, MA

Goals.This study investigates the differential ocular motor performance of native English speakers, compared to non-native English speakers, on a lateral concussion screen called the King-Devick (K-D) test under objective recordings of eye movements. More specifically, we tested temporal, spatial, and kinematic oculometry of native English speakers and those who spoke English as a second language on the K-D test.

Project:A total of 54 subjects were evaluated in this study. 27 were native English speakers and 27 for whom English was a second language (ESL). A computer-generated King-Devick test was administered to all participants under infrared-based video-oculographic (VOG) recordings. Subjects also completed a Bilingual Proficiency Scale survey, which quantitatively measures how dominant someone is in their primary versus secondary language.

Results:Test times showed significantly slower times for ESL-speaking participants compared to native English speakers (54.40 +/- 15.37 vs. 42.79 +/- 8.56 P = 0.0014) . saccades was significantly slower for ESL2 (353.16 +/- 97.18 vs 285.18 +/- 44.56 P = 0.0021) In addition, the total number of saccades for ESL was significantly higher (154, 59 +/- 31.44 vs. 0.0282). The maximum extraction speed in both groups was very similar and there were no significant differences (345.14 +/- 50.66 vs. 354.87 +/- 45.78). Finally, there were modest correlations between BDS scores and the aforementioned oculometry. The correlation coefficient between the BDS score and the total test time and KDI are −0.1 and −0.3 respectively, which means that if the subject has a higher BDS score (less dominant in the primary language), total test time and KDI are less.

Conclusions:These findings highlight the performance disparities that linguistics can impose on the King-Devick test, a rapid number-naming task often used in lateral concussion screening. While these assessments are best implemented in the preseason to establish baselines within the title, which could explain changes in performance for non-native English speakers, we often don't have this clinical opportunity, and if so, You must consider the language. taken into account for the interpretation

Ultrasound determined knee and hip muscle parameters predict formalized force measurements in adults with osteoarthritis of the knee

Jordan Stumph, Bachelor of Science; Carly A. Creelman, MA; Dr Alfred Gellhorn

Goals.Osteoarthritis of the knee (OA) is a highly prevalent and disabling disease, and interventions to slow its progression are urgently needed. Research has shown lower quadriceps strength in patients with knee osteoarthritis than matched controls and that greater knee extensor strength predicts less pain and better physical function. Little is known about the role of hip muscle strength in symptomatic knee OA. However, there is a strong theoretical basis for its importance, since the hip musculature determines the position of the knee joint.

We hypothesize that measuring muscle size and fat infiltration of the hip abductors, hip adductors, and knee extensors with ultrasound in adults with knee osteoarthritis will be feasible and will correlate with formal strength measurements. .

Project:We enrolled nine people (18 knees) with unilateral knee OA in this cross-sectional study. Muscle thickness and echo intensity of the quadriceps, hip abductors, and adductors were measured using ultrasound. Force measurements were obtained with a portable dynamometer. Pearson's correlation coefficients relating muscle thickness and echogenicity to strength were determined. Parameters for the symptomatic and asymptomatic sides were compared.

Results:The thickness of the quadriceps muscle measured by ultrasound correlates with the knee extension torque (r=0.70, p=0.001). Hip abductor muscle thickness correlates with hip abduction torque (r=0.70, p=0.001). Hip adductor muscle thickness correlates with hip adductor torque (r = 0.43, p = 0.07). Echogenicity measured by ultrasound was negatively correlated with hip adductor torque (r = −0.62, p = 0.006), but was not significant for other muscle groups. No significant differences in muscle thickness or strength were found between the symptomatic and asymptomatic sides.

Conclusions:This is the first report of a correlation between ultrasonographic muscle measurements and strength in adults with osteoarthritis of the knee. Muscle thickness measured by ultrasound is strongly correlated with formalized measurements of the knee extensor, hip abductor, and adductor pairs. Obtaining these measurements in a clinical setting is feasible and may help guide the prescription of exercise therapy and provide a longitudinal biomarker.

Evaluation and imaging of the upper urinary tract in a cohort of veterans with spinal cord injuries or disorders

Sophia Miryam Schuessler-Fiorenza Rose, MD, PhD; dr. John P. Lavelle

Goals.An estimated 35% of veterans with SCI/D have renal failure, a complication of neurogenic bladder. The VA Handbook on Continuity of Care for Veterans with SCI/D recommends annual upper urinary tract (UUT) and creatinine evaluations. This study examines compliance with these recommendations.

Project:A retrospective cohort study of VISN21 veterans with SCI/D (n = 1954) was conducted using the VA National Patient Care Databases (fiscal years 2000 to 2012). Results are the percentage of veterans with SCI/D who receive an annual superior UUT evaluation and creatinine measurement. Manual chart review verified the participant's SCI/D status. The UUT or renal function assessment was determined by the presence of appropriate ICD-9 codes. Exclusion criteria were death in the first year of the study or new injury in the last year of the study (n=143). The cross-sectional percentage of veterans with a UUT evaluation per year and the longitudinal percentage (number of years a veteran received the required evaluation out of the total eligible years) were calculated.

Results:Upper urinary tract evaluation was performed annually by only 2.3% of this veteran cohort during the 12-year study period. 14.6% had a UUT evaluation in 50% or more of the eligible years, while 37.4% did not. On average, 22.8% (range 7.9% - 31.9%) received UUT each year. UUT imaging (mean 20.8% per year) was more common than advanced renal function assessment (8.8%). 41.6% of the cohort had an annual measurement of creatinine. 41.5% had a measurement in at least half of the eligible years. 3.4% had no creatinine measurement.

Conclusions:1) Few veterans with SCI/D receive annual evaluations of the upper urinary tract. 2) Annual creatinine measurements were taken in <50% of the cohort. Neurogenic bladder can lead to renal insufficiency and failure, which can be prevented or alleviated by prospective monitoring of the UUT for anatomic and functional changes. Identification of barriers to recommended follow-up should be a high priority.

Use of artificial spinal cord in the treatment of spinal cord injuries

Radhika Sharma, Licenciada en Ciencias; Asad Mazhari, MD; Taania Girgla; Tonya J. Whitehead, BS, MS; Richard R. Honablue, MS, MD; Harini G. Sundararaghavan, PhD; Jay M. Meythaler, MD, JD; Dr. Jean Peduzzi

Goals.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 try to replace the damaged elements (neurons, supporting cells) and stimulate the growth of ascending and descending axons, while also addressing the changes induced by injury. We hypothesize that the artificial spinal cord will cause functional improvement and morphological changes in the spinal cord after producing spinal cord injury by removing the spinal cord segment.

Project: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 sham surgery consisting of a T9-T11 laminectomy. The second group underwent removal of a segment of the spinal cord and a blank hydrogel was implanted. The third group underwent removal of a segment of the spinal cord and the implanted hydrogel contained stem cells, neurotrophic growth factors, an enzyme to prevent scar formation around the injury site, and a scaffold base of electrotrophic fibers. aligned. Outcome measures are being assessed using the BBB score, the beam test, the Hargraves test, and the inclined plane test. Data will be analyzed using a two-way ANVOA with a post hoc Scheffe comparison. Statistical significance is considered to be present at P < 0.05.

Results:Rats with spinal cord injury underwent environmental enrichment, exercise, and behavioral testing in the weeks following 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 continues on these mice.

Conclusions:This study is still ongoing. Combining multiple treatment approaches, which have already shown functional improvement, could lead to results that would greatly benefit the development of effective treatment for people with spinal cord injuries.

Using outreach as an opportunity to expand diversity in the PM&R residency

Julia L. Iafrate, DO; Ryan CC Kruse, MD; Dr. Stephen J. Wisniewski

Goals.The goal of this outreach project is to break down barriers to diversification in Mayo Clinic's Physical Medicine and Rehabilitation (PM&R) program. Funding new initiatives is always a challenge, especially in the era of the Affordable Care Act. In a historically underdiversified hospital system, the PM&R department has attempted to create opportunities for the integration of people from different backgrounds. Recently, a unified effort was made to increase exposure to special programs for underrepresented minorities and people with disabilities at Mayo Clinic. PM&R's Diversity and Inclusion Committee aims to include key faculty and residents in conducting outreach to underrepresented medical communities when they travel to national meetings.

Project:In collaboration with the Mayo Office for Diversity, and in an effort to reduce costs, faculty were encouraged to visit nearby medical schools during lecture trips to answer questions about the residency program. Schools identified as high performing based on the enrollment of underrepresented individuals were strategically selected. Key support from the executive committee in allocating additional time for travel, facilitating networking efforts, and assisting with website development was essential to the success of this project. Involving Mayo employees or alumni who graduated from the schools visited added another layer of connection to the interactions.

Results:Since this initiative began, the number of underrepresented medical students enrolling in PM&R's residency program or visiting student rotations has increased. This recent success shows 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 trips within the department. In the future, as PM&R alumni from these underrepresented schools grow, this will further enhance the authenticity of the outreach program.

Use of Physiotherapy in the Treatment of Lumbar Degenerative Spondylolisthesis from 2000-2011

José A. Sclafani, MD; Alexandra Constantin, PhD; Pei-Shu Ho, PhD; Venu Akutota, MD; Leighton Chan, MD

Goals.Degenerative lumbar spondylolisthesis is a frequently identified deformity in symptomatic low back pain. Physical therapy is often used as first-line treatment in newly diagnosed spondylolisthesis to develop balance of the trunk muscles, improve function, and decrease overall pain. This study is an analysis of the use of physical therapy to treat degenerative spondylolisthesis in Medicare beneficiaries from 2000 to 2011.

Project:This study used an initial cohort comprising 5% of all patients with ICD-9 codes for back pain registered in the Centers for Medicare & Medicaid Services Carrier File, Outpatient File, or Inpatient File. , from 2000 to 2011. A cohort of recipients with a new ICD-9 diagnostic code for degenerative lumbar spondylolisthesis was isolated. Beneficiaries with a concomitant diagnosis of low back trauma, infection, or malignancy were excluded. Current billing codes for various physical therapy modalities from 2000 to 2011 were used to identify the number of procedures performed each year in this cohort, using the CMS Carrier file. Numbers are reported as 15-minute billing units unless otherwise noted.

Results:A total of 95,647 subjects with a new diagnosis of degenerative spondylolisthesis were included in the analysis. A total of 104,373 baseline physiotherapy assessments were performed in this cohort. The mobility and flexibility exercises involved 1,148,328 billing units. The active strengthening modalities represented 554,274 units (47,122 training units for walking and climbing stairs; 251,511 units of dynamic functional performance; 255,641 units of neuromuscular reeducation). 1,274,420 units of passive modalities were recorded (89,241 massage therapy units; 150,046 electrostimulation units; 343,826 ultrasound units; 691,307 manual traction units) and 47,146 total hydrotherapy billing units.

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 versus active modalities of strength and trunk stabilization exercises.

Variations in rehabilitation regimens and their impact on treatment outcomes for rotator cuff tears

Cristina Página; Emily N. Peterson, MS; Gregory D. Ayers, MS; Nitin Jain, MD, MSPH

Goals.Patients with rotator cuff injuries are often referred for nonoperative treatment. There is a lack of data on the use of physiotherapy techniques, adherence to programs and home therapies. Our objective was to evaluate the variations in rehabilitation programs and their impact on the results of degenerative rotator cuff injuries.

Project:Subjects: Patients with rotator cuff injuries confirmed by clinical examination and imaging. Methods: Our ongoing longitudinal cohort study includes data from 108 patients undergoing nonoperative treatment for rotator cuff injuries. All patients received a prescription for physiotherapy and were considered adherent if they reported having exercised for a maximum of six months of follow-up. Questionnaires were completed by each participant at enrollment and at 3-, 6-, and 12-month follow-up. The Shoulder Pain and Disability Index (SPADI) was our primary outcome measure.

Results:Mean SPADI scores showed a significant improvement at the end of follow-up (45.6+/-24.4 to 25.3+/-22.8), and pain subscores decreased at a faster rate than disability scores. The rate of adherence to physiotherapy was 88.6%. There were similar patterns of decline in SPADI for patients who received physical therapy with a therapist compared to those who only exercised at home. The most used techniques were stretching (46%), strengthening (45%), bands (32%) and weights (33%). Patients who performed strengthening or stretching exercises had better results at 6 months than those who did not perform strengthening or stretching exercises.

Conclusions:Physiotherapy can result in significant clinical improvement for patients with degenerative rotator cuff injuries. Patients who underwent rehabilitation with a physical therapist had similar results to those who exercised alone at home. Patients who incorporated stretching or strengthening into their rehabilitation program had better pain and function compared to patients who did not stretch or strengthen. These data can be used to design an evidence-based standardized rehabilitation program for the non-surgical treatment of rotator cuff tears.

Vitamin D deficiency in elderly Southeast Asian patients admitted to a rehabilitation center in sunny Singapore

Keng Kong, MD

Goals.The objectives of this study were to investigate the prevalence of vitamin D deficiency in a cohort of elderly Southeast Asian patients admitted to a rehabilitation center in sunny Singapore and to establish factors associated with vitamin D deficiency.

Project:This was a prospective study of 134 patients older than 65 years admitted to a tertiary rehabilitation unit for a period of 15 months. Data collected included patient demographics (age, gender, ethnicity, body mass index), premorbid ambulatory status using the functional ambulation category, frequency of falls in the past 2 years prior to current hospitalization, diagnosis of rehabilitation for the admission, medical comorbidities, calcium and vitamin D supplementation (defined as taking supplements at least 5 days per week in the past month, as reported by the patient), and functional status at admission and discharge from rehabilitation, as measured by the Measure of Functional Independence.

Blood was drawn for 25-hydroxyvitamin D3 (25OHD3) level within 7 days of admission to rehabilitation. Serum levels of calcium, phosphate, albumin, magnesium, and parathyroid hormone (PTH) were also measured. We define vitamin D deficiency using Holick's classification as follows: vitamin D deficiency is considered when the vitamin D level A vitamin D level ≥30 ng/mL is considered normal/

We analyzed the data with SPSS version 16. We used univariate logistic regression analysis to assess factors associated with vitamin D deficiency. Factors studied were age, sex, ethnicity, body mass index, calcium and/or vitamin D supplementation. D, pre-ambulation morbidity measured on the FAC, recurrent falls (history of ≥ 2 falls in the 2 years prior to admission), and FIM score on admission to rehabilitation. A value of p < 0.05 was considered statistically significant.

Results:The mean age was 72.0 ± 5.7 years, with a slight predominance of the male sex (58.2%). Ethnically, the majority of patients were Chinese (88.1%). Stroke was the most frequent rehabilitation diagnosis (49.3%). 59 patients (44%) presented vitamin D deficiency and 56 (41.8%) vitamin D insufficiency. In the univariate analysis, age, sex, calcium supplementation and/or vitamin D, premorbid outpatient status, and mean FIM score at admission were not significantly associated with vitamin D deficiency. Only race and recurrent falls were significantly associated with vitamin D deficiency. Malays/ Indians and recurrent falls were more likely to be at risk of vitamin D deficiency. Those with recurrent falls, those with ≥3 falls had significantly lower mean 25OHD3 levels than those with 2 falls (15.9±7, 4 ng/ml compared to 20.8±1.7 ng/ml, p=0.006). In multivariate logistic analysis, race and recurrent falls 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 due to the significant impact of vitamin D on musculoskeletal function.

Determinants of recovery from a 161 km ultramarathon

Joseph Chin, BS; Dr. Natalie Badowski; Kristin Stuempfle, PhD; Carol Parise, PhD; Martin D. Hoffman, M.D.

Goals.This study examined short-term recovery from a 100-mile ultramarathon using functional and subjective measures and explored what factors determined recovery rate.

Project:Participants in the 2015 Western States Endurance Race completed two 400m sprints during the 21 days prior to the race and on days 3 and 5 after the race, blood was drawn for creatine kinase. (CK) in plasma after the race. running, and provided ratings of lower body muscle soreness and soreness (10-point scale) and overall muscle fatigue scores before the race, immediately after the race, and in the following 7 days.

Results:Among the 72 finishers who completed the study, 400m race times were 26.3% slower (p=0.001) on day 3 and 12.4% slower (p=0.01) on day 5 compared to pre-race times. Muscle soreness and soreness indices and muscle fatigue scores statistically returned to pre-race levels 5 days post-race. Lower body muscle soreness and soreness during the recovery period were modeled by time (1.1 point decrease each day), post-race plasma CK concentration (0.8 and 1.5 point increase high for a CK value of 10,001-27,999 and ≥28,000 U/L compared with ≤10,000 U/L, respectively) and age (0.4 points less for each decade of aging).

Conclusions:Post-race plasma CK and age are the main determinants of resolution of lower body muscle soreness after an ultramarathon. Proper training would be recommended to mitigate muscle damage and optimize ultramarathon recovery.

Melanoma in Lower Limb Deformity - M.I.L. D. Evaluation and treatment physiatry

Dr. David Berbrayer

Goals.Develop a multidisciplinary clinic that involves the treatment of lower limb melanoma and evaluate the outcome.

Project:The largest academic group for melanoma, Intensive Care Oncology and Plastic Surgery, turned to Intensive Care Physiatry to develop a team to manage complications after chemotherapy and lower limb bondage procedure to restore function and quality of life in patients treated for melanoma. staffed by a physical therapist, physical therapist, occupational therapist, pediatrician, podiatrist, nurse, prosthetist, and orthopedist to assess each patient within 4-6 weeks of surgery and develop a treatment plan. Treatment complications included: wound management, foot drop, peripheral neuropathy, partial pelvic floor amputation, pain management, increased physical activity, and improved quality of life. This clinic has been running for 6 months. The first challenge was the accuracy of the referral in intensive care and the organization of the team to obtain the best results. Additional diagnoses included detailed psychiatric history and examination, EMG and nerve conduction study, imaging studies of affected parts. Treatment included: wound healing, pain management, orthopedic footwear and orthotics, ankle-foot orthotics, prosthetics, and an active physiotherapy program. Family membership and education took place during rehabilitation management and the clinic included physiatry residents and medical students. of practice for plastic surgeons, not only performing life-saving surgeries, but also considering function and quality of life.

Results:In 6 months:

6 males, 4 females

age range: 25-50

2 complete high school, 8 university

all married or partners

2 Peripheral neuropathies with successful pain control, diagnosed and monitored with EMG/nerve conduction

1 foot drop treated with AFO

4 partial feet treated with extra deep shoe and orthotics

3 transtibial amputations with prosthesis.

Conclusions:

1. This is an example of a partnership between surgery and oncology in large academic intensive care facilities and the role of physiatry

2. All patients participated in an exercise program that improved physical and cognitive outcome.

3. Assisted diagnoses in the care of all patients who reported satisfaction

4. Education of surgeons and oncologists creates an ongoing dialogue about the best evidence-based care

5. This unique clinic is now applying for funding to support activities and grants to explore future research opportunities.

Presentation of posters Thursday, February 18, 2016

Spontaneous lumbar spondylodiscitis with atypical presentation: a case report

Rodion Erenburg, MD; Jameel Khan, MD; Margaret M. Nunez, DO; Sanjeev Agarwal, MD

Diagnosis of the case:Spontaneous lumbar spondylodiscitis with atypical presentation.

Case description:A previously healthy 41-year-old man presented to the physiatry clinic complaining of severe nontraumatic low back pain radiating to the right flank that began insidiously over the course of 1 week. Pain was rated 10/10, exacerbated by valsalva, relieved by rest. He initially presented to the emergency department 4 days earlier, where a CT scan of the abdomen and pelvis showed nothing of interest and he was discharged on pain medication with no relief. By the time of his visit to the clinic, the patient's pain had progressively worsened to the point where he was no longer able to walk independently. He denied fever, chills, weakness, urinary or bowel incontinence. On examination, the patient was distressed but without neurological deficits. MRI of the L spine revealed a broad-based L5-S1 central disc herniation with extensive inflammatory changes and medullary edema of the adjacent vertebral body. The patient was admitted for hospital evaluation. Tissue biopsy was negative for Gram stain, and pancultures did not grow organisms. Neurosurgery did not recommend any intervention. The patient remained afebrile and was treated conservatively with oral steroids and analgesics. The patient was discharged on the seventh day of hospitalization with no neurological deficits, minimal low back pain, and in an outpatient physiotherapy program.

discussions:Spontaneous spondylodiscitis is quite uncommon in the general population. Diabetes or recent invasive spinal procedures carry a higher risk. Classic signs include constitutional symptoms, focal neurologic deficits, and positive blood cultures, all absent in this case. Timely diagnosis and early neurosurgical evaluation can greatly reduce morbidity from possible neurological sequelae.

Conclusions:Clinicians should maintain a high level of suspicion for inflammatory spondylodiscitis, as this condition can present atypically and carry significant morbidity if not promptly diagnosed.

A case of anterior interosseous nerve syndrome with Martin-Gruber anastomosis

Steven Chan, physician

Diagnosis of the case:The Martin-Gruber anastomosis is an abnormal pattern of innervation, in which nerve fibers normally travel along the anterior interosseous nerve to innervate many of the intrinsic muscles of the hand. This pattern of innervation does not produce any clinical symptoms, but with 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 anastomosis.

Case description:A 55-year-old woman attended the electrodiagnostic laboratory due to weakness in the right arm of 2.5 months' evolution, without previous trauma. She initially noted difficulty turning the key in the car's ignition, and this progressed to weakness in grasping and turning objects. She also described numbness in her right hand and all fingers, especially evident on waking in the morning. Physical examination revealed weakness with abduction of the fingers, flexion of the interphalangeal joint of the thumb, flexion of the distal interphalangeal joint of the index and middle fingers, and pronation. She also had difficulty bringing the tips of her right thumb and forefinger together in an attempt to make an "OK" sign. Needle electromyography (EMG) revealed acute denervation and reduced recruitment in the flexor digitorum profundus of the right hand (slides toward the index and middle fingers) and first dorsal interosseous muscles, and reduced recruitment in the flexor thumb length. Needle EMG was normal in the right deltoid, biceps, triceps, pronator teres, flexor digitorum superficialis, flexor digitorum profundus (slides into the ring and little fingers), and opponens pollicis muscles. Nerve conduction studies were negative for ulnar neuropathy at the wrist and elbow, but revealed mild median sensory neuropathy at the right wrist (composite sensory index was greater than 1.2 milliseconds). Other nerve tests also demonstrated a Martin-Gruber anastomosis in her right upper extremity. Given the denervation in the muscles innervated by the anterior interosseous nerve (AIN), along with normal needle EMG of other medially innervated muscles, he was diagnosed with anterior interosseous neuropathy. In the context of a Martin-Gruber anastomosis, this resulted in denervation of the distally supplied ulnar-supplied muscles, explaining the weak abduction of the fingers and the observed denervation of the first dorsal interosseous muscle (in the absence of a ulnar neuropathy in the nerve). ). to drive). It was concluded that the patient had a Martin-Gruber anastomosis, with superimposed anterior interosseous neuropathy. The patient was treated conservatively with relative rest, exercise therapy for the right upper extremity, and steroid injection into the carpal tunnel (for paresthesias in the hands). His symptoms improved, and at a follow-up visit to the orthopedist, he regained strength in his thumb and finger flexors and finger abductors.

discussions:The AIN is a branch of the median nerve, with a purely motor function. Compression of this nerve produces weakness in flexion of the interphalangeal joint of the thumb, flexion of the distal interphalangeal joint of the middle and index fingers, and pronation. AIN syndrome is rare, accounting for less than 1% of all upper extremity compression syndromes, and electrodiagnostics must have a high understanding of this condition to aid in diagnosis. The Martin-Gruber anastomosis is an abnormal innervation seen in 7.7 to 34% of the population. This neural communication usually involves nerve fibers that travel along the median nerve and branch from the AIN to innervate the adductor pollicis, first dorsal interosseus, and abductor digiti minimi muscles. This condition does not cause any clinical symptoms, but in the context of an AIN syndrome, the distal muscles are affected. This patient had signs of weakness that were consistent with an AIN syndrome, but this did not explain her weakness in abduction of the fingers. Further electrodiagnostic testing revealed the patient's Martin-Gruber anastomosis. With this underlying abnormal innervation, the AIN syndrome produced weakness in the abductor digitorum as well as the denervation seen on EMG of the first dorsal interosseous muscle. Like many people with AIN syndrome, she made a spontaneous recovery within 6 to 8 weeks.

Conclusions:This case report presents a patient with abnormal innervation combined with a rare neuropathy. Anterior interosseous neuropathy represents less than 1% of all upper limb compression syndromes. Electrodiagnosis must have a high clinical suspicion of this condition to diagnose it, especially in the setting of abnormal innervation such as a Martin-Gruber anastomosis.

A case of bilateral avascular necrosis of the femoral head in a healthy young woman.

Usman Choudhary, DO; Dr. Kevin Jiang; Dra. Sonia Shetty

Diagnosis of the case:Avascular necrosis of the bilateral femoral head in a healthy young woman

Case description:The patient is a 54-year-old woman with bilateral progressive atraumatic groin and hip pain for the past six months. She had a history of pelvic fracture 30 years ago, but she was healthy with no significant medical history or prior functional deficits. Over the past 3 months, the pain has become severe to the point where she needs a cane to walk and she is unable to sit for long periods of time. She has been to five different hospitals and has had an MRI of her hips and pelvis, which revealed no abnormalities. She went to our emergency department to seek another opinion. The patient reported that she smoked one cigarette a day and drank one or two beers a week. She had no history of steroid use, she denied excessive alcohol use, and she denied a history of diabetes or thyroid disease. Her family history was positive osteoarthritis.

On physical examination, the patient was 5'5", 150 lbs, and had a BMI of 55. She had a remarkable antalgic gait with a positive bilateral Trendelendberg. 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 5 degrees, internally rotated neutral, abducted 5 degrees, and adducted 5 degrees.

Pelvic radiography revealed bilateral avascular necrosis of the femoral head with collapse of the femoral head. The patient decided to undergo bilateral anterior total hip arthroplasty. The surgery was successful and without complications. The patient was admitted to the PM&R service after the 3rd postoperative day. He made excellent progress and upon discharge he transferred independently, walked up to 500 feet and was able to climb 6 steps.

discussions:Avascular necrosis (AVN) of the femoral head is a pathological process resulting from the interruption of the blood supply to the bone. This ischemia usually causes death of the marrow and subsequent collapse of the osteocytes in the necrotic segment. AVN is a little-known condition that can be traumatic or non-traumatic. There is an increase in the frequency of idiopathic cases. This was an unusual case in which no etiologic factor was identified, but the patient had nontraumatic bilateral avascular necrosis. Many associated risk factors for avascular necrosis were identified, including glucocorticoid use, excessive alcohol consumption, thyroid disease, thrombophilic disease, none of which this patient had. Also, the diagnosis took over 6 months despite seeing multiple providers along with an MRI evaluation. It has been shown that early diagnosis of the disease is likely to prevent further damage from joint destruction. Chemotherapy and kidney transplants are often associated with the disease. Whereas previously temporary surgical joint preservation and subsequent joint replacement were often the only treatment option, today joint-sparing and conservative measures play an increasingly important role. Rehabilitation can help the patient decrease pain and improve function.

Conclusions:Despite no identifiable risk factors, this case of prolonged bilateral hip pain and gait dysfunction in a previously healthy young person highlights the importance of appropriate early testing. Atraumatic bilateral avascular necrosis of the femoral head should continue in the differential with close follow-up. If left untreated, it can lead to a subchondral fracture and subsequent collapse.

A case of leptomeningeal neurosarcoidosis

Justin Louis Weppner, DO; Dr. Austin Albright; Geoffrey R. Smith, MD; Nina Baker, MD, MPH

Diagnosis of the case:Complete T7 paraplegia secondary to leptomeningeal neurosarcoidosis.

Case description:A 57-year-old patient presented to a tertiary intensive care academic hospital with headache, generalized weakness, inability to walk, back pain, generalized paraesthesia, and urinary incontinence. Magnetic resonance (MR) images of the cervical, thoracic, and lumbar spine were obtained, revealing numerous areas of nodular enhancement along the cervical, thoracic, and lumbar spine in relation to the tumor. Noncontrast brain MRI revealed diffuse nodular leptomeningeal enhancement most prominent in the basal cisterns. The patient was admitted to the hospital with a diagnosis of cauda equina syndrome secondary to a nodular tumor. Her condition continued to deteriorate and she progressed to complete T7 paraplegia with mixed upper and lower motor neuron findings. During the course of treatment, the patient began to develop intermittent bowel incontinence and dysfunction with intact lower sacral reflexes. Chest CT scan revealed multiple enlarged supraclavicular, mediastinal, and hilar lymph nodes in association with malignancy versus sarcoidosis. Lymph node biopsy revealed a prominent inflammatory infiltrate characterized by abundant nonnecrotizing granulomas suspicious for sarcoidosis versus an inflammatory process. Extensive work was done for infectious etiology, including bacterial, fungal, and viral processes that were negative. Laboratory evaluation was significant for elevated serum C-reactive protein and lactate dehydrogenase. The serum angiotensin-converting enzyme level was normal. The patient was started on methylprednisolone 1 gram daily for three days, which resulted in minimal improvement in her lower extremity. She was switched to oral prednisone 80 mg daily on a tapering schedule for the next two months and started mycophenolate mofetil 500 mg twice daily. The patient was admitted for comprehensive rehabilitation. Upon discharge from inpatient rehabilitation, she had an overall positive change in Functional Independence Measure score of 6 points. The patient's course of rehabilitation was complicated by poor cognition and perception of her medical condition, which is believed to be secondary to sarcoid infiltration of the brain. The patient was discharged home under the care of her husband with home physiotherapy and a follow-up plan for Physical Medicine and Rehabilitation. The patient is currently undergoing outpatient treatment for neurosarcoidosis.

discussions:Sarcoidosis involving the spinal cord is extremely rare, affecting less than 1% of patients with sarcoidosis. The cervical and thoracic spinal cords are most frequently affected, and there is often patchy involvement. The image usually suggests a spinal cord tumor. Patients with spinal cord involvement often have elevated levels of C-reactive protein and lactate dehydrogenase. The serum angiotensin-converting enzyme level is usually not elevated. Cerebrospinal fluid examination may reveal elevated protein, leukocytosis, and oligoclonal bands. Treatment is usually with corticosteroids and immunosuppressive drugs. Patients are often dependent on steroids and tapering off may lead to a clinical worsening of the patient's condition. Laminectomy and subsequent biopsy are often performed to confirm the diagnosis. More extensive surgeries, when used to decompress the spinal cord, have been associated with decreased postoperative neurological function in the neurosarcoid population due to 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 rare and often a diagnostic challenge because it may be the first presentation of the disease. The diagnosis depends on the exclusion of neoplasms, infections and demyelinating diseases and is supported by the demonstration of systemic sarcoidosis. Diagnosis may require laminectomy and spinal cord biopsy if no other systemic areas are available for biopsy; however, the disease is not treated with spinal cord decompression even when arthritic changes are present. The mainstay of treatment includes corticosteroids and immunosuppressive drugs. Patients with neurosarcoidosis have neurologic deficits similar to those of nontraumatic spinal cord injury, but may have fluctuations in neurologic status, require treatment with steroids and immunosuppressive drugs, and respond unpredictably to surgical decompression. The physiatrist must know the clinical presentation, diagnosis, treatment and prognosis to guide the course of rehabilitation.

A case of post-surgical gouty arthritis presenting as sepsis after knee joint replacement: a case report.

Hana F. Azizi, MD PGY-4; Antonio Howard, MD; Gary Inwald, D.O.

Diagnosis of the case:A 64-year-old woman with a history of obesity and osteoarthritis was admitted to acute rehabilitation three days after elective total left knee arthroplasty.

Case description:On admission, he reported pain in the right knee that was disproportionate to the examination. He had chills with no fever, severely limited range of motion with no erythema, swelling, or tenderness in his right knee joint. Two days later, she developed a high fever. Initial laboratory tests, including complete blood count and cultures, were negative for signs of infection. Subsequent laboratories showed an elevated erythrocyte sedimentation rate (ESR 139), C-reactive protein (CRP 18), and uric acid (11.6). Radiographs of the right knee and ankle joints were normal. Colchicine was started due to clinical suspicion of a gout attack and an intra-articular injection of corticosteroids was given to the right knee. The patient responded quickly to these measures and experienced decreased pain and improved range of motion in the right lower extremity after 2-3 days and was able to participate in therapy. Repeat analysis on day 10 of admission showed CRP of 0.4, ESR of 100.0, and uric acid of 10.0, all trending downward.

discussions:Most gout attack cases experience excruciating pain, tenderness, redness, warmth, and swelling in a joint. Our patient underwent various diagnostic tests and consultation evaluations due to an unusual presentation of gout. Severely limited range of motion and pain in the right lower extremity affected early ambulation and prolonged hospital stay. A study in post-surgical patients with gout showed equally extensive investigation 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 a post-surgical gout attack. The atypical presentation of gout should be considered in patients with fever, pain in the extremities, and elevated uric acid. Early and accurate diagnosis facilitates appropriate early 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; Ana Felicia. Ambrosio, MD, MS

Diagnosis of the case:nonsystemic vasculitic neuropathy

Case description:A 68-year-old woman with hypertension, diabetes, and hepatitis C presented with bilateral upper and lower extremity weakness, distal lower extremity sensory loss, hyporeflexia, intermittent low-grade fever, and weight loss. Electromyography (EMG) revealed sensorimotor axonal polyneuropathy with denervation in the arm and leg, consistent with acute motor and sensory axonal neuropathy (AMSAN), a variant of Guillain-Barré syndrome (GBS). However, the patient did not respond to a five-day course of intravenous immunoglobulin (IVIG).

Differentiators included vasculitic neuropathy (VN), nutritional deficits, toxins, and paraneoplastic syndromes. Additional investigations revealed elevated C-reactive protein (155.8 mg/L) and ESR (123 mm/h). ANA, ANCA, cryoglobulins, creatine kinase, and ganglioside antibodies were negative. The gastrocnemius biopsy showed transmural inflammation of the vessels. Sural nerve biopsy demonstrated loss of large and small myelinated fibers with ongoing axonal degeneration. These findings were consistent with midvessel peripheral vasculitic neuropathy. The patient was then started on systemic glucocorticoids and cyclophosphamide, after which the patient showed 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 inflammatory peripheral nerve ischemia. VN is typically associated with systemic vasculitis (eg, Wegener syndrome, Churg-Strauss syndrome, polyarteritis nodosa, or cryoglobulinemia), but it can present alone as in our patient. Diagnosis requires EMG, nerve conduction studies, and neuromuscular biopsy. The first-line treatment of GBS is IVIG or plasmapheresis, while VN requires glucocorticoids in addition to immunosuppressive therapy for severe cases.

Conclusions:Rehabilitation physicians should consider re-evaluating patients who have been diagnosed with GBS and who do not respond adequately. Our patient was initially treated by AMSAN, but only showed functional improvement after the correct diagnosis of VN and treatment with glucocorticoids.

Case report of epidural lipomatosis complicating the treatment of a patient using chronic prednisone for transverse myelitis

Samuel T. Clanton, MD, PhD; Dra. Leslie Rydberg

Diagnosis of the case:A 43-year-old man with a medical history including neurosarcoidosis and C4-7 transverse myelitis diagnosed in 2010 and chronically on variable doses of prednisone presented to an intensive care unit with worsening upper and lower extremity weakness. Magnetic resonance imaging revealed active demyelination at C6 and abnormal signal and edema at C2-T2, as well as the presence of thoracic lipomatosis. He was admitted and was given methylprednisolone 1g x 5 days and an infusion of Remicade. He was discharged home with prednisone 60 mg/day.

Case description:The patient was then admitted for acute inpatient rehabilitation (AIR). The neurological examination on transfer showed 2/5 flexion in the lower limbs and 3/5 strength in the extensor and ankle, and at least 4/5 strength in the upper limbs. After three weeks of progressive improvement in rehabilitation, the patient noted a subtle deterioration in the strength of his lower limbs. The neurological examination of him was variable during this period, but within 4 to 5 days, the patient was unable to activate either the hip or knee flexors. The MRI revealed an improvement in his previous inflammatory lesions, but a dramatic worsening of the previously observed lipomatosis, resulting in compression of his spinal cord from T6-T8. He then underwent a T4-T10 right hemilaminectomy and decompression and then transferred back to AIR to complete rehabilitation.

discussions:Spinal epidural lipomatosis (SEL) is a rare condition in which fatty tissue proliferates into the extradural space and can cause spinal cord compression. It is most commonly associated with exogenous steroid exposure and most commonly affects the thoracic or lumbosacral spine. It is important to recognize SEL, as it can mimic primary neurological diagnoses such as transverse myelitis, but it can be caused by the steroids used to treat it.

Conclusions:Spinal epidural lipomatosis is a condition that can cause spinal cord compression that mimics impairments seen in patients with conditions treated with steroids, such as transverse myelitis or multiple sclerosis.

Case Report: Improvement in Chronic AC Joint Pain After PRP Injection

Jovauna M. Currey, MD; Dr. Ronald Takemoto

Diagnosis of the case:Grade 1 AC joint injury

Case description:A 38-year-old man presented to the clinic with a 6-month history of non-radiating pain, 6/10, in the upper left shoulder after being knocked down and landing with his left arm outstretched. The examination was significant for tenderness in the AC joint, positive scarf test with no visible deformity. Crepitus was noted at the AC joint with overhead movements. There was no instability. The radiograph showed osteoarthritis in the AC joint. Ultrasound showed a positive geyser signal over the AC junction. He was initially treated with an intra-articular injection of ultrasound-guided prolotherapy along with a x2 home exercise program. Prolotherapy only helped for 5 days and reduced pain to 5/10. At 6-month follow-up, the patient still had 5/10 pain. An ultrasound-guided intra-articular injection of PRP was performed in the left AC joint with continuation of his exercises at home. After two months the pain has decreased to 1/10, however he states there is still a painless 'popping' sensation with overhead movement. The patient received SPADI shoulder evaluation at each visit, the scores were: 37.6% at the 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 AC joint pain. There are several publications on the use of PRP in different shoulder injuries, however, there are still no case reports of its use in grade 1 chronic AC injuries.

Conclusions:We believe this is the first case report on the use of PRP in grade 1 chronic painful joint lesions in CA. As evidenced by the decrease in this patient's SPADI scores after intra-articular injection of PRP, PRP appears to have been beneficial in this regard.

Case series describing the efficacy of oral and injectable steroids for the treatment of symptomatic perineural cysts

Jason S. Frederick, MD; Dr. A.S. Mohsen Tahani

Diagnosis of the case:perineural cysts

Case description:Three patients, one male and 2 females, were evaluated for chronic pain with radicular symptoms including limb weakness and sensory changes. Each one obtained magnetic resonance studies of the spine that showed perineural cysts, 2 at the cervical level and 1 in the sacral region. In all cases, the perineural cysts were located along the spinal roots which correlated with the distribution of the patient's symptoms. Two of the patients received a short, reduced dose of oral steroids. The third patient received a caudal epidural steroid injection. Treatment effects were measured at 1- and 2-month follow-up clinic visits and telephone assessments. Pain relief was recorded in all three patients with a 60% to 80% improvement in mean VAS scores. Two of the 3 patients also reported increased limb strength and sensation in the distribution of affected nerve roots.

discussions:Perineural cysts, also known as Tarlov cysts, occur most frequently in the sacral region at the junction of the dorsal ganglion and posterior nerve root. With a reported prevalence of 1.5% to 4.6% in the general population, perineural cysts are mostly asymptomatic. However, about 1% cause symptoms due to nerve compression, including pain, weakness, and sensory deficits. While there are many case reports exemplifying the successful management of perineural cysts with surgery, few have demonstrated successful symptomatic management with conservative treatments. An earlier case series by Mitra et al in 2008 demonstrated the effectiveness of such conservative therapies, specifically oral and injectable steroid treatment.

Conclusions:Based on the treatment courses and the results of this case series and previous studies, oral and injectable steroid therapy may provide an alternative to surgery in the treatment of symptomatic perineural cysts.

A quality improvement project: improving sleep documentation in TIRR Unit 6

Erika L. Moody, MD; Cole Linville, DO, MBA

Goals.The goal of this quality improvement project is to identify the most common reason for sleep disruption in TIRR Memorial Herman Hospital patients admitted to Unit 6 (brain-injured patients) by implementing a documentation protocol of the sleep/wake cycle. Sleep disorders are very common after a brain injury. Insomnia, fatigue, and sleepiness are the most frequent complaints associated with sleep after traumatic brain injury (TBI). 1 Narcolepsy (with or without cataplexy), sleep apnea (obstructive or central), periodic limb movement disorder, and parasomnias occur less frequently. 1 Depression, anxiety, and pain are common comorbidities associated with TBI that have a substantial influence on sleep quality.1 Sleep disruption can worsen the neuropsychiatric, behavioral, and physical symptoms of TBI. 2 In addition, sleep disruption impairs recovery and can lead to cognitive decline. 2 Persistent sleep disturbances independently predict worse functional and social outcomes one year after a mild TBI. 3 Patients with insomnia after stroke showed reduced general health-related quality of life and deficits in energy and thinking domains. 4 Brain magnetic resonance imaging has shown an association between poor sleep quality and the severity of white matter hyperintensities. 5 Short (<5 hours) and long (>9 hours) sleep durations are associated with increased risk of mortality from stroke.6 The purpose of this study will be achieved through multidisciplinary team education and a published sleep registry. in each patient's room. . This will be evidenced by at least a 50% improvement in documenting why a patient is awake during the two-week study period in February 2015.

Project:For this study, the Plan-Do-Study-Act (PDSA) cycle was implemented for quality improvement. Our team consisted of physicians, clinical nurse manager, operations administrator, pharmacy staff, nurses, and nursing assistants from TIRR Memorial Hermann Hospital. This study was conducted in Unit 6 of the TIRR Memorial Hermann Hospital. The design and intervention of this study included educating the multidisciplinary team on the accuracy of recording bedtime sleep/wake cycles in the patient's sleep record, which included the reason for sleep interruption. Pre-intervention data was reviewed and analyzed from August 1-31, 2014. Post-intervention data was reviewed and analyzed from February 2-15, 2015. Data collected included room number and location of bed (bed A vs. bed B), sex, age, main diagnosis, date of admission and discharge, length of stay, time of admission and day of the week of admission, hours of sleep recorded (from 9:00 p.m. to 6:00 a.m.), sleep medication requested, and documented reasons for sleep disruption.

Results:Pre-intervention data from 1 to 31 August 2014 were reviewed. Reasons for sleep disruption were not routinely documented in the electronic medical record (EMR) sleep record. The team was documenting a full hour of sleep when known sleep disturbers occurred, such as during medication administration, midnight vital checks, scheduled catheterizations or toileting records, etc. During the staff meeting with the clinical nurse manager and operations administrator, we discovered that there is no standardized process for staff to record patient sleep. Nurses and licensed practical nurses are making end-of-shift charts in the early morning hours "from memory," so it's questionable whether EMR sleep records are accurate. The staff identified multiple sleep disturbers, either by medical order or by hospital policy. After implementing the sleep/wake cycle documentation protocol, the goal of at least a 50% improvement in documenting the reason for sleep disruption was achieved.

Conclusions:Reported reasons for sleep interruption increased from 32 to 94 (194% increase). Unaccounted hours decreased from 39 to 4 (90% decrease). The average hours of sleep recorded per patient decreased from 7.1 hours/night to 5.4 hours/night. Bathing, medication, and vital signs at midnight were the 3 most common reasons for interrupted sleep in the brain-injured population in the TIRR 6 unit. Patients in the TIRR 6 unit are frequently interrupted during their hours of sleep and this sleep disorder has many potential negative health side effects and poorer functional recovery in this population. The team is likely overestimating the hours of sleep in the EMR sleep log. The improvement in the accuracy of sleep recordings can probably be attributed to the intervention of instructing and educating nursing staff, although this is unlikely to be sustainable in the long term.

A rare case of acute longitudinal transverse myelitis with involvement of C4-T6

Gracia Maloney, MD; Padma Srigiriraju, MD

Diagnosis of the case:A rare case of acute longitudinal transverse myelitis with involvement of C4-T6

Case description:A 57-year-old man was admitted to intensive care after developing bilateral weakness and numbness in the lower extremities. Nuclear magnetic resonance revealed an intramedullary spinal cord injury with spinal edema. A neurological evaluation was started, which included: lumbar puncture with CSF studies and additional images. No causative factor has been identified. The patient received 5 days of methylprednisolone, IVIG, and Rituxin; however, neurological symptoms progressed to upper extremity weakness and respiratory failure, requiring intubation. Tracheostomy was performed after weaning failure from the ventilator and the patient was transferred to long-term intensive care. After medical stabilization, he was transferred to intensive care rehabilitation. Initially, it was full assistance for transfers. This improved for maximum assistance. Initially, he had full mobility assistance, but evolved to use a wheelchair with supervision for a distance of 500 feet.

discussions:Transverse myelitis is a rare disease that has multiple presentations and etiologies, including infectious, inflammatory, autoimmune, traumatic, radiation-induced, and idiopathic. Spinal cord involvement can be classified as acute partial, acute complete, and longitudinally extensive. Recovery and prognosis differ 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 rehabilitation clinician to understand. A thorough understanding of the disease allows for effective management and patient education.

Conclusions:Given the rarity of longitudinal transverse myelitis, the variation in etiology, and the extensive time over which treatment is carried out, there are no large studies that provide conclusive evidence on the prediction of prognosis and rehabilitation outcomes. The presented case provides an in-depth look at the challenges faced in managing an idiopathic case of longitudinally extensive transverse myelitis. The case highlights the complexity and importance of the diagnosis and rehabilitation process.

A rare case of akinetic mutism and its rehabilitation outcome

Andre Patton; Esther Yoon; Mohammad S. Islam, MD; Carlos Arias, MD; Yamilette Burgos-Quinones, MD

Diagnosis of the case:A 57-year-old woman with akinetic mutism in the context of paraneoplastic encephalitis secondary to multiple myeloma.

Case description:After being admitted to the hospital for confusion, dizziness, and anarthria, a 57-year-old woman is diagnosed with paraneoplastic encephalitis secondary to multiple myeloma. A predominant symptom of this syndrome is akinetic mutism, a neuropsychiatric syndrome characterized by a lack of spontaneous speech and movement with relatively preserved attention in an awake and alert patient. After almost 5 months of acute medical care, the patient was admitted for rehabilitation.

discussions:At 5 weeks, the patient continued to show a variable pattern in her rehabilitation course with an overall positive trend in her progress. Despite this fluctuation, the days in which she is more involved in her therapy have increased in frequency, resulting in gains in mobility and ADLs. Initial PT/OT and PFS assessments found the patient required maximum or full assistance on most functional measures. With ADL, gait, and transfer training, as well as therapeutic exercise, the patient not only increased her own function, primarily by improving supervision, but also decreased the amount of time and effort required to complete these tasks. . In the last days of her rehabilitation stay, the patient began to speak coherently and in complete sentences, she began to participate in her discharge planning, and began to experiment with eating by mouth.

Conclusions:To the best of our knowledge, this is the first reported case of akinetic mutism after paraneoplastic encephalitis secondary to multiple myeloma and its course of rehabilitation. We suggest that intensive rehabilitation, together with the involvement of family relationships, has a positive effect on the functionality of a patient with akinetic mutism. The possible correlation with the administration of steroids leads to the hypothesis of their benefit in the rehabilitation process.

A rare case of severe hemophilia and Moyamoya syndrome (HAMS) diagnosed in the inpatient rehabilitation unit

Isaac P. Syrop, MD; Jesuel Padro-Guzman, MD

Diagnosis of the case:Severe Hemophilia and Moyamoya Syndrome (SHAM)

Case description:A 21-year-old man with a history of hemophilia A was admitted to the emergency department after a syncopal event in the shower. In the ER, he presented with acute changes with a head CT scan showing an acute right subdural hemorrhage with a right-to-left midline shift and a bilateral uncal herniation. The patient was taken directly to the operating room for hemicraniectomy and evacuation of the hematoma. After a prolonged course of 17 days in the Neuro ICU, including a right frontal infarction, he was referred to rehabilitation for the management and disposition of him. The rehabilitation team, together with neurology, found the presentation of this patient very peculiar, both with hemorrhagic and ischemic stroke. Cerebral angiography was requested, which confirmed the diagnosis of moyamoya. As described in some case studies, the rehabilitation team was interested in the relationship between hemophilia A and moyamoya. Subsequent clinical investigation revealed mild facial dysmorphia and developmental delays. Genetics were consulted and molecular cytogenetic studies identified a large deletion on the long arm of the X chromosome containing 3 OMIM genes (F8, MTCP1, and BRCC3). Deletions in this region are associated with severe hemophilia A and moyamoya syndrome (HAMS) (Blood. 2014;123(25):4002–4). Based on genetic testing, the diagnosis of SHAM syndrome was confirmed. When physical therapy first assessed the patient, he was performing bed mobility with maximum 2-person assistance and transfers with 2-person moderate assistance. Over the next 3 weeks, the patient did well and was able to walk 35 feet with minimal assistance from 2 people using a rolling walker. Unfortunately, beyond 3 weeks after admission, the patient experienced various neurological and medical setbacks and suffered functional regression.

discussions:Throughout this patient's complex hospital course, the rehabilitation team played a crucial role in the investigation, management, and rehabilitation of an extremely rare syndrome. A review of the literature shows only 4 probable people with this new 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 summary marks the fifth case ever filed. In addition to aiding in the prognosis for that individual patient, the diagnosis of SHAM syndrome may have consequences for her family, and genetic counseling is recommended.

Conclusions:An inpatient rehabilitation unit at a tertiary referral hospital admits patients with multiple diagnoses and coordinates care across multiple specialties. When working in an interdisciplinary team, as exemplified in this case, a physiatrist is in a unique position to combine multiple clinical findings into a single diagnosis, such as SHAM syndrome.

A rare case of symptomatic Os Vesalianum

Mohammad S. Islam, MD; Nicole E. Levy, Bachelor of Science; Dr Mahmood Syed

Diagnosis of the case:A rare case of symptomatic Os Vesalianum

Case description:This is the case of a 35-year-old man who has had severe pain in his left foot for three months. Initially, it was thought to be an old fracture of the fifth metatarsal bone based on X-ray imaging. It was managed conservatively with CAM booting, use of NSAIDs for pain control, and physical therapy. These treatment methods failed to alleviate the patient's symptoms. MRI showed os vesalianum as opposed to the previously suspected avulsion fracture. After several months of conservative treatment, the patient opted 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. Due to the rare incidence of this condition, it is often misdiagnosed as in this case. Therefore, imaging is a very important tool in the diagnosis of this condition. In this case, magnetic resonance imaging was essential to establish the diagnosis of os vesalianum and rule out an avulsion fracture of the fifth metatarsal as the source of the pain in this patient's foot.

Conclusions:Because it is such a rare diagnosis, os vesalianum can be misdiagnosed and therefore not properly treated. Imaging methods like X-rays and MRI are vital tools in discerning the correct diagnosis here. This condition can be managed conservatively or surgically with good results. Although this condition is quite rare, it is essential to properly diagnose it using available imaging modalities to optimize the best treatment for each patient.

A rare case of upper trunk brachial plexopathy after a urological procedure: a case report

Stanley Poole, hacer; Dr. Kenneth Rodrigues

Diagnosis of the case:This presentation is to raise awareness of the potential for brachial plexus injury during a prolonged urologic procedure. A case of brachial plexopathy was found in a 43-year-old man after a urological procedure of urinary diversion of the ileal conduit. Nerve palsy due to positioning on the operating table is commonly seen in the elbow and popliteal fossa. Brachial plexus injury is a less recognized complication of prolonged urologic procedures.

Case description:A 43-year-old right-handed man with T9 ASIA A SCI with a history of bilateral upper extremity ulnar neuropathy presented with new-onset right upper extremity weakness of 0-1/5 strength of shoulder abduction and shoulder flexion. elbow on the manual muscle testing (MMT) scale with decreased mild tactile sensation in the right C5 and C6 dermatomes immediately after a urologic ileal conduit urinary diversion procedure. NCS/EMG was performed and electrophysiological evidence of acute right upper trunk brachial plexopathy with ongoing axonal denervation was found. Due to the patient's weakness, the motor units could not be tested for reinnervation.

discussions:A brachial plexus injury can cause motor, sensory, and sympathetic disturbances. Trauma accounts for a large proportion of brachial plexopathies. The upper trunk is formed by the C5-6 roots. Thus, upper trunk lesions result in weakness of nearly all C5-6 innervated muscles and loss of sensation involving the lateral arm, lateral forearm, lateral hand, and thumb. This case is possibly the result of a positional traction injury due to prolonged surgery. It should be noted that this case may be compatible with Turner-Parsonage idiopathic neuritis due to anesthesia of the upper brachial plexus involving the C5 and C6 nerve roots.

Conclusions:Upper trunk brachial plexopathy after a urologic ileal conduit urinary diversion procedure is rare; Recognition of this possible adverse outcome should be considered and may warrant further study.

A rare cause of tetraparesis; Lead poisoning from retained bullet shrapnel

Emma Nally, MD; Emily Kivlehan, MS; Robert Bunning, MD

Diagnosis of the case:Severe quadriparesis from lead poisoning caused by retained projectile fragments.

Case description:A 31-year-old soldier with gunshot wounds (GSW) in 2006 with removed styles on his left femur was admitted to intensive care three times in 2015 with complaints of abdominal pain, vomiting, constipation, severe progressive weakness, sleepiness, fatigue and weightloss . Laboratory evaluation revealed unexplained anemia and elevated liver function tests, with occult heme-positive stools. Esophagogastroduodenoscopy, percutaneous liver biopsy, and PET-CT were inconclusive. On the third admission, the lead level was 129 ug/dL (normal less than 10 ug/dL). Intravenous and then oral chelation therapy was started. Shrapnel fragments trapped in the cystic inflammation of the thigh were removed. Lead levels decreased and the patient was admitted for acute rehabilitation. Initially he was quadruperal 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 walk 300 meters with a walker at a supervised level.

discussions:Lead toxicity is a relatively rare but catastrophic multisystem disorder often characterized by constipation, myalgia, decreased mental ability, polyneuropathy, and abdominal pain. This patient kept mints for 17 years without toxicity. Formation of a cystic structure may have caused lead absorption and progressive symptoms over 4 months. Inaccurate presentation and reduced exposure to patients with lead poisoning can delay treatment, but early diagnosis can prevent serious functional impairment.

Conclusions:Progressive neuropathy must trigger a heavy metal screen before symptoms become severe. Projectile fragments that have not caused toxicity for many years can still become toxic, especially when found in the fluid of a pseudocyst or joint. For unexplained neuropathy, a history of GSW may be relevant.

A retrospective chart review of infection and complications from electrodiagnostic nerve conduction and electromyographic studies in an adult outpatient care setting.

Lisa Marie Williams, MD; Ninad Karandikar, MD; min kim do

Goals.The infection rate from electrodiagnostic studies is considered rare. There have been several isolated outbreaks of EMG-related infections; however, to the best of our knowledge, the infection rate attributed to EMG is unknown. In addition, complications such as pacemaker malfunction, compartment syndrome, and bleeding have also been reported, but the frequency is unknown. The aim of this study is to estimate the risk of infection and complications of pacemaker malfunction, compartment syndrome, and bleeding from electrodiagnostic studies in an outpatient care setting.

Project:This is a retrospective observational chart review study.

The population included all persons who attended an adult physical medicine and rehabilitation (PM&R) outpatient clinic and a neurology electrodiagnostic laboratory in a closed health system from December 2005 to December 2014.

Using the electronic health record, we performed a retrospective chart review of 3993 patients who underwent EMG/NCS and had associated International Classification of Diseases (ICD) 9 infection codes linked to the chart within 90 days after the EMG/NCS encounter. The current Procedural Terminology (CPT) code for electrodiagnostic procedures was 95905, 95860 to 95864, and 95907 to 95913. A comprehensive list of more than 100 infection-related ICD-9 codes, as well as ICD-9 codes related to pacemakers, bleeding and Compartment syndrome was used. A detailed chart review was performed if there was a documented infection, hemorrhage, or ICD-9 compartment syndrome code within 90 days of EMG/NCS

Results:There were 12 associated ICD-9 codes within 90 days of the reviewed electrodiagnostic studies from December 2014 to December 2015. All 12 associated codes were related to infection. No codes related to pacemaker malfunction, bleeding, or compartment syndrome were found. A total of 68 cases of infection were found in 3,993 electrodiagnostic procedures over a consecutive nine-year period. A more detailed review of the graphs revealed that these infections were not associated with EMG/NCS. In addition, there were no pacemaker-related complications, findings of campartment syndrome, or related bleeding from electrodiagnostic studies performed during the period December 2014 to December 2015.

Conclusions:The guarantee that there is a low risk of complications in electrodiagnostic studies has been the basis for advising patients before undergoing this procedure. Infection, bleeding, compartment syndrome, and pacemaker malfunction are theoretical risks. This is the first large-scale retrospective chart review study to look at complications of EMG/NCS studies. Our retrospective chart review study revealed no associated infections, bleeding, compartment syndrome, or EMG/NCS-related pacemaker malfunction.

A unique presentation of seronegative spondyloarthritis presenting as chronic neck pain

Samuel T. Dona, MD; Amir ElShami, MD; Lauren Kremm, D.O.

Diagnosis of the case:A 40-year-old man with a history of colorectal cancer and schizoaffective disorder presented for an initial evaluation of chronic neck pain. Nine months earlier, the patient reported that he sustained a neck injury while immobilized after an altercation. At presentation, the patient reported constant neck discomfort exacerbated by movement and relieved by NSAIDs. Furthermore, the story was complicated by acute psychosis with the patient endorsing symptoms related to recent "alien abductions and surviving zombie attacks".

Case description:On physical examination, there was a decreased range of motion of the cervical, thoracic, and lumbar spine in all planes. Hypertrophy was observed in cervical paraspinals and bilateral trapezius. Radiographs of the cervical spine revealed arthrodesis of the facet joints bilaterally at all levels suggestive of ankylosing spondylitis (AS). The patient then underwent a formal AE evaluation. Positive laboratory results for elevated ESR and CRP; negative for rheumatoid factor, ANA and HLA-B27. Radiographs of the thoracolumbar spine demonstrated quadrature of the vertebral body at various levels and syndesmophytes consistent with AS. Patient referred to Rheumatology for complete evaluation. Rehabilitation efforts included pain control with NSAIDs and opioids, as well as a TENS unit with physical therapy.

discussions:Recognition of seronegative spondyloarthropathy, a potentially debilitating condition involving the axial skeleton, is necessary when evaluating young individuals presenting with chronic neck pain. In this single case, the diagnosis was difficult due to complaints of generalized neck pain with a concomitant history of psychiatric illness. There is a need to implement guidelines on the rehabilitation of seronegative spondyloarthropathy with recent literature advocating for medical optimization in addition to early initiation of physiotherapy.

Conclusions:It is important that the physician include seronegative spondyloarthropathy in the differential among the possible causes of musculoskeletal pain affecting the axial skeleton. Consolidation of clinical findings with objective data will lead to an accurate diagnosis, guide early treatment, and alter disease progression with improved functional outcome.

Young woman with Klippel Feil syndrome and periscapular pain: case report

Brian Snitily, MD; Leah G. Concannon, MD

Diagnosis of the case: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 arthrodesis was referred for evaluation of bilateral periscapular pain. All her life she has had difficulty raising her arms above her head, but the pain started a year ago. The examination revealed scapular elevation at rest. Shoulder abduction was limited to 90 degrees both actively and passively, with decreased scapular rotation. In addition, there was mild bilateral inferior medial scapula twitching bilaterally at rest that worsened with shoulder movement. The neurological examination was normal. Review of a previous MRI of the cervical spine confirmed the diagnosis of Sprengel deformity with the presence of a bony connection between the upper part of the scapula and the C5 vertebral body (omovertebral bone). She draws attention to the fact that the patient had not been informed of her diagnosis of Sprengel's deformity, despite having consulted various specialists about her Klippel Feil syndrome.

Given the absence of neurological alterations, the patient was referred to physiotherapy focused on optimizing aerial activities and strengthening the periscapular musculature. After six weeks of physiotherapy, she noted an improvement in her periscapular pain and reported greater ease in performing household activities and caring for her young children.

discussions:Sprengel's deformity results from the failure of the scapula to descend during fetal development and is usually identified at an early age. It is usually accompanied by various other abnormalities, especially in the cervicothoracic vertebrae or rib cage. The most common anomaly is Klippel Feil syndrome (present in 7-42% of people with Sprengel deformity), in addition to missing or fused ribs, chest wall asymmetry, cervical ribs, congenital scoliosis, and cervical spina bifida. Due to the elevated position of the scapula, there is limited ability to rotate the scapula upwards as it rests against the posterior ribcage, restricting range of motion of the shoulder. This restriction in range of motion may be magnified by the presence of an omovertebral bone or fibrous connection between the scapula and the middle cervical vertebrae, observed in 35% of individuals with Sprengel deformity. This restriction in range of motion can lead to disuse atrophy of the periscapular muscles, shoulder impingement, and functional limitations for overhead activities.

Conclusions:For adults with uncorrected Sprengel deformity, physical therapy focused on conditioning the periscapular muscles is a reasonable initial approach to reduce pain and improve functional activities.

Acute-onset upper lumbar radiculopathy in a rare case of Burkitt's lymphoma

Salvador Portugal, DO; Gregorio Burkard, DO; Carlos Kim, MD

Diagnosis of the case:Acute-onset upper lumbar radiculopathy in a rare case of Burkitt's lymphoma

Case description:This patient is a 33-year-old female who presented to a spinal outpatient clinic for initial evaluation of gradual-onset mild non-radicular low back pain that began 2 weeks earlier without causing any events. At the time of the initial visit, the patient denied "warning signs" and the physical examination was significant for right lumbar paraspinal muscle tenderness with normal neurological examination. The patient was treated for a lumbar strain with conservative treatment that included NSAIDs and a muscle relaxant.

Over the course of 2 days, her symptoms became progressively more severe, leading to follow-up with a new complaint of numbness in her right anterior thigh. The patient had right hip flexor weakness with sensory deficits in the anterior thigh. The patient's symptoms were recalcitrant to a pack of Medrol. Contrast-enhanced lumbar MRI revealed a large 14 x 7 x 6 cm psoas mass infiltrating the right L1-L2 and L2-L3 neural foramina with mass effect at the exit of the right L1 and L2 nerve roots. Biopsy and other tests revealed that the mass was of the sporadic subtype of Burkitt lymphoma. The patient was hospitalized and started chemotherapy treatment.

discussions:Burkitt's lymphoma is a rare cancer that is considered the most aggressive of all cancers. In the United States, the sporadic subtype is estimated to have an incidence of 3 cases per 1 million people and predominantly affects males. Our patient had no warning signs or risk factors associated with Burkitt's lymphoma (HIV or immunodeficiency). While it is standard practice to ask all "red flag" questions, they do not always provide the doctor with a suspicion of cancer as evidence in a rapidly aggressive cancer.

Conclusions:This rare case is clear evidence of the aggressive nature of Burkitt lymphoma with rapidly progressive upper lumbar radiculopathy. Given the atypical response to oral steroid medication and the rapid progression of this patient's neurological symptoms, the need for early diagnostic imaging (MRI) enabled prompt diagnosis and timely treatment to improve this patient's chances of survival. .

Acute sensory ataxic neuropathy in a patient with underlying vitamin B1 and E deficiencies

Victoria G. Treadway, MD; Julie Lanphere, DO

Diagnosis of the case:Acute sensory ataxic neuropathy

Case description:A 38-year-old man with chronic polyneuropathy of unknown etiology presented with a 1-week history of progressive unsteadiness of gait and ascending paresthesias, preceded by gastrointestinal disease. Initial evaluation was notable for CSF albuminocytologic dissociation, vitamin B1 and E deficiencies, and NCS demonstrating sensory axonal neuropathy.

A presumptive diagnosis of GBS was made and the patient received a 5-day course of IVIG as well as vitamin replacement. He was then released for inpatient rehabilitation with continued functional impairments. The examination was notable for areflexia and mild weakness (4/5) in the bilateral hip flexors, knee flexors, and ankle dorsiflexors. Proprioception, light touch, and pinprick sensation were abnormal in the upper and lower extremities. Based on this presentation, suspicion of a Miller Fisher variant (specifically acute ataxic sensory neuropathy) was raised.

During his rehabilitation course, the patient demonstrated improvements in gait and balance, while his weakness remained stable. He was discharged to his home where he participated in outpatient PT.

discussions:Guillain-Barré syndrome is a broad term that encompasses a spectrum of autoimmune neuropathies. This patient had several features shared by the various clinical subtypes of GBS, including a history of infection, monophasic course, areflexia, distal paresthesias, CSF albuminocytologic dissociation, and NCS abnormalities. However, the presence of sensory ataxia and axonal sensory neuropathy in this case is more consistent with the acute sensory ataxic neuropathy subtype. The presence of an underlying polyneuropathy and vitamin deficiencies add a layer of complexity to this case, as they may have also contributed to her symptoms.

Conclusions:Acute sensory ataxic neuropathy is a subtype of GBS associated with sensory ataxia and an axonal sensory neuropathy in the NCS. In our experience, these patients may benefit from IVIG and acute rehabilitation with an emphasis on training gait, balance, and proprioceptive techniques.

Alien hand syndrome after metronidazole use

Rachel Welbel, MD; Dra. Diane A. Thompson

Diagnosis of the case:Alien hand syndrome after metronidazole encephalopathy

Case description:A 52-year-old man was admitted to the acute rehabilitation unit after resection of a right cerebellar metastatic melanoma. On admission, he had left-sided dysmetria and decreased bilateral hip flexor strength. He had leukocytosis, with C. difficile infection, and was started on metronidazole 500 mg TID. He altered mental status and left-sided hemiplegia developed over the next 24 hours. Brain MRI revealed restricted diffusion in the splenium and posterior corpus callosum and a hyperintense FLAIR signal in all bilateral parietal and occipital lobes. On physical examination he was noted for unconsciously repeatedly grabbing his right arm with his left arm, as well as accusing others of the act. This discovery is consistent with the alien member. Metronidazole was changed to vancomycin to continue treatment of c. hard. His symptoms began to improve within 12 hours. His neurological exam returned to normal within 2 weeks and he was then discharged.

discussions:Other differential diagnoses for the patient's presentation included leptomeningeal disease, acute infarction, active malignancy, and meningitis. However, symptom onset and resolution corresponded to metronidazole use, and as no other etiology was discovered, metronidazole encephalopathy was the primary diagnosis. Hyperintense FLAIR lesions in the corpus callosum have been documented in metronidazole encephalopathy. In addition, the 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 to occur with the use of metronidazole.

Conclusions:Metronidazole is a commonly used drug to treat c.difficulty and toxicity has been linked to encephalopathy. This case indicates that, in the presentation of the alien hand syndrome, drug toxicity should be excluded as a cause. Metronidazole, in this case, was quickly identified and discontinued, allowing the patient to fully recover.

A comprehensive rehabilitative treatment plan for a patient with Ollier's disease

Timothy D. Flesher, MS, MD; Steven Farrell, MD; Cathy Hites, fisioterapeuta; Christine Robinson, TO

Diagnosis of the case:Ollier's disease

Project:Case Description: A 30-year-old man with a history of Ollier's disease has had several recent falls and left hip pain. Imaging and needle biopsy revealed left femoral chondrosarcoma, which required left-sided hemipelvectomy. A comprehensive rehabilitation stay resulted in his discharge to his home.

discussions:Ollier's disease is a rare and sporadic disorder in which benign intraosseous cartilage tumors, called enchondromas, develop near bony growth plates, causing a shortened, curved deformity. Treatment is surgical correction of the deformity. The incidence of secondary chondrosarcoma in Ollier's disease is approximately 25%, with the pelvic and shoulder girdles being the most affected.

Therapy challenges:Due to enchondromas in the hands, the patient had difficulty with ADLs. He couldn't hold the bath tongs. He became an expert at displacing enchondromas when dressing. He also used his arms and right lower extremity to propel his wheelchair, his previous primary mode of locomotion. A tumor on the left proximal humerus left his left arm 3 inches shorter than his right arm, so a left side platform was added to the walker. The patient was discharged ambulating up to 150 feet using a platform walker.

PM&R Challenges:Hemipelvectomy resulted in significant pain control problems. Medication management was successful in allowing greater participation in therapy. The hand enchondromas had open areas monitored for infection. Possible surgical removal of lesions to improve functional results was discussed.

Conclusions:Using an integrated approach from all rehabilitation disciplines enabled this unique patient with Ollier's disease to maximize pain control and improve function through integrative therapies despite the challenges of a hemipelvectomy and significant hand injuries. . The program resulted in a successful home discharge.

An unusual case of intractable seizures in ciguatera poisoning

Armen Derian, MD; Dra. Katherine Lin; Josué Rothenberg, DO; Seema Khurana, DO

Diagnosis of the case:New intractable seizures in a pediatric patient with ciguatera poisoning

Case description:Ciguatera poisoning is the most frequently reported toxic shellfish disease associated with the consumption of contaminated tropical fish (barracuda, snapper, grouper, eel, sea bass). Larger predatory fish (>70 cm) are at higher risk of carrying the toxin as it accumulates in the food chain. The toxin has known physical and functional manifestations, which can vary depending on the type and amount of fish consumed. A self-limited course of symptomatic control and supportive care remains the hallmark of treatment. This is the case of a previously healthy adolescent fisherman who presented with an unusual case of prolonged intractable generalized tonic-clonic seizures refractory to standard anticonvulsant medications. These seizures developed after she consumed her catch of the day, a pogie fish and a mutton snapper. They measure >75 cm, and the patient ate twice as much as his relatives, neither of whom developed serious neurological sequelae. They only had nausea and vomiting, but none of them developed seizures. In addition, he presented weakness, paresthesias, neuropathic pain, and functional impairment that responded to rigorous hospital rehabilitation not previously described in the literature. The electroencephalogram on admission confirmed seizure activity, showing generalized slowing down, frequent rhythmic clonic movements with superimposed polypoints, diffuse cortical hyperexcitability consistent with encephalopathy, and diffuse cerebral dysfunction. His seizure activity was controlled with a strong cocktail of anticonvulsant medications: levetiracetem 1500 mg twice daily, divalproex sodium 200 mg twice daily, and oxacarbazepine 450 mg twice daily. The patient presented severe functional deficits, which required maximum assistance in mobility, transfers, gait, posture, and balance. He also exhibited severe upper body tremors that limited his ability to perform activities of daily living. After a week of intensive inpatient rehabilitation consisting of three hours daily of physical and occupational therapy, the patient was able to ambulate 300 feet on flat surfaces and demonstrated improved heel-shin coordination, rapid alternating movements, and toe testing. and nose. He showed full motor strength on manual muscle testing in all extremities, with improvement since hospitalization for rehabilitation. The patient was discharged home on levetiracetam 1500 mg twice daily, which was slowly tapered. Six months after discharge, the patient continued levetiracetam 375 mg twice daily and was unable to completely discontinue the drug due to persistent seizure activity and paresthesias.

discussions:It is estimated that between 10,000 and 50,000 people a year suffer ciguatera fish poisoning. Gastrointestinal symptoms, such as nausea, vomiting, diarrhea, and abdominal pain, begin within hours and usually resolve in one to four days. Neurological symptoms usually follow gastrointestinal symptoms, and presentations may include paresthesias, dysesthesias, generalized pruritus, myalgias, hot and cold temperature disturbances, mental fatigue, muscle weakness, ataxia, and memory loss. In severe cases, seizures, altered mental status, and coma may occur. However, the current literature does not include definitive reports of status epilepticus associated with ciguatera fish poisoning. Although the neurological manifestations can become chronic, in most cases the symptoms disappear within weeks, but can last up to six months. This is the first case of intractable seizures prolonged beyond the previously cited six-month expected window for symptom resolution after confirmed ciguatera poisoning. Therefore, monitoring of epileptic activity after six months should be considered in all patients presenting with neurological sequelae after ciguatera toxin poisoning. In addition, our patient suffered from residual functional impairment, which responded remarkably to physical and occupational therapy that objectively showed a doubling in his measures of functional independence (FIM).

Conclusions:Despite being the most commonly reported disease of toxic shellfish, the diagnosis of ciguatera poisoning is clinical, with no human biomarkers to confirm its presence. The diagnosis should be considered in patients who develop gastrointestinal and neurologic symptoms after eating large tropical fish. After initial stabilization with intravenous mannitol, anticonvulsants, and symptomatic control, patients should be referred to inpatient rehabilitation, as they will benefit from three hours of physiotherapy and occupational therapy daily to improve their functional independence. Nine days after starting rehabilitation, our patient's FIM scores doubled. This supports the notion that it remains extremely important that rehabilitation be used early in the hospital course for best functional outcomes. As such, although rehabilitation has not been associated with recovery from ciguatera fish poisoning in the literature, it should play an important role in selected case management.

An unusual case of pigmented villonodular synovitis

Mohammad H. Zaidi, DO; Hamad Saleemi, DO; Bilal Khan, DO; Yu-Jen Lai, MD

Diagnosis of the case:Pigmented villonodular synovitis

Case description:A 66-year-old woman with a history of thyroid cancer presented with pain in her right hip. Imaging studies revealed a large mass emanating from the right hip adjacent to the sciatic nerve posteriorly, associated with femoral head erosions. 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 hospital rehabilitation, where a FIM gain of 46 points was achieved in 7 days.

discussions:PVNS is an inflammatory condition of the joint capsule that causes damage to adjacent structures. It typically affects men in their third decade of life with an incidence of 1 per 500,000. 80% of cases involve the knee joint, while only 15% involve the hip. MRI usually shows nodular masses within the joint capsule. Arthroscopy reveals hairy protrusions and nodular densities emerging from the synovium. Histopathology shows synovial infiltrates with hemosiderin-laden macrophages and large synovial nodules as a result of a chronic inflammatory process. Definitive diagnosis requires biopsy. Hemarthrosis was established as the cause of the different histological findings. There is still no consensus regarding the definitive etiology of this disease process. Treatment options include radiation therapy and synovectomy. Recurrence rates of up to 45% have been reported after radiation or synovectomy. Definitive management is through joint replacement.

Conclusions:This case highlights an atypical presentation of PVNS of the hip, in which symptoms and demographics are markedly different from the expected clinical presentation. Excision and arthroplasty followed by acute rehabilitation can provide an excellent clinical outcome.

An unusual case of noncommunicating spontaneous cervical and lumbar vertebral osteomyelitis disguised as upper extremity and low back pain: a case report

Esteban Erosa, DO; Francisco Lopez, MD, MPH

Diagnosis of the case:Cervical and lumbar discitis/osteitis with associated bilateral paravertebral and prevertebral phlegmon, severe canal stenosis, and compression of the theca at L3-L4 from an unknown source of infection.

Case description:The patient is a 73-year-old man who, 4 weeks before admission, presents with pain and swelling in the left wrist and low back pain after using a mallet. His wrist pain radiated to his neck and he was initially treated with physical therapy after negative imaging of his arm as an outpatient. Back pain that radiates to both legs gets progressively worse. The pain was intermittent, sharp, and scored 10/10 on the VAS; it was relieved by rest and exacerbated by movement. He also noted a ten-pound weight loss and occasional chills. At first he was independent. Upon entering the medication floors, he was unable to walk without assistance. An MRI showed cervical and lumbar vertebral osteomyelitis. Workup, including cardiac imaging and biopsy, were negative for malignancy, as well as bacterial or fungal infection. ESR and CRP were markedly elevated. He started empirically with IV antibiotics and PT/OT at the bedside. After 1 month of treatment, the patient improved and was ambulating 200 feet with a straight cane under moderate-assisted supervision.

discussions:Spontaneous bacterial vertebral osteomyelitis has been documented in the literature and attributed to advanced age. To the best of our knowledge, this is the first case to present in two isolated vertebral regions. Our patient had no history of intravenous drug use, systemic infection, malignancy, surgical/interventional manipulation, or immunosuppression, but was elderly.

Conclusions:This case demonstrates the importance of considering spontaneous vertebral osteomyelitis as a differential diagnosis in our elderly population.

An unusual presentation of a monkey hand.

Sarabjeet Arneja, MD

Diagnosis of the case:A 38-year-old woman arrives at the rehab clinic with a monkey hand on her left side. Her left hand shows evidence of hypothenar, thenar, and first dorsal interosseous atrophy. The 4th and 5th digits to the left of it are declined to bless. She cannot make a fist with her left hand or oppose with her thumb; Left Froment's sign is positive. There is worsening weakness of the left hand along with numbness/paresthesias. Along with the weak handgrip, there is also decreased left-hand finger abduction strength and decreased wrist extension. It was discovered incidentally that she had left nystagmus. Sensory deficits are seen in the left upper and lower extremities compared to the right, and in the back on the left side. There is hyporeflexia on the left side compared to the right. She has difficulty walking on her balls and heels, although she has not noticed any serious loss of balance.

Case description:The patient was started on Neurontin for a functional differential diagnosis of brachial plexitis versus cervical cord injury. Electrodiagnostic evaluation showed mild right ulnar neuropathy at the elbow, bilateral median neuropathy at the wrists, and a C8/T1 left cervical nerve root lesion. A cervical MRI showed an expansive cervical and thoracic intramedullary mass leading to T12, as well as cerebellar tonsils below the foramen magnum with torsion of the cervicomedullary junction. She was referred for neurosurgery and underwent occipital decompression for Arnold Chiari malformation and cervical syrinx. Unfortunately, the patient continued to experience worsening symptoms of weakness, paresthesias, and pain in the left upper and lower extremities. The patient began a rehabilitation course, which included physiotherapy and occupational therapies to work on the range and strengthening of the intrinsic muscles of the hand, as well as the strengthening of the hip flexors and dorsiplantar flexors of the ankle, in addition to training the gait and balance. Additional additional 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 probably occur due to defects in the growth of the rhombencephalon against traction by a tethered cord or a defect in neural tube closure in early fetal development, resulting in cerebrospinal fluid leakage.

The syrinx is believed to be due to craniospinal pressure due to blockage of cerebrospinal fluid flow into the subarachnoid space at the level of the foramen magnum, which generates pressure backup in the venous system and dissipates in the spinal parenchyma. spinal cord and central canal, leading to the formation of the syrinx.

Decompression of the posterior foramen magnum is performed at the craniocervical junction to restore normal CSF flow in the area of ​​the foramen magnum. Duroplasty is avoided due to concerns about CSF leakage and pseudomeningocele. Reoperation rates are significantly higher without duraplasty (13 vs. 2 percent). Syringe shunt placement is used primarily for patients with a Chiari malformation who fail subsequent decompression due to progressive symptoms or enlargement of the syrinx.

This patient is now a candidate for a syringe shunt placement procedure.

Conclusions:Arnold Chiari malformation is a source of morbidity in patients. Early detection is important to prevent worsening of symptoms. As in this case, the patient may present atypically and require extensive clinical, radiological, and electrodiagnostic examination 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 chronic widespread pain diagnosed as relapsing polychondritis

Aashish Deshpande, MD

Diagnosis of the case:This is the case of a 51-year-old woman treated for many years for worsening pain problems, beginning in the back and subsequently affecting various regions of the body. After numerous diagnostic evaluations without answers, a clinical diagnosis of Relapsing Polychondritis was given, providing the patient with an answer to her pain problems. Evaluation, study, and treatment are discussed.

Case description:A 51-year-old woman presented to the General Physiatry outpatient clinic with low back pain radiating to the bilateral lower extremities. With failure of conservative treatment and care, evaluation showed osteoarthritic changes and disc bulges in the lumbar spine consistent with the initial presentation. Subsequently, the patient began to develop problems of severe and uninterrupted pain in the head and neck, arms and legs, chest, abdomen, and lower extremities. The patient also had painful waxing and waning joint arthralgias. No trauma, infection, or other etiology was found for the generalized pain problems. Treatment included long-term and short-term high-dose narcotics with side effects that were often detrimental and limiting. After initial referral to rheumatology without a diagnosis, she was recently referred for follow-up. She consulted with the head of the rheumatology department at a university tertiary care center and received a clinical diagnosis of Relapsing Polychondritis (RP) by meeting 3 of McAdam's criteria, including bilateral auricular chondritis, nasal chondritis, and ocular inflammation. Subsequently, she was given a high dose of methotrexate and steroids, not only with an improvement in her pain problems, but also with an actual reduction in the high doses of narcotics being used. She continues to be followed up at 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 it appears to be an immune 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. After careful review of the patient's 4- to 7-year course of pain problems and symptoms, it is possible that she suffered at different times from headache, radiculopathy, rashes, nausea/dizziness, arthralgia, and nonspecific ocular dysfunction. In fact, his initial presentation of back pain and radiculopathy may have been caused by type II collagen dysfunction in the discs. Diagnosis is clinical, using the generally accepted McAdam criteria. Laboratory tests are usually nonspecific, including anti-collagen type II antibodies. Initial investigation for immune-mediated diseases was performed with negative results. Treatment is directed at the clinical manifestations, such as NSAIDs for joint problems, immunosuppressive agents, or cytotoxic agents for more severe inflammatory problems. The prognosis of RP is mixed with fluctuating and slowly progressive inflammatory manifestations throughout the body. The disease is potentially lethal, with pulmonary complications being the most notable. The patient is slowly improving with treatment.

Conclusions:In a patient presenting to the general physiatry clinic, prolonged and severe chronic pain represents a difficult and challenging issue. We present a case of chronic pain in multiple regions of the body diagnosed with Relapsing Polychondritis. The public is urged to be aware of this rare entity and to consider diagnosis in similar cases when pain problems go undiagnosed or require high levels of narcotic medication.

An unusual presentation of lateral hip pain in a runner

Anish A. Mirchandani, DO; dr. Jaspal Singh

Diagnosis of the case:A 35-year-old athlete with lateral hip pain discovered a proximal IT band tear.

Case description:A healthy 35-year-old athlete presented for evaluation for left 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 began gradually and was exacerbated by running. She described the pain as dull and achy in the area. On physical examination, the patient presented tenderness in the lateral region of the left hip below the iliac crest. She also noted weakness with hip abduction and internal rotation, which also mimicked her pain. An MRI of the left hip was obtained and revealed a proximal iliotibial band (ITB) tear at the level of the iliac wing. She advised the patient to begin a 4-week therapy program, which focused on a hip abduction program, eccentric exercises, and active release therapy. At reassessment after completing a 4-week course of therapy, the patient had complete resolution of her symptoms. On examination, she no longer had marked weakness in her left lower extremity or tenderness over her left lateral hip. She was able to consistently resume a running program. Finally, after follow-up, the patient reported that she had successfully completed two marathons without the return of symptoms.

discussions:This is the first reported case, to our knowledge, of a significant proximal ITB tear in an athlete presenting with lateral hip pain. This case also highlights the importance of considering the proximal pathology of the BIT in the athlete population, mainly females, and having a confirmatory diagnosis to offer the patient a physiotherapy program appropriate to the affected area.

Conclusions:The origin of lateral hip pain in the athletic population can be variable. This case illustrates the importance of considering proximal ITB pathology as a source of lateral hip pain in athletes, particularly women.

Analysis of the factors that contribute to the functional improvement of liver transplant recipients during hospital rehabilitation

Hejun Yuan, MD, PhD; Kim Barker, MD; Samuel M. Bierner, MD; Dr. William M. Lee

Goals.Liver transplant (LT) recipients have significant functional impairments and some need to be admitted for inpatient rehabilitation (IPR). Our objective is to analyze the factors that contributed to the improvement in FIM score changes for LT who completed the IPR.

Project:A retrospective chart review of 18 LT recipients admitted for IPD was performed. Demographic data, length of stay (LOS) in intensive or acute care or IPR, discharge destination, laboratory data (before and after), and functional independence measure score (FIM at admission and discharge) were collected from each patient. patient.

Results:descriptive statistics: Normally distributed variables included delta scores (change score: discharge - admission) for the following FIM variables: bladder and bowel control, LE bandaging, toileting, bathroom and shower transfers, mobility, and walking. In our sample, the delta scores were not normally distributed: for all the FIM cognitive scales, bowel/bladder accidents, eating, personal hygiene, EU clothing, and bed and wheelchair mobility.

Mean (SD) (Range): age at admission 55.6 (11.6) (32, 69) years. Post-transplant days: 29 (13.4) (14.60); length of stay before transplantation: 14.8 (10.6) (1, 41); THE IRF: 12.9 (7.4) (3.32). Change scores (discharge minus admission) for Cognitive END: 3.1 (3.9) (-1, 13); FIM engine: 20.5 (13.4) (1.45).

Regression analysis:

Linear regression analysis of the dependent variable (change in FIM-Motor score) gave F = 4.06 (SD = 16), which was significant, p = 0.031. The R-squared was 0.804 (adjusted R-squared 0.61). Root MSE = 9.14. The significant independent predictors were: heart rate at discharge, length of stay in IRF, hospital days before liver transplantation, and number of days after liver transplantation. Using standardized "beta" coefficients, these coefficients were: HR -0.582; LOS 0.466; Hospital days pre-LT 0.672; and Days after transplantation -0.6. Age, sex and MELD score, among other variables, pre-LT were not significantly related.

Conclusions:Some LT recipients have significant disability after transplantation and may benefit from rehabilitation. The length of stay before transplantation is a strong predictor of this need. The duration of the stay in the IRF is strongly related to the improvement in the FIM Motor score. FIM engine gains of 20 points can be expected. The change in the FIM cognitive score was not significant in our sample.

Anatomical landmarks for the location of the long head of the biceps brachii tendon with ultrasound validation

Saiyun Hou, MD, PhD; Sheng Li, MD, PhD; Dr. John Harrell

Goals.The aim of the study was to establish anatomic landmarks for the location of the biceps tendon groove based on intrinsic anatomic relationships and to validate the location with ultrasonographic measurements.

Project:Twenty-five healthy young volunteers were recruited for the prospective study. We established two anatomic landmarks, the landmark related to the vertical line of the medial epicondyle and the landmark of the coracoid process. The groove of the long head of the biceps muscle was visualized on ultrasound and marked on the skin. The distance from the sulcus skin mark to the vertical line of the medial epicondyle and coracoid process was measured horizontally at 0° and 45° external rotation of the shoulder, respectively. On average, the 95% confidence interval (CI) of the distance was calculated and its correlation with height, weight and body mass index (BMI) was analyzed.

Results:The vertical lines of the medial epicondyle were medial to the groove at 0° and 45° of external rotation of the shoulder. The distance between the groove and the vertical line of the medial epicondyle was 9.3 mm (95% CI, 6.8 to 11.8) and 21.5 mm (95% CI, 18.9 to 24.1) at 0° and 45° external rotation of the shoulder, respectively. The correlation coefficients were 0.04/0.10, 0.32/0.42, and 0.26/0.37 for weight, height, and BMI at 0°/45° of shoulder external rotation, respectively. The distance between the coracoid process and the sulcus was 44.0 mm (95% CI, 41.5 to 46.5) and 62.2 mm (95% CI, 59.2 to 65.2) at 0° and 45° external rotation of the shoulder, respectively. The correlation coefficients were 0.36/0.41, 0.36/0.54, and 0.18/0.12 for weight, height, and BMI at 0°/45° of shoulder external rotation, respectively.

Conclusions:The medial epicondyle vertical line and the coracoid process landmark are useful anatomic landmarks for locating the biceps groove. Localization based on anatomical landmarks is essentially uncorrelated with titer weight, height, or BMI.

Anterior humeral circumflex artery: defending from musculoskeletal ultrasound-guided biceps tendon sheath injections

Arben Brahaj, MD, RMSK; Peter (I-Kung) Wu, MD, PhD; Sampada Acharya, MD; Minna J. Kohler, MD; Shweta Kishore, MBBS, MD

Goals.Local corticosteroid injections are commonly used to treat anterior shoulder pain attributed to long head of the biceps tendinopathy (LHBT). Injections close to the biceps groove, especially when performed by palpation of anatomical points, carry the risk not only of TLBT rupture or atrophy, but also of vascular injury or injection into the anterior humeral circumflex artery (AHCA), whose ascending branch anterolateral aspect (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 most of the humeral head, and LHBT, has been associated with avascular necrosis of the humeral head. Due to the inherent imprecision and risks associated with palpation-guided LHBT steroid injections, this study sought to raise awareness of the anatomy of AHCA and its relevance to complications of LHBT sheath injections. Using musculoskeletal ultrasound (MUS) to visualize AHCA versus LHBT, we further demonstrate the utility of MUS guidance, which has been shown to increase the accuracy of steroid injections compared to palpation guidance, in avoiding complications.

Project:Greyscale color Doppler and MUS scans were performed on the anterior shoulders of 12 subjects with LHBT tendinosis to localize the AHCA and its AAB in relation to the LHBT. The MUS findings were correlated with the medical literature on AHCA anatomy.

Results:Grayscale ultrasound enhanced with color flow Doppler scans accurately localized the ABA lateral to the LHBT in the bicipital groove at a mean distance of 19.2 ± 11.9 mm, allowing for a successful guided steroid injection by MUS in the LHBT, avoiding vascular lesions.

Conclusions:The proximity and course of the AHCA along the LHBT presents a high risk of vascular injury or intravascular injection that can occur during palpation-guided LHBT sheath injections. The use of MUS to visualize the local anatomy when performing injections can improve patient safety and prevent complications.

Transfer of the anterior interosseous nerve to the ulnar nerve for the treatment of traumatic ulnar nerve palsy

Roderick G. Gear, MS4; Faren Williams, MD, MS; David Mazin, MD; Marci Jones, MD; Dr. A.S. David Magit

Diagnosis of the case:Traumatic ulnar nerve palsy

Case description:A 24-year-old woman, dominant right hand, who suffered a distal fracture of the left humerus secondary to a traffic accident. She had surgical fixation with scan 4 weeks later positive for left ulnar claw hand with 0/5 intrinsic muscle strength, abductor digiti minimi and flexor digitorum profundus (FDP), ulnar head. Electrodiagnostic study three months after injury revealed no ulnar sensory or motor responses. Needle study revealed axonal loss in muscles supplied by the ulna, but not in muscles supplied by other peripheral nerves. An EDX study five months after injury did not demonstrate ulnar sensory or motor responses, but did show reinnervation in the FDP, ulnar head. At this time, the intrinsic muscles of the hand and the hypothenar eminence were significantly atrophied. The patient had a marked claw hand and lacked light tactile sensation in an ulnar distribution. Due to lack of distal reinnervation, the patient underwent anterior interosseous to ulnar nerve transfer at the wrist and revision of the nonunion humeral fracture. After one week, the patient had increased sensation on the ulnar side of the ring finger with persistent numbness in the little finger.

discussions:Functional recovery after traumatic peripheral nerve injury depends on the motor end plate reinnervation time and the number of regenerated axons that reach their target. After nerve transfer, axonal regeneration allows for nerve coaptation and recovery of distal sensory and motor function. This patient had positive prognostic factors for functional recovery. She was young, healthy, and injured on the non-dominant end of her. The second EMG suggested some regeneration of the proximal ulnar nerve. Serial EMGs performed at routine increments will help quantify the extent of reinnervation.

Conclusions:The physiatrist EMG, in close collaboration with surgeons, can help define nerve damage, prognosis, and the 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 best functional result.

Aphasia in a patient with a dominant right hand secondary to right cortical stroke

Jared Levin, MD; Dr. Thuy D. Vu

Diagnosis of the case:Transcortical motor aphasia secondary to stroke in a right-handed patient

Case description:A 71-year-old male, right-handed, transferred to Rehabilitation for stroke, initially presenting left hemiparesis and dysarthria. In the emergency room, he was found to have left facial droop, aphasia, and left hemi-neglect. There was no report of weakness on the right side. Head CT scan showed loss of differentiation between gray and white matter in the right fronto-parietal lobes. Follow-up with MRI/MRI confirmed the absence of left cortical lesion. The patient presented expressive aphasia, with intact comprehension and repetition. He was diagnosed with Transcortical Motor Aphasia. The patient underwent intensive speech therapy training and showed persistent improvement in his language production.

discussions:It is well known that more than 90% of the population is right-handed and that this is related to the left hemisphere that contains the primary motor cortex. On the other hand, it is believed that lefties generally have their primary motor cortex in the right hemisphere. Likewise, it is believed that in more than 95% of people, specific areas of the left hemisphere are responsible for speech and language, while the right hemisphere controls attention, visual cognition, and communication skills. It has been shown that hand control and language often occur in the same hemisphere. Our patient is unique in that he is right-dominant with what appears to be a right-dominant language center. According to a study by Knecht et al, in which transcranial Doppler ultrasonography was used to assess hand and language proficiency, of all right-handed individuals, approximately 4% have a right cortical language center. This would place our patient at around 0.16% of the population.

Conclusions:Our patient presented aphasia secondary to a right cortical stroke, identifying a neuroanatomical anomaly that became more singular due to the lack of association between his dominant motor and linguistic centers.

Apical lung mass presenting as brachial plexopathy: a case report of electrodiagnostic findings

Bindu Sundar, DO; Nida Glevekas-Martens, DO

Diagnosis of the case:Apical lung mass presenting as brachial plexopathy: case report of electrodiagnostic findings

Case description:A 66-year-old male, with a history of hypertension, hyperlipidemia, chronic smoker, referred for electrodiagnosis due to weakness and pain in the right arm. The patient reported that he had symptoms of a stroke a few weeks ago, which caused transient weakness on the left side that resolved. Shortly after his discharge from the hospital, he noted weakness and numbness, especially in his right fifth finger and the middle of his forearm. He noted that the symptoms initially began with pain in the neck that radiated to the arm, as well as intermittent sharp pain in the shoulder and mid forearm. The patient was referred to the EMG clinic for investigation of possible right-sided ulnar neuropathy. The examination was significant for decreased wrist extensor motor strength in 4-/5, flexors and extensors of the fingers in 3+/5, and severe weakness in all intrinsic and thenar muscles of the fingers. The reflexes were diminished in the right triceps and the brachioradialis in 1+/4. EMG demonstrated a normal median sensory response, but abnormal ulnar sensory, median, and motor responses. The right median antebrachial cutaneous nerve was also asymmetric with respect to the left. There was no focal slowing or conduction block in the right elbow.

discussions:The patient had typical symptoms of ulnar neuropathy, but the electrodiagnosis pointed to proximal pathology. In this case, it was located at the level of the medial cord of the lower trunk due to abnormal responses of the medial antebrachial cutaneous nerve. The patient underwent subsequent imaging studies that showed an apical lung mass on the right side.

Conclusions:Upper extremity brachial plexopathy can sometimes present as a peripheral mononeuropathy, in this case an ulnar neuropathy. However, electromyographers should consider including brachial plexopathy in their differential if there are physical examination findings of more extensive involvement. Brachial plexopathy of uncertain etiology should be investigated for other causes of nerve compression. In this case, an apical mass was revealed that compressed the plexus.

Arachnoiditis presenting as chronic ankle pain: a case report

Michael Auriemma, MD; Simon Willis, MD; dr Eric Wisotzky

Diagnosis of the case:arachnoid

Case description:A 62-year-old man, with a significant medical history of type 2 diabetes and anterior cervical discectomy and C3-C4 fusion, presented with an 8-month history of severe, throbbing pain in the left ankle greater than the right ankle, of insidious onset. . soon concentrated above the lateral malleolus. He denied relief with gabapentin or prior steroid injection into the left tibiotalar joint. Magnetic resonance imaging (MRI) of the left ankle revealed nothing, while lumbar MRI indicated mild to moderate neural foraminal stenosis at L5-S1 bilaterally. Physiotherapy and bilateral L5 transforaminal epidural steroid injections offered no relief. An electromyography was performed which showed evidence of a predominantly motor rather than sensory axonal polyneuropathy. Further review of the lumbar MRI indicated the presence of lumbar arachnoiditis. Pregabalin, tramadol, lumbar interlaminar epidural, electrical stimulation, and acupuncture have all been tried without benefit. Given the lack of response to all treatments, arachnoiditis was considered the main pain generator. The patient was referred for a spinal cord stimulation (SCS) trial and experienced immediate relief upon completion of the trial. As a consequence of a successful trial, the patient is currently awaiting treatment with permanent surgical placement of an SCS.

discussions:Arachnoiditis is a disorder consisting of chronic and intractable pain caused by inflammation of the arachnoid. Causes include infection, previous injury, chemical irritation, and a previous history of spinal surgery. Typical symptoms include numbness, paresthesias, and burning pain in the lower back and legs. Isolated ankle pain is a rare presentation of arachnoiditis. There is currently no definitive cure and treatment is aimed at controlling pain and other symptoms.

Conclusions:It is important to maintain arachnoiditis in the differential diagnosis of difficult-to-control pain, especially in patients with a history of spinal surgery.

Evaluation of the usefulness of objective tracking of pelvic movement for the clinical evaluation of gait performance in lower extremity amputees

Gerasimos Bastas, MD, PhD

Goals.Early and reliable detection of impaired gait performance through objective assessment tools would go a long way toward protecting the health and livelihoods of the more than 1 million Americans living with lower extremity loss. Non-optimized prostheses make physical activity more strenuous, can cause direct or indirect injuries, predispose to secondary degenerative diseases such as osteoarthritis and low back pain, and are the main cause of user dissatisfaction. Insidious changes in people's abilities and needs affect the "performance match" between the user and the device, and usually manifest late in clinically significant gait deviations. Clinical assessment in the outpatient setting relies solely on subjective observational gait analysis (OGA), a non-standard practice fraught with known reliability challenges, regardless of observer training level, even with data-based tools. checklists, and its low correlation with instrumented gait analysis. measurements. In the absence of validated methodologies to assess gait performance in lower limb amputees (ALL), we currently lack standardized assessment measures to identify gait deviations in a timely manner, in a way that also allows response to be quantified and monitored. the intervention . Previous work has shown differences in pelvic movement between physically fit individuals and ALL. The pelvis, as a link 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 movement of the pelvis are directly affected by the biomechanical performance of each lower limb. Therefore, objective pelvic motion tracking (OPMT) can serve as a good indicator of prosthetic gait performance. Our study is the first to attempt a clinical correlation of walking ability with objective metrics of gait parameters in ALL, which can be used in real time in the outpatient setting to help guide care. We show that OPMT can help clinicians clinically distinguish gait patterns in their ALL patients.

Project:Using a single inertial measurement unit (IMU) containing accelerometers, gyroscopes, and magnetometers, we recorded the pelvic motion patterns of 4 healthy controls, 7 transfemoral (TFA) and 5 transtibial (TTA) amputees, while walking. The device is lightweight, wireless, affects gait, and is worn at the waist and placed over the fifth lumbar vertebra (L5). Reports range of pelvic motion in the coronal, sagittal, and transverse planes, side-to-side symmetry, acceleration/deceleration phases, gait speed, and time with one and/or both lower extremities on the ground. Subjects were tested in typical outpatient (outpatient) settings. Clinicians (a physiatrist, a prosthodontist, and a physical therapist) experienced in caring for amputees observed the subjects' gait tests, classifying their gait ability as "adequate" (-A) or "requires intervention" (- IR) by consensus, according to the standard of care. The multidimensional scale was used to visualize symmetries for the pelvic acceleration waveform in the direction of progression, lateral pelvic tilt, and transverse rotation.

Results:We present here preliminary walk test data from 4 healthy controls, 5 TTA and 7 TFA ALL. We observed differences in speed/cadence, stance/swing times, and pelvic range of motion for the TTA and TFA levels (most pronounced at the top level), consistent with previously reported findings. We were able to demonstrate significant differences in the symmetries for the pelvic acceleration waveform in the direction of progression, lateral pelvic tilt, and transverse rotation (the symmetries refer to the percentage of concordance of the temporal variation of the declared parameters normalized to the gait cycle). ) : healthy 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%), which allows a multivariate pathognomonic grouping capable of distinguishing “adequate” gait capacity from that which “requires intervention”.

Conclusions:Our data analysis indicates that monitoring of objective kinetic and kinematic parameters of pelvic motion can serve as a good indicator of ALL walking ability. OPMT can reliably indicate when a prosthetic device warrants adjustment or revision in people with lower limb amputations. The numerous objective metrics captured can characterize joint states of localized functional optimum, for different levels of amputation, as well as clinically significant deviations. Based on these preliminary data, further studies are needed to validate the utility of OPMT in the clinical evaluation of walking ALL. The introduction of objective means to assess ALL gait performance would have a very significant clinical impact. Standardization of assessment will allow clinicians to save time, reliably document and communicate objective results, monitor performance, rate prescribed interventions, and quantify their effectiveness. Tools like OPMT can enable the creation of evidence-based practice guidelines for providing care for amputees.

Masking of avascular necrosis as radiculopathy: a case of premature closure

Vince Si, MD

Diagnosis of the case:Idiopathic avascular necrosis of bilateral femoral heads

Case description:This is a 67-year-old woman with no significant medical history who attended the clinic for evaluation of lower back and left leg pain for 2 years. The pain is described as dull and radiates down the side of the left leg, through the knees, sparing the foot. The pain is worse when standing, but is also present in the supine and sitting position. Functionally, she walks 5 blocks with a straight cane and has great difficulty climbing 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 the right L5 nerve root. Later, her PCP referred her for treatment for radiculopathy.

On examination, the patient had minimal pain on flexion and extension of the back. Examination of his legs revealed atrophy of the left quadriceps, decreased range of motion in the left hip in flexion, external and internal rotation. He was also unable to flex the hip and flex/extend the knee against gravity. He had an antalgic gait with left circumduction. His exam was concerning for intrinsic hip pathology versus radiculopathy versus peripheral neuropathy. EMG was negative for radiculopathy or peripheral neuropathy, and hip radiography showed bilateral avascular necrosis (AVN) of the femoral head, worse left than right. She was diagnosed with idiopathic VAP of bilateral femoral heads and referred to orthopedics for surgical evaluation. She began a course of physical therapy to strengthen her core and hip-girdle complex with the goal of stabilizing her hip joints and reducing 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 with no history of steroid use, alcohol abuse, trauma, osteoporosis, or coagulopathy. Furthermore, this case highlights the difficulty of an accurate diagnosis, as the symptoms can be broad and non-specific and can easily be confused with more common clinical diagnoses such as radiculopathy, IT band syndrome, or intrinsic knee pathologies.

Conclusions:Idiopathic AVN can be a diagnostic dilemma due to its rarity and often nonspecific symptoms. Therefore, it is important to perform a detailed examination of the hip in patients complaining of back, leg, or knee pain and to keep hip pathologies within the differential.

Withdrawal of baclofen secondary to gastrointestinal malabsorption in a patient with colitis

Ali Valimahomed, MD; Jesuel Padro-Guzman, MD

Diagnosis of the case:baclofen withdrawal

Case description:This is the case of a 76-year-old woman with a medical history of multiple sclerosis (MS) who was admitted to the hospital with bright red blood from her rectum and diarrhea. Colonoscopy revealed pseudomembranous colitis and biopsy was positive for ischemic colitis. Infectious investigation, including Clostridium difficile testing, was negative. During hospitalization, she presented progressive urinary retention, altered mental status, spasticity, tachycardia, and respiratory failure requiring intubation. She was given intravenous methylprednisolone for a suspected MS flare with no improvement in symptoms. The electroencephalogram was negative for seizures. Noncontrast computed tomography of the head was negative for the acute process. Finally, it was concluded that the symptoms were due to baclofen withdrawal secondary to gastrointestinal malabsorption as a result of colitis. The patient was transferred from oral baclofen to intravenous diazepam, with gradual resolution of symptoms. The colitis was treated medically with intravenous fluids and Lomotil as needed. The patient was successfully extubated and returned to medication at home.

discussions:Although medication nonadherence is often suspected in baclofen withdrawal, this case illustrates that acute gastrointestinal dysfunction such as colitis (ischemic, inflammatory, or infectious) can lead to oral baclofen malabsorption with subsequent withdrawal symptoms. In cases of suspected baclofen malabsorption secondary to gastrointestinal dysfunction, transition to intravenous antispasmodics is prudent.

Conclusions:It is important to recognize the symptoms of baclofen withdrawal. Clinicians should monitor withdrawal signs and symptoms in patients with acute gastrointestinal conditions because of the possibility of impaired absorption.

Barriers to the acquisition of personal wheelchairs in a Multidisciplinary Center for Assistive Technologies: a quality improvement project

Mark Fisher, Bachelor of Science, MD; Brad Dicianno, BS, BA, MS, MD

Goals.To assess the impact of various barriers to purchasing manual and powered wheelchairs obtained through a university-affiliated assistive technology center.

Project:Approval of the Quality Improvement Subcommittee was obtained. A retrospective chart review was conducted using a random sample (n = 82) of individuals with initial evaluation in 2014. Insurance company, equipment received, equipment upgrade (difference between equipment owned at presentation and equipment prescribed), supplier ( independent variables) and The days from the initial evaluation to adaptation (dependent variable) were collected. Equipment was coded using an ordinal scheme based on the number of functions provided by the equipment. A linear regression analysis was performed with dummy variables and using Insurance A as a constant to detect an association of independent variables with acquisition time.

Results:The R square of the regression model was 0.279 (p < 0.001). Compared to Insurance A, higher equipment codes delayed the delivery of Insurance D (Beta -0.386, p=0.017). Equipment upgrades delayed the delivery of Insurance A more than Insurance B (Beta -0.263, p=0.021) or Insurance D (Beta -0.289, p=0.015). Average delivery time was longer for Insurance C (Beta 0.306, p=0.007) and Insurance D (Beta 0.255, p=0.019) compared to Insurance A. The provider used did not have a significant impact on delivery time. delivery (p=0.069). Comparative acquisition time averages for the insurance company and the equipment group were calculated.

Conclusions:Insurance C and D (both public insurance) delayed the total acquisition time. The greater the disparity in equipment between the customers' old equipment and the new equipment, the longer the delay in approval of Insurance A (private insurance) compared to Insurance B (private insurance) and Insurance D. a Estimated delivery time based on prescribed equipment and customer's insurer.

Home Acupuncture Training on the Battlefield: A Course That Gets Straight to the Point

Gregory L. Condie, DO; Ajit Pai, MD; David Drake, medico

Goals.Battlefield Acupuncture (BFA) is an emerging tool as a way to combat pain without the use of narcotics. This modality is generally not taught in physical medicine and rehabilitation (PM&R) residency programs; but it is gaining interest due to its use by the military and VA health systems. Currently, there is no standard curriculum for residents to learn BFA techniques. Published research produced a few research articles on implementing acupuncture or integrative medicine in residency training, but none specific to BFA. Understanding residents' attitudes and assessing their level of competency after BFA training will allow us to better implement a new certification process for residents and improve their pain management skills as medical residents during residency.

Project:2nd, 3rd, and 4th year graduate resident physicians in a unique residency training program participated in a 3-hour educational lecture and demonstration. The practical training was completed by a BFA certified instructor with ASP acupuncture pins. A post-training survey using a 5-point Likert scale was administered to assess residents' perceptions of proficiency with BFA techniques and whether the training enhanced their education.

Results:Resident Physicians (n=18 participated; n=12 responded to survey) 50% overall felt a session was appropriate and enhanced their education. 58% have used the training techniques since the training was delivered. 58% considered that the training would not affect their choice of residence. 46% said they would recommend others to start a similar training, and another 48% were not sure. While 33% agreed to use this in their future practice, 41% were undecided, while 24% disagreed or strongly disagreed with the idea.

Conclusions:In our sample, the training of resident physicians in BFA techniques is effective and, in general, well received. This training can be integrated into the curriculum on a continuing or semester basis. This can be used as a model for other programs to emulate.

Enhanced temperature probe placement during an electrodiagnostic evaluation (EDX) of carpal tunnel syndrome (CTS)

Jennifer Soo Hoo, médica; Leilei Wang, MD, PhD

Goals.It is well established that temperature influences nerve and muscle function and should be taken into account when analyzing EMG findings to avoid misdiagnosis. The purpose of our study was to determine the best location for the temperature probe during a CTS study.

Project:We obtained infrared temperature readings using a Slim-Line INR 462 infrared thermometer with Laser Sighting probe, which can measure temperature changes in real time, from both hands of 7 asymptomatic individuals on the proximal and distal phalanges of each finger, thenar, hypothenar, and wrist. on the dorsal and palmar side. The temperature differences were then compared and analysed. We used a hair dryer and an infrared heating lamp to warm the hand of 2 subjects and then monitored hand temperature every minute until the temperature returned to baseline.

Results:We found that there is a remarkable variability in temperature between individuals and within the same individual in different parts of the hand. We also found that there are variable temperature differences from side to side within the same individual. After warming a patient with a hair dryer for 45 seconds, we found that temperatures cooled rapidly with distal phalanx temperatures returning to <30°C after 1 to 2 minutes, and proximal phalanx temperatures returning at < 30 °C after 4 to 5 minutes.

Conclusions:We found that reading the temperature on the back of the hand does not predict the temperature of the fingers. Side-to-side temperature variation argues against placing the temperature probe on the contralateral extremity in the proper location. We also found that skin temperature drops rapidly after heating with common heating techniques and returns to pre-heat temperature within a few minutes. Given the large temperature gradient within a specific digit, further study is needed to determine which location should be used for temperature correction. These issues are currently under investigation.

Beyond the muscle: a case of bronchiolitis obliterans with organizing pneumonia as a preceding manifestation of polymyositis with positive anti-Jo-1 antibodies

Craig Van Dien, MD; Laurent Delavaux, MD; Dr. Iqbal Jafri; Dr. Sara Cuccurrullo

Diagnosis of the case:polymyositis

Case description:A 54-year-old man with a history of hypertension and bronchiolitis obliterans with organizing pneumonia (BOOP) who was previously taking long-term steroids is admitted for acute inpatient rehabilitation for functional deficits related to proximal muscle weakness. The patient was initially diagnosed with BOOP in September 2014 and was treated with long-term steroids ending in April 2015. In March 2015, the patient reported onset of proximal upper and lower extremity weakness resulting in decreased of the functional state. . Electromyography in May 2015 demonstrated subacute or chronic diffuse myopathy of the bilateral lower extremities. Prior to admission for rehabilitation, the patient was reassessed in an acute medical center and evaluation demonstrated elevated levels of creatine kinase, myoglobin (serum and urine), aldolase, and serum anti-Jo-1 antibodies. Scleroderma, ACH binding/blocking antibodies, and antinuclear antibodies were negative. He underwent a muscle biopsy with pathology that later demonstrated inflammatory myopathy with moderate atrophy of myofibrils, including perifascicular atrophy compatible with polymyositis. The patient was started on oral steroids and was transferred to an acute rehabilitation center. During his rehab stay, he continued on oral steroids with improvement in functional status from moderate assistance with transfers and activities of daily living (AVDs) and ambulation to independent contact tutor assistance with most ADLs and supervision with wandering.

discussions:Polymyositis is an idiopathic inflammatory myopathy that is usually clinically characterized by proximal muscle weakness. The association between interstitial lung disease and polymyositis is commonly reported, with fewer reports of BOOP as a preceding manifestation of polymyositis.

Conclusions:This is an interesting and rare case of BOOP as an anterior manifestation of anti-Jo-1 antibody-positive polymyositis with clinically significant proximal muscle weakness manifesting with a reduction in steroid dose.

Bilateral Carpal Tunnel Syndrome in the Presence of Transthyretin Amyloidosis (TTR): Case Report

Alcinto Steven Guirand, MD; Sean A. Lacey, BSC

Diagnosis of the case:Bilateral carpal tunnel syndrome in the presence of transthyretin (TTR) amyloidosis

Case description:A 78-year-old man with newly diagnosed wild-type TTR cardiac amyloidosis and moderate-to-severe bilateral carpal tunnel syndrome presented to a tertiary center outpatient clinic with bilateral numbness of the hands and decreased manual dexterity. He was approximately thirteen years old after carpal tunnel release of both wrists with good symptom relief. Electrodiagnostic studies were requested to assess for the presence of bilateral carpal tunnel syndrome or cervical radiculopathy.

Sensory and motor conduction studies of the right and left upper extremities were performed. This was followed by needle EMG of selected proximal and distal muscles of the right upper extremity. There was electrical evidence suggesting the presence of severe bilateral median neuropathies in the wrists, as seen in carpal tunnel syndrome. There was additional evidence to suggest bilateral nonlocalized ulnar sensory neuropathies. There was no evidence of cervical radiculopathy.

discussions:Deposition of wild-type and variant TTR in the tenosynovial tissues of the wrist has been shown to be a cause of idiopathic carpal tunnel syndrome. Variant wrist deposition generally occurs early in the course of the type II amyloid neuropathy phenotype of familial TTR amyloidosis. Carpal tunnel syndrome in the wild-type depot setting may be the major finding in patients with senile systemic amyloidosis predominantly affecting the cardiovascular system.

Conclusions:In patients with TTR amyloidosis, idiopathic carpal tunnel syndrome may be the initial manifestation of the disease. The presence of bilateral symptoms may be even more suggestive of familial or wild TTR amyloidosis.

Bilateral femur fractures in a patient treated with bisphosphonates: case report

Jahnna Levy, DO; Nayeema Chowdhury, DO; Dr. Wayne Stokes

Diagnosis of the case:A 62-year-old woman with a two-year history of bilateral hip pain was found to have bilateral subtrochanteric stress fractures of the femur while taking a daily dose of bisphosphonates for five years.

Case description:A 62-year-old line dancer presented to an outpatient clinic complaining of two years of pain in the right hip greater than in the left, extending distally to the knees with occasional swelling in the right knee. He denied accidents, falls or trauma. The pain was described as sharp, with occasional radiation to the groin. His pain was exacerbated by weight bearing, walking, climbing stairs, and dancing. He had a complete resolution of his pain with rest. She has been a professional line dancer for over 30 years, practicing approximately 4 hours a week with no recent change in her technique. Previous medical history was significant for osteoporosis. Current medications were highlighted by beta blockers and the recent discontinuation of a bisphosphonate taken 5 days a week for 5 years. Physical examination revealed a limitation of 15 degrees in external rotation to the right with pain, otherwise the examination was normal. Bilateral hip radiographs were ordered, which revealed bilateral subtrochanteric stress fractures with right lateral cortical fractures larger than the left and mild osteoarthritis of the right hip. The patient received bilateral non-weight bearing lower extremity precautions for a minimum of three months due to the risk of fracture progression to complete dislocation and was referred to orthopedics to consider surgical intervention.

discussions:Bisphosphonates are a class of drugs used in the treatment and prevention of various bone diseases, including osteoporosis, Paget's disease, osteogenesis imperfecta, 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 breakdown of bone to restore the balance between osteoblasts and osteoclasts. Common potential adverse effects include esophageal and stomach erosion, osteonecrosis of the jaw, and cardiac arrhythmias. Unusual potential adverse effects include atypical femoral or subtrochanteric fractures.

Conclusions:Three large randomized trials, including the Fracture Intervention Trial + Long Term Extension Trial, the HORIZON Trial, and the Pivotal Fracture Trial, looked at different bisphosphonates and reviewed the relative risk of atypical low-impact hip fractures in postmenopausal women taking bisphosphonates. Although rare, patients treated for 5 years or more have a 0.13-0.22% relative risk of atypical subtrochanteric or femoral shaft fracture; however, prevention of the fracture outweighs the risk.

Bilateral pes cavus: underestimated biomechanical culprit of foot pain

Milagros Llull-Vera, MD; Mooyeon Oh-Park, MD; Nahyun Kim, M.D.

Diagnosis of the case:Bilateral pes cavus: an 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 that her feet were "spinning" during weight bearing, which interfered with walking. She denied foot trauma, paresthesias, or weakness. She had a pair of custom-made orthoses with partial relief. There was no family history of neuromuscular disease, and previous electrodiagnostic tests were normal. Clinical evaluation revealed bilateral arched feet, callus on the fifth metatarsal, and a positive peek-a-boo sign. Biomechanical evaluation showed varus hindfoot and valgus forefoot in neutral subtalar position with bilateral gastrocnemius tightness. The neurological examination was normal. Lateral Coleman's block test revealed correction of the bilateral calcaneovarus. After the application of a 1/8” lateral forefoot post, the patient reported an immediate reduction in pain and instability. She was prescribed modification of her current insoles, including forefoot/rearfoot lateral placement and heel lift. The patient was also instructed on daily stretching of the gastrocnemius and shoes with rigid lateral buttresses without anti-pronation reinforcement.

discussions:Pes cavus, characterized by an increased height of the medial arch, is often associated with pain and/or instability of the foot and ankle. Pes cavus can present with biomechanical deficits, including forefoot valgus and limited ankle range of motion due to gastrocnemius muscle tightness. The plantarflexed first ray relative to the lateral forefoot causes the hindfoot to invert, resulting in ankle and hindfoot instability. Correction of hindfoot varus with Coleman's lock test indicates subtalar joint flexibility and supports orthopedic intervention. Key principles of orthotic prescription include forefoot lateral fixation (if the forefoot is in valgus), hindfoot lateral fixation (if there is a correctable hindfoot deformity), and heel lift to accommodate taut heel cord. In addition, education on proper footwear and gastrocnemius stretching should be included in the treatment plan.

Conclusions:Addressing the underlying biomechanical deficits in the cavus through systematic orthopedic treatment is essential to successfully manage foot pain and instability.

Bone complications after pelvic radiation: an unusual case of hip pain

Sonal Oza, MD; Dr. Monica Rho

Diagnosis of the case:Bone complications after pelvic radiation: an unusual case of hip pain

Case description:A 65-year-old woman with stage III vaginal cancer developed left lateral thigh pain three weeks after radiation therapy. She had complete pelvic, groin, and vaginal radiation; brachytherapy and chemotherapy with Cisplatin in 2010. In 2011 the symptoms evolved to paraspinal and gluteal left low back pain; weakness in the legs, cramps and burning when walking. The patient needed a cane and was unable to climb stairs. When she presented to our clinic in 2012, she was after 5 injections (lower back, left buttock, right thigh, 2 in the hip bursa) with no relief. Examination elicited pain with hip flexion, internal and external rotation. Left hip flexion was limited to 20 degrees. She had pain when lying supine and carrying weight. The march was severely antialgic. Hip radiography revealed avascular necrosis (AVN) of the left hip. Magnetic resonance imaging of the pelvis demonstrated bilateral sacral insufficiency and fractures of the right pubic body. DEXA scan indicated bilateral hip osteopenia. Bisphosphonate therapy was started. The patient participated in hydrotherapy and core strengthening exercises in the PT. She underwent a total left hip replacement in 2015. The hip pain is almost gone and her gait has improved.

discussions:Radiation is associated with the death of bone cells. It induces an acellular matrix and causes fibrosis, endothelial proliferation resulting in microvascular occlusion. These processes increase susceptibility to fractures and AVN. Radiation is associated with an incidence rate of pelvic insufficiency fractures of 8.6-17%, with 5-year cumulative incidence rates of 5.1-63%. The sacrum is most often affected as it transfers the weight of the spine. Conservative management is indicated. AVN is rare, with incidence rates of 0.4 to 1.2%. Risk factors include steroid use, advanced age. The evidence is unclear whether steroids with chemotherapy increase occurrence.

Conclusions:Hip pain in patients with post-radiation gynecologic malignancies should be evaluated for avascular necrosis and insufficiency fractures.

Botulinum Toxin as an Optional Treatment for Failback Syndrome: Case Report

Robert Kinne, MD; Tallat Rizk, MD

Diagnosis of the case:failed back syndrome

Case description:A 62-year-old man presented to the PM&R clinic with back pain and significant weakness due to failed back syndrome with associated paraspinal muscle spasms. The patient had a significant history of L4-L5 lumbar disc herniation, for which he previously underwent L4-L5 laminectomy approximately two years prior to presentation, followed by L4-L5 spinal fusion after experiencing refractory low back pain. Despite these two surgeries, as well as multiple epidural steroid injections, the patient continued to require daily narcotic pain medication and suffered from limited mobility. Subsequently, he was treated with an injection of botulinum neurotoxin (botox) into the bilateral lumbar paraspinal muscles. The patient reported 80% to 90% pain relief, he was more physically active, and was able to stop taking all narcotic pain medications without experiencing complications.

discussions:As demonstrated in animal studies, botulinum neurotoxin has several proposed mechanisms in addition to its muscle paralyzing 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 a treatment for widespread chronic back pain, with encouraging initial results. However, to date, there has been very limited analysis of Botox injection as a treatment modality in the specific population of patients with failed back syndrome. This is a relatively prevalent condition, often complicated by spasms of the paraspinal muscles, which can leave the patient with a high degree of morbidity and subsequently a large amount of healthcare expense.

Conclusions:Failed back syndrome is a condition commonly seen in PM&R and can be difficult to treat. This condition is often associated with and can be complicated by spasms of the paraspinal muscles. While many treatment options exist for this patient population, most have significant side effects and limited efficacy. Botulinum neurotoxin injection is a possible treatment modality that should be considered and deserves further study.

Brachial neuritis: a case of late diagnosis

dr. David Haustein; Jennifer M. Thomas, MD

Diagnosis of the case:Brachial neuritis involving the anterior interosseous nerve

Case description:A 53-year-old man developed sudden severe pain in his upper back. Concerned about a heart attack, he went to the emergency room, where he was diagnosed with pleurisy and released. The pain persisted despite oral analgesics and he later developed paresthesias in his left little finger and weakness in his hand. Receiving a revised diagnosis of cervical radiculopathy, he presented for an EMG seven months after symptom onset. He had weakness in flexion of the left index finger and flexion of the interphalangeal joint of the thumb, but otherwise normal strength. Median and ulnar sensory and motor conduction studies were normal, but 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 a rare neurological syndrome that can cause significant impairment. Most patients complain of sudden-onset extreme neuropathic pain followed by multifocal weakness and wasting of the upper extremities; these early symptoms are often mistakenly attributed to a pathology of the cervical spine or shoulder. Electrodiagnosis often confirms 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 often presents with severe shoulder pain, paresthesias, and weakness. For many patients, the diagnosis is delayed until the patient is evaluated by a musculoskeletal or neurological specialist. Given the severity of pain and weakness that affect function and quality of life, prompt diagnosis and evidence-based treatment will help prevent morbidity from this rare condition.

Breaking the Cycle: A Case Study of Cannabinoid Hyperemesis Syndrome

Logan McCool, do; Dr Olga Epstein

Diagnosis of the case:Cannabinoid hyperemesis syndrome with peptic ulcer disease

Case description:A 24-year-old man with a medical history of episodic abdominal pain presents with cyclical vomiting and two types of abdominal pain: vague and “hollow”. The patient reports significant relief from his vague abdominal pain with warm baths. The patient was evaluated for ID and GI and underwent a thorough investigation with abdominal imaging along with colonoscopy and esophagogastroduodenoscopy. The results revealed no abnormalities other than gastritis on endoscopy. After initially denying it, the patient later admitted to smoking at least 3-4 marijuana joints per day in the week prior to hospital admission for self-management of hollow abdominal pain. The patient's nausea and vague abdominal pain resolved, but he continued to complain of hollow abdominal pain at discharge. After discharge, the pathology report of the upper gastrointestinal endoscopy revealed infection byH. 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 first described in 2004.¹🇧🇷 CHS is classically characterized by a triad of chronic cannabis use, cyclical episodes of nausea and vomiting, and frequent hot baths.^1–9🇧🇷 The patient's abdominal pain is multifactorial due toH. pyloriinfection and cannabinoid hyperemesis syndrome. To the authors' knowledge, this is the first known case in which marijuana use was limited to one week prior to the presentation of cyclical nausea and vomiting.^1–9🇧🇷 This patient represents a growing demographic^6,10seeking self-management of pain with marijuana, and the case study highlights the importance of recognizing cannabinoid hyperemesis syndrome and counseling patients on more effective therapies.

Conclusions:Physiatrists must acknowledge the growing practice of self-management of pain with marijuana¹⁰, and the unusual and apparently paradoxical presentation resulting from cannabinoid hyperemesis syndrome.

Brush your teeth! Post-dental procedure herpetic encephalitis: case report

Dena Abdelshahed, MD; Dr. Neil Jasey

Diagnosis of the case:Herpetic encephalitis after molar extraction

Case description:A 75-year-old man underwent extraction of two molars and placement of a cadaveric bone graft. Soon after, he developed facial swelling and fever and was started on amoxicillin. After completing the antibiotic, he developed diarrhea and dehydration, so he went to the emergency room ten days after the initial extraction.

He was admitted with dehydration and developed altered mental status, decreased responsiveness, and tonic-clonic seizures with spasms in his right arm and right face. He was treated with antiepileptics while a brain CT scan was performed. CT revealed a possible subacute infarction in the right cortex and loss of differentiation between gray matter and white matter in the medial and anterior pole of the right temporal lobe within the insular cortex. The magnetic resonance showed increased T2 and decreased T1 in the same distribution compatible with herpetic encephalitis.

Lumbar puncture yielded 12,000 leukocytes with 90% lymphocytes. He started with empirical antibiotics; Gram, 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 Aciclovir. At the time of admission to rehabilitation, he was NPO requiring PEG tube feeding, aphasic, and minimally interactive. She was started on neuroprotective medications, including vitamin B and coenzyme Q10, as well as amantadine to promote arousal; he eventually discharged home to family on PO diet, verbally answering questions and following orders with moderate consistency.

discussions:There are no published reports of HSV encephalitis after a 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 possible occurrence, especially in patients with previous herpetic infections.

Conclusions:Herpetic encephalitis is a recently reported possible complication after dental procedures.

Central Pain Syndrome After Acute Spinal Subdural Hematoma (HSD) - Case Report

Kristina Quirólgico, MD; Dr. Heidi Schambra

Diagnosis of the case:A 42-year-old woman with scoliosis underwent revision posterior spinal fusion. Intraoperative neuromonitoring changes led to an emergent MRI showing a T7-8 SDH with mass effect. The procedure was aborted. Later, she developed weakness and pain in her lower extremities.

Case description:After 7 days of conservative treatment, the patient was transferred to the acute rehabilitation inpatient unit. The patient had numbness to light touch in the T7-8 dermatomes, a painful tape-tearing sensation in the T8-T12 distribution, and intense burning pain to light touch in the left L1-S1 dermatomes. He also couldn't move his left lower extremity against gravity. Repeat MRI showed resolution of SDH and minimally increased spinal cord edema at T7-8 involving the dorsal columns and right ventrolateral spinal cord. He was started on gabapentin and increased by 300 mg daily to 1200 mg TID, with the subsequent addition of amitriptyline 40 mg daily. With each increase in dose, the patient's pain improved and she recovered functionally. At discharge, she walked with a cane and the pain was limited to the left foot.

discussions:Central pain can occur after an injury to the central nervous system. Common symptoms are allodynia, dysesthesia, and muscle pain described as cramping or constriction. The patient's complaints of left-sided allodynia, “banding” pain, and level numbness are consistent with involvement of the dorsal columns and right spinothalamic tract. Gabapentin has been shown to relieve diabetic neuropathy and postherpetic neuralgia in clinical trials. Both gabapentin and amitriptyline have been shown to relieve allodynia in animal models, but few randomized controlled trials exist to support their use for central pain due to acute spinal cord injury in humans. Both drugs have been shown to be beneficial in controlling pain in this patient.

Conclusions:For central pain from acute spinal cord compression and swelling from subdural hematoma, gabapentin and amitriptyline can be used effectively to control pain.

Central pontine myelinolysis after treatment of severe hyponatremia due to the use of diuretics in the management of arterial hypertension

Andrea McKay, MD; Dra. Radhika Bapinedu

Diagnosis of the case:central pontine myelinolysis due to rapid correction of symptomatic hyponatremia after use of diuretics

Case description:A 65-year-old woman admitted to inpatient rehabilitation after prolonged hospitalization secondary to central pontine myelinolysis. She has HMP for hypertension and diabetes, which had been treated with metformin and lisinopril, but she had been off treatment for some time. Her problems started in March 2015 when she was visiting her family in Asia and complained of severe headaches. After a local doctor saw her, it was assumed that her headaches were due to high blood pressure and she was subsequently started on a thiazide diuretic. Despite treatment of her hypertension and improvement in her blood pressure readings at a subsequent visit, the headaches and nausea persisted. Approximately 6 days after starting the diuretic, she was discontinued and had an MRI which was normal. Her symptoms were symptomatically managed until about 4 days after the MRI, when her symptoms worsened and she also complained of dizziness. She was taken to the emergency 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 treatment with hypertonic saline intravenous fluids, after which she initially became more receptive and alert. One week after starting treatment, she developed sudden-onset dysphagia, aphasia, and decreased level of consciousness. Initial MRI was negative after this episode, repeat MRI showed involvement of the pons and basal ganglia, indicating pontine and extrapontine myelinolysis.

After diagnosis, his sodium was managed with free water restriction with eventual normalization. During her stay in rehab, she made very good progress. She had significant spasticity that responded well to oral baclofen, as well as mood lability and dysphagia. Initially, she required PEG tube feeding, but recovered before discharge and her mood stabilized after titration of her medications. She left rehab feeling that her independence had been restored despite her difficult medical course.

discussions:Thiazide diuretics are often the first-line treatment for hypertension, and the side effect of severe hyponatremia may go unnoticed. This case is a reminder that care should always be taken when prescribing medications, especially in clinically complex patients. This case also reminds clinicians that when treating patients with hyponatremia, which is common in many rehabilitation patients, it must be done with care and close monitoring. Central pontine myelinolysis is not a common occurrence and may be overlooked in the treatment of hyponatremic patients.

Conclusions:Careful sodium correction should be made in the management of hyponatremia, which is common in our TBI and stroke populations.

Medication management in the rehabilitation setting can be very difficult, especially with patients with multiple comorbidities, great care must be taken to avoid any iatrogenic injury.

Seated medial cervical ramus blocks: a new technique

Rajat Mathur, MD

Diagnosis of the case:To describe a seated approach to cervical facet procedures in patients who cannot tolerate prone or reclining positions.

Case description:Case 1: a 75-year-old woman presented with axial pain in the midcervical spine without radiation to the upper extremities, referred to Clínica da Dor for diagnosis of cervical medial branch block (MBB). Several failed attempts to perform prone, supine, or lateral medial branch blocks secondary to tremors and muscle cramps. The patient was then placed in a sitting position and the fluoroscopic unit adjusted to allow the injection to be performed using the lateral approach. The patient underwent successful radiofrequency ablation in a sitting position. Case 2: A 47-year-old man with a medical history of reflux disease presents with cervical facet arthropathy for diagnosis of left medial branch block. Due to the severity of his reflux disease, we decided to approach BLM 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 positioned parallel to the medial rami.

discussions:Patients in the above cases reported significant greater than 50% improvement of axial cervical spine pain after BMM and radiofrequency thermal coagulation of medial branch sensory nerves affecting facet joints with successful results.

Conclusions:During BMM, it is critical to avoid accidental entry into the vessels, nerve root sheath, or subarachnoid space. Care is essential to ensure that the tip of the needle is placed directly over the posterior elements in the lateral view while the patient is seated. The vertical approach can be very beneficial in obese patients, with movement disorders, lung disorders. Other advantages include allowing for patient comfort with easy positioning and breathing.

Cervical Radiculopathy Pain Resolves With Shoulder Injection

Suleiman Lapalme, MD; Pamela Hansen, MD; Frank Jackson, D.O.

Diagnosis of the case:radiculopatía cervical

Case description:An 81-year-old man presented to his physician with an acute, nontraumatic onset of severe pain and weakness in his left shoulder. Ultrasonography and radiography identified calcific tendinosis and a rotator cuff (MR) tear. In the left shoulder, 2mL of 1% Lidocaine, 2mL of 0.25% Bupivacaine and 80mg of Kenalog 40mg/mL were injected, with marked improvement in pain. However, at his four-week follow-up visit, the weakness persisted. The weakness was attributed to his RC tear. He was not an MRI candidate due to an implanted pacemaker. He was referred to an orthopedic surgeon to consider repair. The astute surgeon felt the severity of the weakness was unusual and he consulted with our team. We performed an EMG, which revealed a severe C5 radiculopathy with 3+ denervation in the C5-innervated muscles with minimal recruitment. A CT myelogram identified a severe left C4-5 foraminal stenosis.

discussions:Timely decompression is an important prognostic factor in severe radiculopathy, and unfortunately this unusual series of events has led to a delay in diagnosis. It is important to note that "diagnostic" injections are not always truly diagnostic. Steroid in close proximity to a pain generator may lead to improvement in symptoms. There is some systemic absorption that can lead to pain relief and obscure the true pain generator. The placebo effect is also important, which is reported to be around 30%.

Conclusions:In patients with shoulder pain and weakness, care must be taken in making a diagnosis. Although in this case the patient's symptoms and response to injections suggested shoulder pathology, it missed radiculopathy and may have led to a worse outcome. This could have been avoided with a higher index of suspicion for alternative diagnoses, closer follow-up, and observation of specific patterns of weakness that may suggest radiculopathy.

Chronic Low Back Pain Evaluation and Assessment Leading to Unusual Diagnosis of Marfan Syndrome

Aashish Deshpande, MD

Diagnosis of the case:A patient presented to the clinic with axial low back pain without symptoms in the lower extremities. Additional examinations revealed dural ectasia seen on MRI of the lumbar spine. After further review and discussion, a working diagnosis of Marfan syndrome was considered and the patient was counseled about further evaluation and testing.

Case description:The patient presented to the MSK outpatient clinic with a history of pain in various areas of the body, including the neck, wrists, knees, and lower back. Most of the problems were perceived by the patient as minor at the time of the office visit, except low back pain. In particular, the low back pain has worsened significantly over the last year. He had a remote history (more than 5 years) of a car accident, with no specific injuries or low back pain problems. He reported 8 to 10 months of increasing low back pain with no precipitating event and no radiating pain/numbness/tingling in the lower extremities. Without incontinence, without paraparesis or other associated symptoms. Examination showed no neurological signs or symptoms, no low back pain 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 in the lumbar midline, as well as in the paraspinal tissues, reported tenderness most notably at L5-S1. Pelvic and hip examination was negative for pain reproduction. Palpation of the knee, wrist, and finger joints 1 and 2 produced tenderness without deformity, looseness, or swelling. The rest of the clinical examination was non-contributory. The patient received anti-inflammatories and limited-use muscle relaxants and was referred for physiotherapy. The patient discontinued PT after 6 sessions, indicating not only increased low back pain with massage and exercise therapies, but also increased pain in the hips, knees, and wrists with activities. An MRI of the LS spine was ordered to further assess the patient's symptoms. The MRI report indicated several areas of attenuated T2 signal in the lumbar spine, mainly in the lower segments. These were interpreted as dural ectasia. Upon further questioning, the patient indicated a personal history (not previously discussed with any physician) of joint hypermobility and in her youth the ability to "dislocate" her hips and knees. She didn't think about it, since several members of her family had similar problems. A differential diagnosis of Marfans syndrome was discussed with the patient, with counseling and education on the manifestations of joint preservation and pain management that may occur. At this time, tracking data is not available.

discussions:Marfan syndrome is a multisystem disorder of connective tissue usually associated with mutations in fibrillin and occasionally with mutations in transforming growth factor receptor beta 1 or 2. resources. The Ghent criteria are often used for the definitive diagnosis. The common presentation in a patient with Marfan 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 often occur daily, are exacerbated by upright posture, and do not improve with recumbent position. On review, the patient's mild hip pain may have been a manifestation of proximal leg pain dural ectasia. He did not have any of the other common symptoms and did not discuss a personal or family history of the diagnosis.

Conclusions:The case presented shows that a thorough review of a patient's history (often not fully clarified after several visits) and evaluation can lead to an unusual diagnosis and therefore a completely different treatment paradigm. In this case, low back pain as the initial presentation led to the presumptive diagnosis of Marfans Syndrome not only for this patient, but possibly for several relatives.

Clinical and electrophysiological aspects of non-traumatic bilateral anterior compartment syndrome in a patient with sickle cell trait

Dana Sutton, MD; dr. Omar Baez

Diagnosis of the case:Bilateral deep fibular neuropathy secondary to non-traumatic anterior compartment syndrome

Case description:A 17-year-old man with sickle cell trait developed sharp bilateral leg pain while running toward a bus and skidding. Because the pain persisted despite over-the-counter pain relievers, he sought medical attention in the emergency room later that night. Evaluation showed a serum creatine kinase (CK) of 8563 U/L. The patient received intravenous fluids, but CK eventually reached 29420 U/L and he developed weakness in his feet. Magnetic resonance imaging showed severe myositis in the anterior compartment of the legs bilaterally and measured compartment pressures above 60 mmHg. He underwent a bilateral fasciotomy and was subsequently released to an acute rehabilitation center.

Four months later, nerve conduction studies and electromyography (NCS/EMG) were performed. The study revealed bilateral deep peroneal neuropathies with atrophy of the innervated muscles and without sensory deficits. Activation produced only distant motor units in the left tibialis anterior muscle.

discussions:The patient suffered from bilateral anterior compartment syndrome of the leg, the most common location of the disease. As the deep peroneal nerve passes through this compartment, it can be compressed by excess pressure. Our case represents electrophysiological evidence of such a lesion. 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 for this condition, as sickling of red blood cells at low oxygen levels may cause further ischemic injury in the setting of elevated compartment pressure. Previously, the literature did not demonstrate a direct correlation between the two conditions.

Conclusions:We present a case of exertional compartment syndrome of the lower leg with posterior bilateral deep fibular neuropathy. The patient's sickle cell trait may have predisposed him to the rare condition.

Clinical Course of Hemophagocytic Lymphohistiocytosis from Diagnosis to Rehabilitation: Case Report

Dr. Daniel Reid; Marina Ma, MD; Robert Bunning, MD

Diagnosis of the case:Hemophagocytic lymphohistiocytosis (HLH), critical illness polyneuropathy, critical illness myopathy.

Case description:A 59-year-old woman with a medical history of hypertension, psoriasis, osteoarthritis, and gastroesophageal reflux disease initially complained of flu-like symptoms. Despite antibiotic treatment, she continued to deteriorate and developed an altered mental status. Initial investigation showed fever, hepatosplenomegaly, pancytopenia with severe thrombocytopenia of 12,000, elevated lactate of 7, and elevated ferritin. She then developed a seizure that led to intubation and admission to the intensive care unit. Peripheral smear and bone marrow biopsy confirmed the diagnosis of HLH. Treatment was started with the abbreviated protocol HLD-2004 consisting of etoposide and dexamethasone. After treatment, she was withdrawn from the vasopressors and her pancytopenia resolved. The neurological examination of her improved from complete paralysis to 1/5 in the proximal muscles and 3/5 in the distal muscles. She was transferred to acute inpatient rehabilitation (AIR) for critical illness wasting and polyneuropathy versus critical illness myopathy.

discussions:HLH occurs after strong immune activation, often associated with underlying systemic infection, immunodeficiency, or malignancy. It is characterized by excessive activation of normal T lymphocytes and macrophages. Diagnosis can be made by molecular criteria or five of the following eight: fever greater than 38.4 degrees Celsius, splenomegaly, cytopenia of at least 2 lineages, hypertriglyceridemia and/or hypofibrinemia, hemophagocytosis, low or absent NK cell activity, ferritin greater than 500 ng/mL, and elevated sCD25. Our patient had marked improvement after the start of the treatment protocol, which resulted in discontinuation of etoposide after the fourth dose and weaning from dexamethasone. She improved on the AIR and was released walking 150 feet with a walker and was independently modified for activities of daily living monitoring.

Conclusions:Prompt diagnosis and treatment of HLH are essential to ensure survival. Since HLH patients are severely ill in their initial course, many develop critical illness polyneuropathy versus myopathy, requiring transfer to AIR after acute treatment.

Colon Cancer with Metastasis to the Vertebral Column: Case Report

Ginece J. Jackson, MD; Dr. Sara Cuccurullo; Krishna Urs, MD

Diagnosis of the case:Colon cancer with metastasis to the spine

Case description:A 54-year-old woman 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 a mass effect in the fourth ventricle. She was treated with Keppra and intravenous steroids. She underwent a suboccipital craniotomy and a C1 partial laminectomy with resection of the cerebellar masses. She also had an external ventricular drain placed. She had back pain with no neurological deficit. Imaging revealed metastases in the cervical, thoracic, and lumbar spine without spinal cord compression. She was previously seen by radiation oncology and received a radiation course on the spine. Despite the spinal metastasis, she was able to undergo physical therapy and remained an outpatient. She was discharged home with palliative plans for holocranial radiotherapy 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 bone metastases is 5-10%.¹🇧🇷 If a patient lives long enough, it is possible for colon cancer to metastasize to the bones.

Conclusions:Patients are living longer with colon cancer due to improvements in cancer care. Long-term colon cancer patients are at risk of developing metastatic lesions in the spine. Physiatrists should be aware of this risk and should perform a comprehensive metastatic investigation for these patients presenting with back pain. This ensures a good quality of life with the goal of maintaining outpatients.

Confusing causes of shoulder weakness after discectomy and posterior cervical fusion: a case report

Andrea Cordova, MD; Gary Inwald, D.O.

Diagnosis of the case:acute shoulder weakness

Case description:A 57-year-old woman admitted to the acute inpatient rehabilitation unit 5 days after C3-C5 posterior cervical laminectomy with instrumented C3-C6 fusion for progressive worsening of symptoms of cervical spondylotic myelopathy, including bilateral numbness of hands and gait and balance deficits. During the immediate postoperative period, the patient showed substantial progress in gait and balance, as well as a reduction in bilateral hand numbness. On postoperative day 8, she developed sharp pain in her right shoulder after straightening her arms and turning abruptly in bed. Her physical examination was notable for significant weakness in flexion, abduction, and internal rotation of her right shoulder that was not apparent preoperatively. Sensory deficits were not reported. An MRI of the cervical spine was performed, which revealed a residual diffuse intramedullary signal abnormality predominantly at the C4-C5 level. She consulted neurosurgery and indicated that the patient's new weakness was secondary to an isolated paralysis of right C5. She was started on oral steroids but showed little improvement after 3 days. On postoperative day 12, an MRI of the right shoulder was performed for further evaluation and demonstrated a near-full-thickness focal tear of the anterior majority of the right supraspinatus fibers, along with supraspinatus and infraspinatus tendinopathy. and distention of the supraspinatus. the right supraspinatus infraspinatus muscle. The patient was then started on a therapeutic regimen that included scapular mobilization, active and passive range-of-motion exercises of the shoulder, as well as strengthening of the rotator cuff muscles with remarkable recovery of function.

discussions:It is well established that C5 palsy with resultant deltoid motor weakness can occur after posterior and anterior spinal approaches for cervical spine pathology. The prognosis and etiology are still poorly understood, as most cases go unreported. Most cases will respond to conservative treatment or a short course of oral steroids. Other possible causes of acute shoulder dysfunction include brachial plexopathy, shoulder pathology, and suprascapular neuropathy.

Conclusions:Isolated C5 paralysis after posterior decompression procedures for cervical spondylotic myelopathy is not an uncommon occurrence. MRI findings of the cervical spine may suggest this complication; however, these have not been conclusively established in this patient. Additional radiological tests demonstrated concomitant rotator cuff tendinopathy of the right shoulder. This case demonstrates the importance of exploring all possible causes of acute shoulder weakness, especially in non-traumatic cases and after cervical spine surgeries, in order to establish adequate therapeutic regimens for optimal functional outcome.

Contrasting functional results of different approaches to the management of retroperitoneal masses

Lindsay N. Ramey, MD; Dra. Jennifer Baima

Diagnosis of the case:Retroperitoneal tumors

Case description:Patient 1 is a healthy, active 39-year-old woman with a 6 x 6 cm retroperitoneal mass in the upper part of the psoas muscle on CT, confirmed by MRI. She was accidentally discovered during the emergency examination for gastrointestinal complaints, which improved after the resolution of the viral illness. She had no symptoms and the examination was normal. Given the size of her, the mass of her dried up. Partial resection of the iliopsoas was necessary due to massive adherence. The final pathology showed a benign intramuscular hemangioma. Postoperatively, she presented with significant neuropathic pain, refractory to Neurontin, antispasmodic medication, and opioids, as well as hip flexor weakness that limited her activity. She has had partial relief with physical therapy, lyric, acupuncture, and trigger point injections, but she remains functionally limited.

Patient 2 is an 82-year-old man with multiple comorbidities who presents to the emergency department with diffuse pain in the left leg. Hip and knee radiographs were normal. He was diagnosed with ITB Syndrome. Despite physical therapy, his pain worsened and he developed weakness in his legs. Examination revealed positive straight leg raising on the left side, hip flexor weakness, and absence of the patellar reflex associated with 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 the vascular comorbidities, surgery was postponed instead of surveillance. Follow-up images were stable. His symptoms improved significantly with Neurontin and physical therapy, suggesting that spinal stenosis was the source of his symptoms.

discussions:Retroperitoneal masses can have catastrophic results if they are malignant. Surgical resection is generally recommended as biopsies are often inadequate for diagnosis. These cases contrast the symptomatic and functional results of 2 patients with similar masses and different treatments. While the young, asymptomatic patient continues to struggle with pain and weakness after resection, the symptomatic and clinically complex elderly have significant improvement in pain and function without evidence of tumor growth using a conservative approach.

Conclusions:Conservative treatment of small, slow-growing retroperitoneal masses may be appropriate in some cases and may lead to better functional outcomes. Other etiologies of symptoms should be explored and treated.

Conus medullaris syndrome as a presenting symptom in neurosarcoidosis. case report

María Apiafi, MD; Gary Inwald, D.O.

Diagnosis of the case:neurosarcoidosis

Case description:A 62-year-old African American woman with a significant medical history of coronary artery disease with recurrent myocardial infarction, type 2 diabetes, hypertension, cervical spine fusion, presented with low back pain radiating to the lower extremities, numbness, weakness, and incontinence. intestinal and urinary, for several months, with progressive worsening. Her physical examination revealed poor balance, unsteady gait, weakness in the proximal muscles of the lower extremities, rapid reflexes, and raised toes. Investigations: MRI of the spine showed a 1.9 cm enlarged lesion of the conus medullaris and sacral nerve roots. Spinal canal stenosis is seen at T11/T12, probably related to continued compression of the cauda equina. Brain magnetic resonance showed nonspecific findings. Chest CT showed insufficient hilar fullness for biopsy. Gallium scintigraphy was negative after steroid administration. Laboratory studies were significant for elevated serum ACE levels, low CSF ACE levels, however this occurred after steroid administration. The diagnosis of Neurosarcoidosis was based on clinical findings, cerebrospinal fluid, serum and imaging, without systemic signs of this disease. The patient was started on high-dose steroids and was admitted to acute rehabilitation for strengthening and gait training. The patient improved with steroids and the therapy program. When she was discharged, she walked with a straight cane, with improvement in 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. However, it also occurs in children and older people. It often presents with bilateral hilar adenopathies on chest radiograph, ocular or skin involvement. The diagnosis is based on clinical, imaging, histological and cerebrospinal fluid analysis. Signs of spinal cord sarcoidosis often resemble those of a spinal cord tumor or meningomyelitis and may involve the cauda equina. Patients present with an insidious onset of weakness and paresthesia. Occasionally, a sudden paraplegia can occur. Neurosarcoidosis generally occurs in the presence of multisystem disease. Central nervous system involvement occurs in 5-15% of sarcoidosis cases. Systemic disease is not always apparent, 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 adjuvant immunosuppressive therapy, including physical rehabilitation.

Conclusions:Neurosarcoidosis can present without systemic manifestations or a previous diagnosis of sarcoidosis and should be considered in patients presenting with symptoms of transverse myelitis or cauda equina syndrome. Rehabilitation can play an important role in patients' ambulation and functional status.

Profitability and efficiency in the diagnosis of neuromuscular diseases

Vikki A. Stefans, MD; Julie Kaylor, MS, CGC

Goals.To assess and provide guidance on the most cost-effective and efficient routes to specific neuromuscular diagnosis based on actual experience with a variety of methods, with an emphasis on Charcot-Marie-Tooth disease (HMSN) and muscular dystrophy of the girdles.

Project:The submission will be based on our retrospective review of all recent diagnoses through our MDA pediatric clinic with cost data; The names of external companies will be omitted and the data of the patients will be annulled.

Results:The best routes for the accurate diagnosis of neuromuscular disorders have not been fully elucidated in this era of DNA sequencing. Efficacy can be defined as obtaining a diagnosis accurate enough to allow optimal treatment, management, and prognosis; correct genetic counselling; and ideally also eligibility for clinical trials. Efficiency can be considered in terms of costs and charges, as well as response time. Sometimes coverage restrictions can determine the pathway to diagnosis or prevent narrowing a diagnosis beyond a clinical phenotype. Most commonly, this occurs when policies do not cover genetic testing, but do cover imaging, electrodiagnostic, and/or biopsy. Cases will be presented to illustrate these points, as well as data to support the cost-effectiveness of the recommended protocols in Charcot-Marie-Tooth disease and limb-girdle muscular dystrophy specifically, based on recent experience over the past several years at a tertiary center. . academic center for pediatric medicine. Center.

Conclusions:It can sometimes be successfully argued that the cost of well-selected genetic tests will be lower than traditional methods, as well as inherently more specific. However, large panels can vary in effectiveness and cost-effectiveness based on their specificity and the selection of specific tests included, all related to similar rather than disparate phenotypes, and ideally offer step-by-step options that focus on the most common specific causes. be evaluated first. In addition, the actual expenses involved in genetic testing vary considerably between different companies for similar selections of single-gene tests, panels, and microarrays; in addition, fully subsidized genetic testing is available for some conditions. Rare and complex presentations that are unlikely to be due to routinely tested genes may be best managed with whole exome sequencing as the first or second level of testing. Occasionally, a variant of unknown significance or an unexpected finding will require the procedure with traditional methods in confirmatory mode.

Myopathy in critical illness awaiting orthotopic liver transplantation: case report

Lisanne C Cruz, MD, MSC; Miguel Escalon, MD, MPH

Diagnosis of the case:Fulminant liver failure requiring orthotopic liver transplantation (OLT), complicated by acute myelopathy due to critical illness.

Case description:A 38-year-old woman recently diagnosed with metastatic neuroendocrine cancer and antiphospholipid syndrome presenting with fulminant liver failure secondary to portal vein thrombosis. While she awaited a liver transplant, the patient's condition was complicated by sepsis, ventilator dependence, dysphagia, metabolic encephalopathy, acute kidney injury, and acute disease myelopathy due to her prolonged stay in the ICU. The patient ultimately underwent OLT and was admitted to acute rehabilitation for walking and strength training and tasks of daily living. Depression and pain were also treated. After remarkable progress, the patient returned home and continued outpatient therapy.

discussions:People who undergo OLT are living longer, and the focus has shifted from survival to post-transplant quality of life. Also, the length of pre-transplant disability has increased as the list of transplants continues to grow. Therefore, individuals are usually debilitated at the time of TOH, as demonstrated in our case. More frequent, more intensive, and longer-lasting rehabilitations, such as acute hospitalization, may be necessary to counteract the effects of pretransplant inactivity, metabolic derangements, and posttransplant immunosuppression. In addition, pre-transplant rehabilitation may be required to improve the function of these patients to withstand surgery and immunosuppression. Learning from the oncology rehabilitation model, improving function before, during, and after transplantation may lead to better outcomes. Physiatrists are in a unique position to coordinate the care of these clinically complex patients, improving function, reducing pain, and improving their emotional well-being.

Conclusions:Patient care before and after OLT requires intensive resource allocation and long-term planning and commitment to mitigate post-transplant comorbidities and optimize physical functioning. Physiatrists can fulfill this role by coordinating care, restoring function, and ultimately improving quality of life.

Cryoablation of residual limb neuroma that allows ambulation: case report

Ryan R. Ramsook, MD; Justo N. Walker, MD; David Spinner, DO, RMSK; Obtener Paul, MD; Lauren Terranova, D.O.

Diagnosis of the case:Residual limb neuroma cryoablation

Case description:A 57-year-old man with a medical history of right hip disarticulation in 1978 had excruciating pain in his right stump for more than ten years. Phantom knife pain 9/10 and allodynia prevented him from using his prosthesis, resulting in him having to use bilateral crutches and a wheelchair to get around. Ultrasound revealed a neuroma in the right stump, for which an ultrasound-guided diagnostic nerve block was performed, with complete resolution of pain. One week later, the patient underwent ultrasound-guided cryoablation of the neuroma. He subsequently had excellent pain relief, allowing her to wear his prosthesis for the first time in over nine years. The patient can now ambulate painlessly in the community with a lofstrand crutch.

discussions:Chronic pain is reported in up to 95% of patients with amputations. Persistent pain in amputees can result from various etiologies, including neuroma formation. Neuromas can develop at the site of section of any peripheral nerve. Although pain from a neuroma is usually well localized to the site of injury, it has also been implicated in phantom limb pain. A diagnostic nerve block with a local anesthetic can help support the diagnosis. Neuroma pain may persist despite conservative treatment and may require interventional procedures, including ultrasound-guided cryoablation. Targeting focal extreme cold temperatures at the neuroma causes demyelination 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 using ultrasound-guided cryoablation therapy. The interventional procedure resulted in improved functionality by allowing him to walk more independently for the first time since a traumatic hip dislocation more than 35 years ago.

Cushingoid facies from a single intra-articular injection of Kenalog in a patient with HIV

Judge Otchere, MD

Diagnosis of the case:Cushingoid syndrome secondary to intra-articular injection of Kenalog

Case description:This is a 60-year-old man diagnosed with HIV who received a single dose of Kenalog 40 mg preparation injected into the right subacromial space for uncontrollable pain due to degenerative change of the right acromioclavicular and glenohumeral joints. The injection was prepared with 1 cc of Kenalog and 2 cc of lidocaine and bupivcaine. He reported facial swelling, mild tremors, cramps, neck gibbosity, and an increase in collar size of 1.5 cm two to eight weeks after the Kenalog injection. The patient's serum cortisol and DHEAS 2 weeks after the Kenalog injection were 2 and 48 mcg/dL, respectively. The Cotrosyn test revealed an increase in cortiosol level of 6.5 mcg/dL from baseline of 0.9 mcg/dL 1 hour after intramuscular injection of 0.25 mg cosyntropin.

discussions:Intra-articular steroid injections are slowly absorbed into the systemic circulation; therefore, there is the potential for longer exposure to the external source of intra-articular joint steroid injections. Patients who undergo intra-articular steroid injections may therefore show symptoms of Cushingoid characteristics. The patient's serum cortisol and DHEAS levels were 2 mcg/dL and 48 mcg/dL, respectively, two weeks after the Kenalog injection, demonstrating HPA axis suppression due to the direct consequence of negative feedback from the patient. exogenous steroid in the systemic circulation. Low serum cortisol implies nonendogenous corticosteroid exposure or adrenal insufficiency; however, the normal DHEAS level made adrenal insufficiency less likely. The Cotrosyn test rules out primary adrenal insufficiency and confirms secondary adrenal suppression of HPA due to exposure to exogenous corticosteroids.

Conclusions:Intra-articular injection of corticosteroids is not a benign procedure and may cause extra-articular dysregulation of other organ systems. Due to the possible deleterious effects of ICAI, serum cortisol levels should be monitored before and after injections.

Skin manifestations in patients with a history of cocaine abuse

Dr. Ankit Patel; Dr. Daniel Moore

Goals.Case Diagnosis: Levamisole, a Cocaine Cutting Agent, Induced Ulcers in Patients With a History of Cocaine Abuse

Project:Case Description: Two patients with a history of cocaine abuse presented to a wound center with scattered injuries. WN, a 45-year-old woman with a history of cocaine abuse, was diagnosed with systemic lupus erythematosus (SLE) and was started on steroids for rheumatology. During a hospital stay, she tested positive for cocaine. The wounds were described as dry gangrene, with necrotic slough all over, varying in size. She had a total of 10 ulcers. Nose and shoulder wounds were treated with povidone-iodine twice daily. The right lower extremity and upper arm were debrided and a silver hydrofiber was applied. Petroleum gauze was used on the rest of the wounds. The patient's wound was improving, but she did not return for follow-up and she returned approximately one year later as a referral. During this hospitalization, he was diagnosed with vasculitis secondary to levamisole. And that was identified as the cause of her vasculitis, not her LES. Due to financial constraints, the patient used a triple antibiotic topical ointment. The wounds began to improve significantly with the ointment and cocaine withdrawal. CR, a 47-year-old woman also with a history of cocaine abuse, also presented to the hospital with polytrauma and was initially diagnosed with vasculitis secondary to SLE. After that, she made repeated visits to the hospital due to painful and smelly wounds. Wounds were described as full-thickness ulcers with black necrotic debris. She had a total of 12 ulcers. The patient reported that her sores healed after she stopped using cocaine, but returned when she relapsed. These were found to be secondary to levamisole contamination. The wounds were located on his right forearm, left hand, and right ankle. She was taken to the wound center. She was encouraged to take antibiotics and apply an alginate dressing. She denied debridement for pain. At subsequent visits, she underwent acute debridement and the dressing was changed to a collagen and oxidized regenerated cellulose dressing. Her wounds began to heal and her dressing was changed to a silver sulfadiazine topical dressing.

discussions:These two patients were found to be obtaining adulterated cocaine from the same dealer. Initially, they were diagnosed with vasculitis secondary to SLE and exacerbated by the use of oral corticosteroids. However, patients had ulcer exacerbation with cocaine relapse, presenting as multiple, disseminated ulcers of variable size, painful, and foul-smelling.

Conclusions:Patients presenting to wound care centers with multiple disseminated, malodorous, and painful ulcers should be asked about their use of illicit drugs, as the use of levamisole, a cocaine cutting agent, can lead to the appearance of cocaine-like ulcers. SLE and discontinuation of the offending agent are likely to produce significant improvement in ulcers.

To deisce or not to deisce: sternal precaution is necessary for prevention during rehabilitation

Dr. Kevin Jiang; Dra. Marilyn Pacheco

Diagnosis of the case: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 breast pain. He was admitted to the intensive care unit and intubated due to impending respiratory failure secondary to severe aortic failure and pulmonary edema. The patient failed after several extubation attempts and decided to urgently replace the aortic valve with a mechanical valve. The patient's postoperative period was complicated by acute pulmonary edema and acute kidney injury. One month later, he was clinically stable for acute rehabilitation.

On admission to rehabilitation, his only notable findings were normal vital signs with cardiovascular examination notable for mechanical clicks and bilateral pitting edema. She had decreased left lower lobe breath sounds on lung scan with a well healed sternal incision with no signs of fluctuation. Laboratory tests were significant for a white blood cell (WBC) count of 11.6

One week later, the patient began to complain of increased phlegm and cough. During therapy, he too became tachycardic and SOB. He underwent a chest x-ray, urinalysis and urine culture, of which only the chest x-ray revealed a new infiltrate referring to pneumonia. The patient was started on levofloxacin, but despite treatment, the patient continued to complain of increased phlegm, nausea, and diaphoresis over the next two days, with increased swelling around the chest. His vital signs were notable for a temperature of 99.6 F, a BP of 118/70, P of 112, and R of 20. Laboratory tests were significant for a white blood cell count of 10.4. Urine cultures from him also developed methicillin-resistant Staph aureus de novo, and blood cultures were obtained due to concerns about bacterial seeding of his valve.

A chest CT scan was obtained revealing a dehiscence at the sternotomy site measuring 3 cm x 11 cm with subcutaneous fluid extending to the pericardium and containing small amounts of air suspicious for infection. Subsequently, the patient claimed that he had been using his arms to transfer from the mats and while using the walker. He also claimed that staff were pulling on his arms during transfers and that he was bent over the nightstand. The patient was transferred from the rehabilitation floor and taken in for revision surgery.

discussions:Many patients who undergo acute rehabilitation after a sternotomy can still see 6 to 8 weeks with recommended sternal precautions. The incidence of sternal dehiscence remains low in the general population, around 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 can affect sternal healing include simultaneous bilateral arm movements, pushing, pulling, coughing, and sneezing. Studies in cadavers have shown that the forces required to cause a 2 mm sternal distraction are 220 N for laterally directed forces, 263 N for anteroposterior forces, and 325 N for rostrocaudal forces. Studies have shown that most push and pull forces measured with a dynamometer range from 4.5 N to 27.5 N. For example, opening a car door requires only 12.5 N. However, the coughing can generate forces of 400 N. Frequent coughing can be the major cause of mechanical stress on the sternum. Most likely, an underlying infection or her persistent cough, along with her pre-existing risk factors for morbid obesity and diabetes, could have caused her sternal dehiscence.

Conclusions:Based on this case and the review of the literature, minor deviations from rigorous 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 load-bearing activity with arms close to the body do not cause undue stress on the sternal surgical site and may even be tolerated for inclusion in an exercise regimen.

Development of glioproliferative spinal tumor of donor origin after intrathecal stem cell therapy

Peter (I-Kung) Wu, MD, PhD; Dr. Alcinto S. Guirand; Kevin O'Connor, MD; Dra. Kate E. Delaney

Diagnosis of the case:Paraplegia T11 ASIA C due to spinal glioproliferative tumor of donor origin after intrathecal therapy with stem cells.

Case description:A 67-year-old man with a history of right middle cerebral artery stroke from carotid dissection with resultant left hemiplegia underwent multiple rounds of experimental intraventricular and intrathecal stem cell injections over 4 years in China, Argentina, and Mexico. After receiving autologous and heterologous neuronal, mesenchymal, and embryonic stem cells, he regained strength in his left lower extremity and the ability to walk with a cane and an ankle-foot orthosis. Four months after his last treatment, he developed back pain followed by paraplegia, hypoesthesia below midthoracic level, and neurogenic bowel and bladder for 2 months. Magnetic resonance imaging (MRI) of the brain and spine revealed an intradural mass spanning T9-S1, overlying the conus and cauda equina nerve roots, with inflammation, swelling, and cerebrospinal fluid obstruction. He underwent T10-T12 laminectomy with duroplasty and partial resection of the intradural extramedullary mass. Pathology results revealed a high-grade, neovascularized, proliferative glioma, and genetic analysis revealed donor DNA. Bowel and bladder function and some strength in the right lower extremity returned during postoperative rehabilitation. With repeat MRIs demonstrating progression of the mass, the patient began a course of total spinal radiation therapy. Interval MRIs demonstrated a 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 more and more attention is paid to the development of cell-based therapies, much remains to be understood about their application and awareness must be raised about their unique risks, including inflammation, immunogenic stimulation, graft rejection, abnormal proliferation, heterotopia. and neoplasia. .

Conclusions:Cell-based therapies face significant challenges, including ethical considerations and the need for further research to establish safety and efficacy. Standardized clinical guidelines are needed to improve patient outcomes and prevent complications.

Devic's disease and hospital rehabilitation: a case report

Annie Layno-Moses, MD; Ray Lee, MD

Diagnosis of the case:optic neuromyelite

Case description:This is a previously independent 67-year-old black female diagnosed with multiple sclerosis (MS) 2 years prior to presentation who presented to hospital intensive care with a 2-day history of left-sided weakness and headaches. Head CT scan was negative for acute stroke. Magnetic resonance imaging (MRI) of the brain revealed inflammation of the distal brainstem and upper cervical cord from a demyelinating process associated with Devic's disease. MRI of the cervical/thoracic spine showed enhancement of the cervical cord with edema and possible focal enhancement in the upper thoracic cord. She received intravenous steroid treatment with no improvement, so the patient refused plasmapheresis. Serum neuromyelitis optica (NMO) antibody was positive and the patient underwent 5 plasmapheresis sessions. In addition, the patient presented with unstable atrial flutter with troponin leakage and was receiving treatment with amiodarone. Hematology/oncology and neurology plan to start rituximab after discharge. She was recently diagnosed with NMO in contrast to her previous MS diagnosis. She had developed torticollis, left-right disorientation, and neurogenic bowel/bladder. She scored 15/30 on the SLUMS, indicating severe neurocognitive deficits. She was started on amantadine but showed minimal improvement in cognitive function. The patient completed rehabilitation at the hospital and was discharged to her home with her family.

discussions:NMO is a rare neuroinflammatory syndrome that is well differentiated from MS. Physiatrists should be aware of the misdiagnosis of NMO MS due to the clinical course of Devic's disease: acute attacks are usually severe and can lead to irreversible effects if not adequately and promptly treated. A review of the literature revealed only three other cases with NMO in the rehabilitation setting. Consistent with other documented case reports, our patient showed improvements in feeding, bathing, upper and lower body dressing, and transfers. Minimal improvement in cognition was observed.

Conclusions:Acute inpatient rehabilitation is valuable in an NMO patient for functional gains, but may be limited in cognitive gains. Attention should be directed to the prevention of complications of NMO.

Diagnosis and treatment of the Guillain-Barré syndrome variant of Miller Fisher in a woman with descending weakness and ataxia

Anna Rozman, DO; Michelle Stern, MD

Diagnosis of the case:Diagnosis and treatment of the Guillain-Barré syndrome variant of Miller Fisher in a woman with descending weakness and ataxia

Case description:A 62-year-old woman presented one week post-viral illness with acute shoulder and neck pain and an unsteady gait. Shortly after hospital admission, the patient showed a progressive decline and became unable to perform basic activities of daily living (ADLs). She developed numbness and tingling in her extremities, but she denied sensory loss. On examination, she had right-sided nystagmus, severe pain in the back of the neck, positive head drop, proximal upper extremity weakness with decreased reflexes. During her hospital stay, she developed areflexia with severe bilateral upper and lower extremity weakness, inability to walk, and right foot drop. Subsequent EMG showed abnormal F and H responses, consistent with early-onset Guillain-Barré Syndrome (GBS). The CSF showed albuminocytological dissociation. Her disease course progressed to urinary retention, diarrhea, intractable neuropathic pain, respiratory distress, and adjustment disorder. At that time, the patient received a five-day course of IVIG, along with aggressive, comprehensive occupational/physical therapy. After discharge, she showed improvement in ADLs, distal extremity strength, and range of motion. After two weeks of acute rehabilitation, the patient was able to walk 30 feet with a walker without an ankle-foot orthosis, requiring minimal assistance.

discussions:GBS usually follows an infection and presents with rapidly ascending weakness, mild sensory loss, and diminished reflexes. Most cases present bilaterally, involving the lower extremities with subsequent extension to the upper extremities and may be accompanied by sensory loss. Many patients have 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 injuries with gastrointestinal or bladder involvement. A rare variant of GBS, Miller Fisher syndrome (MFS), presents a triad of areflexia, ataxia, and ophthalmoplegia. However, compared to traditional GBS, patients with MFS often have head and neck involvement before ascending paralysis, as in this patient. Comprehensive IVIG treatment within two weeks is important, along with possible corticosteroids, plasmapheresis, supportive respiratory care, pain control, DVT prophylaxis, and intensive rehabilitation of the patient is essential for full recovery.

Conclusions:Proper diagnosis of the different GBS variants and identification of their specific treatment options, including early intensive rehabilitation, are key factors in the prognosis and return to function of GBS patients.

Diagnosis of thoracic spine tumor misattributed as musculoskeletal back pain

Aaditya Verma, DO; Alexandra M. Rivera Vega, MD

Diagnosis of the case:Metastatic adenosquamous lung cancer with metastases to T3-5 causing spinal cord injury.

Case description:A 56-year-old African American male referred to the clinic for constant severe chest pain in the back. He started 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 by movements that require crossing the upper extremities beyond the midline and waking the patient from sleep. He was seen in the ER several times, with X-ray images showing no abnormalities. Of note, the patient was cachectic and reported unexplained weight loss, night sweats, fever, and chills. We scheduled a new chest x-ray on the day of the visit, as well as a chest CT scan at a week's follow-up, which revealed a mass that nearly obliterated the spinal canal on T4. The patient developed urinary retention and underwent surgical decompression and tissue analysis revealed an adenosquamous carcinoma, probably of the lung. The mass had to be repeated due to tumor recurrence. The patient received palliative chemotherapy treatments and was eventually transferred to hospice care at a nursing home.

discussions:This case highlights the importance of checking for "red flag" symptoms and not investigating the symptoms. The musculoskeletal back pain should resolve in 4 to 6 weeks with conservative treatments, but the patient had intractable back pain lasting more than 6 months and was cachectic, febrile, and had night sweats. No CT scan or MRI was requested prior to referral to our clinic.

Conclusions:Warning symptoms should always be noted and monitored when caring for a patient. They should be sought out and worked on if the patient's constellation of symptoms paints a picture of an emergency diagnosis.

Diagnostic dilemma of facial nerve palsy after Guillian-Barre treatment: a case report

Daniel McNeill, DO; Fred Fridman, D.O.

Diagnosis of the case:bell's palsy

Case description:A 65-year-old man presented to the hospital complaining of paresthesias and bilateral weakness of the lower limbs. Evaluation including lumbar puncture and EMG and recent history of upper respiratory viral 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 intensive care rehabilitation center. On admission to hospital acute rehabilitation, the patient presented full strength in the upper limbs, 4/5 strength in the lower limbs, and proprioceptive deficit in the lower limbs. On day 3, he developed a right-sided facial droop within hours that involved the entire facial nerve, sparing the other cranial nerves. He was transferred back to an intensive care hospital for examination, where he underwent further imaging and a spinal tap. Results from these studies were mixed, showing improvement from initial presentation. Eventually, he was diagnosed with Bell's palsy and treated with gradually tapered prednisone 60mg over 5 days, which rapidly improved his facial nerve palsy over days while lower extremity symptoms remained stable. After treatment, he continued to participate in therapy and his lower extremity weakness slowly improved. He later he was released home.

discussions:This patient provided a unique diagnostic challenge, as new facial weakness in the setting of recent GBS can include multiple diagnoses including: Recurrent GBS, as many patients may have cranial nerve involvement, usually with multiple cranial nerves and often bilaterally; Treatment-related fluctuations, diagnosed with treatment-improved GBS disability scale, a significant decrease within 2 months of treatment; Bell's palsy, which accounts for 80% of all facial nerve palsies and is a diagnosis of exclusion; and chronic inflammatory demyelinating polyneuropathy that is usually diagnosed with GBS recurrence after 8 weeks, or with 3 episodes of neurologic deterioration.

Conclusions:New facial nerve palsy in the setting of recent GBS has a wide differential diagnosis that must be taken into account, as treatments and prognosis may differ.

Differentiating between conversion disorder and hemiplegic migraine: how do you know?

Shannon L. Schultz, MD, MPH; Shangming Zhang, MD; David Gater, MD, PhD, MS

Diagnosis of the case:conversion disorder

Case description:A 38-year-old woman with a complex social history was transferred to rehabilitation for steroid-induced myopathy following an exacerbation of asthma. On the third day of rehabilitation, while talking on the phone, she developed acute-onset aphasia, right-sided weakness, and headache without aura. An MRI, CT scan, echocardiogram, and EEG revealed no organic etiology. She returned to rehab with a stammer of speech, right scalp allodynia, and right-sided weakness. Given the diagnosis of hemiplegic migraine, she started Verapamil. On her fourth day of rehabilitation, she developed a new chorea-like movement in her left upper extremity. She had an additional MRA, lumbar puncture, and EEG obtained, which were all normal. Upon return to rehabilitation, she regained strength in her right upper extremity (4/5), stuttering resolved, and left upper extremity chorea decreased. She continued to have weakness (2/5) in the right lower extremity, which improved significantly with transcutaneous electrical nerve stimulation. Before discharge, she was examined by a neuropsychologist and prescribed Celexa.

discussions:Conversion disorder is a somatoform disorder that presents as neurological symptoms that do not adhere to a known disease process. It is believed to arise as a consequence of stress in susceptible individuals, usually young women. Worldwide, 50/100,000 people are diagnosed each year, with an incidence of 4-12/100,000 new cases per year. In the United States, US$ 20 billion/year is spent on the treatment of this disease. Aggressive rehabilitation, psychotherapy, neurology, and stress management play a vital role in resolving symptoms. In this case, an fMRI would have been indicated if an aura was present to further differentiate between a hemiplegic migraine and a conversion disorder.

Conclusions:It is important to complete a comprehensive examination to rule out an organic cause for any neurological symptoms. Conversion disorder responds well to therapy modalities and resolution usually occurs within two weeks. A multidisciplinary guideline aimed at patient education and awareness, reducing stressful situations, is essential to prevent recurrence.

Disability in the curricula of health professionals: a mapping review

Dr. Caleb Atkins; Dr. Omair Ahmad; Bhargav Mudda, MD; Liu Juan, MD; Margaret A. Turk, MD

Goals.The general consensus is that there is a deficiency in the knowledge, skills and attitudes of health professionals towards people with disabilities. The purpose of this systematic search was to identify recent publications on disability education and review the publications to catalog and analyze their recommendations on the education of health professionals in relation to people with disabilities.

Project:We conducted a comprehensive search for publications from 1990 to April 2014 using 13 education and disability-related search terms in 5 databases. Publications underwent an initial review by defined inclusion/exclusion criteria and then a mapping review (classification into various topics) for publication category. A broader view of the category with more articles addressed broad topics, detailed curriculum information, and teaching strategies.

Results:1,068 articles were identified through this systematic search, which resulted in 226 post-review publications using inclusion/exclusion criteria. Initial mapping noted 106 comments/other (eg, opinion-based, letters to the editor, workshop/meeting summary), 85 quasi-experimental, 39 qualitative, 2 systematic reviews, and 2 RCTs. The main themes of comment/other categories were health professional education reform, deficiency of curriculum content, and recommendations for content/teaching strategies. Of these, 50 addressed disability, rehabilitation or health knowledge; 35, clinical skills; 29, bad attitudes from the provider. 29 posts discussed a multifaceted approach (using at least 2 of the 3 main themes). 18 of 29 recommended contact with a person with a disability, within a variety of contexts, as a key strategy. Didactic (12/29) was the next common one.

Conclusions:The largest publication category on disability education for professionals is based on comments. There is limited, mostly quasi-experimental, research on successful educational strategies. This review of comments/other posts pointed to contact with people with disabilities as the main recommended strategy, but there was no agreement on the context. Future review of the scientific rigor of research-based articles may provide further guidance in choosing an educational strategy.

Disparity between radiological findings and clinical presentation in severe osteoarthritis: is there a role for the biomarker at the point of care?

Melissa P. Osborn, BA; Pablo Paily, MD; Dr. Prathap Jayaram

Diagnosis of the case:Bilateral knee osteoarthritis, stage IV

Case description:The patient is a 69-year-old man with a history of hypertension, hypercholesterolemia, and borderline diabetes mellitus, who attended for severe bilateral primary osteoarthritis of the knee. He continues to be very active, swimming and playing competitive tennis, with a pain rating of no more than 3-4 out of 10. Current medication regimen includes Celebrex 200mg daily. Previous treatment strategies have included injections of steroids and hyaluronic acid with little benefit. He has no desire to undergo knee surgery. Physical examination showed marked enlargement of the bilateral lateral joint, mild effusion, and genu varus of the right knee. Diagnostic imaging includes plain weight-bearing radiographs of both knees revealing bilaterally advanced tricompartmental osteoarthritic changes: the right larger than the left, more severe in the medial compartment of the tibiofemoral joint with loss of joint space, subchondral cystic changes, and sclerosis, as well as intra-articular loose bodies in the left tibiofemoral joint space.

discussions:The radiological findings in this case are significantly more serious than the clinical presentation of the patient. This case demonstrates the value of understanding the chemotactic environment in osteoarthritis. There are a reasonable number of studies that relate the clinical progression of primary osteoarthritis with biomarkers, which in this case would be clinically relevant for prognosis.

Conclusions:This case report demonstrates that radiographic images, while important, must be used in conjunction with physical examination findings, clinical correlation, and the potential chemotactic setting.

Treatment of partial rupture of the distal biceps tendon with platelet-rich plasma

Quan M. Luong, DO, Yin-Ting Chen, MD

Diagnosis of the case:Partial rupture of the distal biceps tendon.

Case description:A 56-year-old man with right elbow pain and weakness in flexion and supination and limited function since a lifting injury in July 2014. MRI reveals tendinosis with grade II partial tear of the distal biceps tendon with hematoma adjacent to the two months after the injury. He completed a full course of physical therapy with a home exercise program with no relief. Physical examination demonstrated tenderness along the distal biceps tendon. The strength was 4/5 in flexion and supination of the elbow; The hook test was negative.

The patient opted for conservative treatment and underwent a series of ultrasound-guided platelet-rich plasma (PRP) treatments performed at 8, 9, and 11 months post-injury. The PRP treatment was collected with the 30 mL collection kit and injected under ultrasound guidance in the ulnar to radial view in the Egyptian view. After the second treatment, the patient had complete pain relief, regained full strength in the elbow, and returned to normal function.

Ultrasound examination was performed at each treatment session. Initial examination showed an enlarged distal biceps tendon with possible hypoechoic lesion in continuity near the insertion on the proximal radius. The second scan revealed an enlarged distal biceps tendon with calcified intratendinous lesions near the insertion. The final examination showed a slightly thickened distal biceps tendon without significant discrete tendinopathic lesions with partial rupture, not as appreciated compared to previous studies.

discussions:Ultrasonography is effective in identifying partial and complete ruptures of the distal biceps tendon, providing an inexpensive, faster, and more dynamic imaging modality compared to MRI, and provides a means for guided biologic treatment. In this case, PRP led to improvement in symptoms and function, and ultrasonography was helpful in monitoring the improvement in tissue quality.

Conclusions:Ultrasound-guided PRP therapy may be considered prior to surgery for the treatment of partial rupture of the distal biceps tendon.

Does performance-based evidence 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

Goals.Fall history is a known predictor of future falls in older adults. For physicians, the question remains how to further stratify their patients to decide who to intervene on. Viable evidence-based tests have yet to be adequately identified. Tests that may serve this purpose include the Brief Physical Performance Battery (SPPB), a 3-task battery (rising from a chair, balance test, and walk test), each SPPB component individually, or the walk test. 8 steps (F8WT) . Each test is fast, simple, and reliable to run. Through an analysis of an existing longitudinal cohort study, we sought to identify which tests predicted fall counts during 4 years of quarterly follow-up.

Project:We conducted an analysis of 424 primary care patients aged ≥65 years and at risk of impaired mobility. We stratified participants with (n=178) and without (n=246) previous reports of falls. Negative binomial regression models were constructed for the primary outcome (number of falls) and ratio ratios (RRs) were calculated. Adjustment variables included age, gender, education, and race (model 1); plus Body Mass Index, Mini Mental State Exam, and comorbid health conditions (model 2); in addition to pain intensity, reported history of depression, visual acuity, and activity level (model 3).

Results:Our findings identify that among patients with no history of falls, the SPPB and F8WT performance tests did not predict future falls within the fully adjusted model. Among those with a history of falls, across all 3 models, the worst balanced SPPB had higher rates of falls compared to those in the highest balanced category. Specifically, a score of 0 identified patients with a 38% higher rate of subsequent falls (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 predicts subsequent fall rates.

Conclusions:The SPPB balance component can identify primary care patients at significantly increased risk of falls.

Does the weather really affect spasticity in stroke survivors?

Xiaoyan Li, PhD; Henry Shin, MS; Ping Zhou, PhD; Sheng Li, MD, PhD

Goals.It is an anecdotal clinical observation that the severity of spasticity is altered by weather and ambient temperature. But there is no quantitative assessment of such an effect. Therefore, the objective was to quantitatively examine the effect of thermal stimulation (heat/cold) using an experimental thermal stimulator.

Project:Thirteen individuals with spastic-hemiplegic stroke (5 women, 8 men, aged 53-78 years, history of stroke: 68 ± 42 months) participated in the experiment. Elbow flexor spasticity was PLUS 1+ or less. A 50 degree elbow extension was applied to the spastic arm at two speeds (5 degrees/sec and 100 degrees/sec) on a custom machine. At least 30 seconds of thermal stimulation (HEAT at pain heat threshold, COLD at 0 Celsius, or BASE at room temperature) was applied to the skin of the contralateral hand via a thermodic probe prior to stretching.

Results:The total torque (resistance to stretch) was dependent on velocity, greater at 100 degrees/s than at 5 degrees/s. Total torque was also significantly affected by thermal stimulation. When normalized to reference total torque, the percentage change in total torque was also dependent on speed and temperature. Overall, COLD increased total torque by 11.0%, while HEAT decreased total torque by 6.3%. The reflex torque, after subtracting the total torque at 5 deg/s from the 100 deg/s, did not differ significantly in the three thermal conditions. Since thermal stimulation was applied on the side contralateral to the spastic side, the effect of thermal stimulation is mediated by central mechanisms. Cold exposure has been shown to increase muscle spindle sensitivity through the thermoregulatory reflex, a precursor to shivering; while heat could inhibit muscle spindle response.

Conclusions:In summary, the results provide objective laboratory evidence for anecdotal clinical observation of change in muscle spasticity following hot and cold stimulation. The finding also supports the therapeutic role of heat stimulation in the treatment of spasticity.

Dropped head syndrome of elusive etiology: report of a case

Benjamin T. Jensen, MD; Dr. Chris Duncan; Scott Swasey, D.O.

Diagnosis of the case:Dropped head syndrome (DHS) is a rare condition of severe cervical-thoracic kyphosis for which the differential diagnosis is broad. The inability to maintain neck extension affects quality of life and can lead to vertebral body fractures, spondylolisthesis, neck pain, and myelopathy.

Case description:A 69-year-old man with a history of diabetes complicated by peripheral sensory and motor polyneuropathy presented to the outpatient clinic with a 2-year history of progressive weakness of cervical extension. Previous physiotherapy (PT) follow-ups did not produce any improvement. Previous evaluation by neurology diagnosed Myasthenia Gravis and started pyridostigmine. However, MuSK antibodies and chest CT for thymoma were negative. Also, he had no improvement in neck strength. Pyridostigmine was discontinued and he was referred for EMG plus physical therapy and referral to PM&R.

Our evaluation revealed active neck extension 5 degrees beyond the neutral point and passive neck extension 10 degrees beyond the neutral point. However, after 30 seconds, her chin slowly flexed toward her sternum. The sternocleidomastoid and rectus abdominis had normal tone. Strength and reflexes were normal. EMG revealed only 1+ right lower cervical fibrillations and sharp waves, but normal morphology of motor unit action potentials. We referred him for neck extension strengthening, a temporary rigid cervicothoracic orthosis (CTO), and an orthopedic evaluation of the spine.

discussions:Electromyographic findings do not suggest myopathy or peripheral nerve etiology as the cause of his profound weakness. The minor denervation on the EMG is probably related to diabetes. While we thought that the CTO would provide better functional alignment during strengthening, our spine team felt that the continuous PT was the best option. After this session, you will be re-evaluated for surgical intervention.

Conclusions:DHS itself is rare, and its etiology may be elusive. Prolonged cervical kyphosis can decrease quality of life and lead to anatomic complications. More research is needed for the diagnosis and treatment of this complicated syndrome.

Early acute rehabilitation intervention for the treatment of mononeuritis multiplex

Idris Amin, MD; Daniel Kao, MD; Dimir Abrar, MD

Diagnosis of the case:A 45-year-old woman had left upper extremity weakness and bilateral distal distal extremity weakness for one month prior to arrival. Previously, the patient was independent in all activities and reported that the weakness had progressed to the point where she could no longer walk.

Case description:The patient was enrolled in a comprehensive rehabilitation program, including physical, occupational, and speech therapy. Simultaneously, the cause of the symptoms presented by the patient was investigated. A lumbar puncture was performed, which ruled out Guillain-Barré syndrome, and a noncontrast cranial CT scan showed a lacunar infarct in the central pons. The patient also underwent a nuclear magnetic resonance in which multiple small infarcts of the pons and middle cerebellar peduncles were observed, compatible with vasculitis. An electromyography test showed severe distal axonal neuropathy. The patient's laboratory tests were significant for elevated inflammatory markers such as rheumatoid factor and myeloperoxidase. With the help of Rheumatology, the patient was diagnosed with Multiple Mononeuritis. The patient was treated with corticosteroids and received intravenous immunoglobulin infusion, with a good clinical response. The patient was discharged home with him after being able to walk with modified independence in a walker. Continuing a rehabilitation program while undergoing the medical examination was shown to be beneficial in accelerating the patient's recovery time and shortening their hospital stay.

discussions:Since the goals of Mononeuritis Multiplex treatment include improving independence, the rehabilitation team played a key role in maximizing the patient's mobility during an extensive medical examination.

Conclusions:The early incorporation of rehabilitation therapy is essential to produce beneficial results in patients with mononeuritis multiplex.

Early confirmation of deep peroneal neuropathy responsible for acute foot drop: case report

Evan C. Grant, MD; Dr. A.S. Gary Fang

Diagnosis of the case:deep peroneal neuropathy

Case description:A 67-year-old man with a history of low back pain and radicular pain in the right leg was admitted after 2 days of falling on his left foot. He was painting his deck and stood on a ladder with his leg resting on a step for an extended period. He woke up the next morning with his left foot drooping and numb. Physical examination revealed numbness of the back and foot drop with preserved eversion. His diagnosis in the emergency room was worsening lumbar radiculopathy, for which neurosurgical consultation and magnetic resonance imaging were requested. Nerve conduction studies (NCS) were performed three days after injury to rule out peripheral neuropathy. Relevant findings included a reduced compound muscle action potential (CMAP) amplitude at the ankle and 5 cm above the ankle (2.5 millivolts and 2.2 millivolts, respectively), compared to 6.7 millivolts at the ankle. right. CMAP was absent in the left fibular head and popliteal fossa. Sensory nerve conductions of the left and right superficial fibula were normal and comparable. These findings suggested a left deep peroneal nerve conduction block below the fibular head. The MRI and neurosurgery appointment was canceled and the patient was discharged the next day.

discussions:Deep peroneal nerve injury that occurs from compression in the front of the leg and below the fibular head is much less common than compression of the common peroneal nerve in the fibular head. EMG/NCS is usually done at least two weeks after a suspected injury. However, early NCS performed on an inpatient served to eliminate the need for neurosurgical intervention and thus expedite discharge.

Conclusions:Initial segmental nerve conduction studies are helpful in localizing some acute peripheral nerve injuries. This can reduce unnecessary tests and shorten your hospital stay. Prolonged compression of the deep peroneal nerve with a ladder step is a rare mechanism of injury that deserves recognition.

Early mobilization of patients with external ventricular drains: use of resources

Ashley Tarkiainen; Paula Bu, AB; Sara Melnyk, MS; Kristen Stout, PT, DPT; Syed O. Shah, MD, MBA; M Kamran Athar, MD; Dra. Nethra S. Ankam

Goals.The development and implementation of early mobilization protocols require further study of the necessary resources. The purpose of this study is to examine the early mobilization of patients in the neurological intensive care unit (NICU) receiving EVD and to document the number of people needed to mobilize the patient and the number of years of experience of the primary therapist.

Project:We performed 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 to June 2015, this checklist was used by physical and occupational therapists to record data on observation of EVD patients 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 carried out by a therapist with less than 2 years of experience. 36.9% of the sessions were carried out by a therapist with 2 to 3 years of experience. Only 27.4% of the sessions were conducted by someone with 10 years or more of experience. The number of people oscillated between 1 and 3 professionals. Most of the mobilizations involved 2 professionals (55.9%), while 1 professional was used in 39.7% of the mobilizations and 3 professionals were used in 8 mobilizations (4.5%). The highest activity levels most frequently achieved were walking with the help of 1 person (65 cases, 36.3%), transferring from bed to chair standing up (30 cases; 16.8%), and walking with the help from 2 or more people (18 cases; , 10.1%). Only 7 occurrences (3.9%) were of absence of activity.

Conclusions:Two professionals may be enough to mobilize EVD patients. At our institution, therapists with less than 2 years of experience can mobilize EVD patients.

Efficacy of temporary spinal cord stimulation (ECS) in the treatment of chronic postherpetic neuralgia (PHN)

Lawerence Kelleher, DO; Navdeep S. Jassal, MD; Benito Torres, DO; Joseph W. Frye, hacer

Diagnosis of the case:Neuralgia postherpética.

Case description:We present two patients with postherpetic neuralgia (PHN), refractory to multiple modalities of pharmacological and interventional treatment, who subsequently underwent trials of spinal cord stimulation (SCS) with temporary percutaneous electrodes for pain relief of PHN in thoracic dermatomas. The electrode was removed 12 days after placement in patient A, while patient B had the electrode removed 7 days after implantation. Both patients had a significant reduction in pain according to the Visual Analogue Scale (VAS) after temporary SCS (patient A from 10/10 to 3/10, patient B from 8/10 to 1/10 at 3-month follow-up). and none of them evolved towards the implantation of devices. In addition to reducing pain, they were able to maximize their function and limit the use of pharmaceuticals.

discussions:PHN is defined as pain that persists for at least 120 days after the onset of the acute rash and is due to neuronal damage involving both the peripheral and central nervous systems. PHN results from sensitization of peripheral nerves, which then increase central neurons, leading to hyperexcitability, hyperalgesia, and allodynia. These symptoms often create a scenario where the patient is unable to carry out his daily life due to the severe pain he is experiencing. By relieving these patients' pain, they were able to almost immediately return to their original function.

Conclusions:We believe these are the first 2 reported cases demonstrating the efficacy of duration-limited SCS in treating the chronic stages of PHN. Although most PHN patients have been reported to have irreversible clinical conditions of peripheral and central sensitization, we showed significant pain reduction in our 2 patients achieved only with the SCS study. In cases of decreased function with pain as the limiting factor, early intervention procedures may play a role in restoring function.

Electrodiagnostic studies in conjunction with magnetic resonance imaging to diagnose proximal median neuropathy: case report

Maria Apiafi, MD; Francisco Lopez, MD, MPH

Diagnosis of the case:Proximal Median Neuropathy

Case description:A 51-year-old woman with a significant medical history of diabetes, hypertension, and a chronic smoker presented for electrodiagnostic studies complaining of pain, weakness, and numbness in her right hand. The patient reported an acute onset of severe pain in her right hand and forearm while she was writing a letter, followed by numbness in her hand and forearm; Her symptoms were limited to the right upper limb only. Her symptoms persisted for several hours, prompting her to visit the emergency department. Due to concerns about an acute stroke, she underwent a comprehensive evaluation and was admitted to the inpatient unit. She was discharged when the complete examination was negative for stroke. In the clinic, the patient stated that the pain, weakness and numbness persisted, but now localized to the right hand, mainly to the three lateral fingers. Physical examination was significant for atrophy of the abductor pollicis brevis, weakness in the grip of the hand, wrist flexors, and long finger flexors, and numbness in all fingertips. Challenge tests for carpal tunnel syndrome were positive for tinnel and carpal compression at the wrist. The left upper limb was normal. Neck, shoulder, and elbow examination was normal. Nerve conduction and needle EMG studies were performed in the right upper limb. A median sensory nerve action potential was missing. Expecting an abnormal median compound motor action potential, only slightly reduced median CMAP amplitude was obtained; latency and conduction speed were normal. Needle EMG studies were able to provide a clearer clinical picture, as all muscles 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 found to be significant for abnormal hyperintense signal in the right pronator teres, flexor digitorum superficialis and profundus, and pronator quadratus, consistent with severe denervation. More importantly, a hyperintense signal was also observed in the median nerve at the level of the radial tubercle, extending 5.6 cm distally. The patient was referred 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 much less common than compression within the carpal tunnel. Proximal compression is primarily attributed to anatomical variations in the forearm, most commonly the pronator teres. Less common causes are compression by the accessory head of the flexor pollicis longus (Ganzer muscle) or a persistent median artery. Symptoms can vary depending on the location of the incarceration, but are often mistakenly attributed to a clinical diagnosis of carpal tunnel syndrome. Electromyography and nerve conduction studies may be helpful in diagnosing proximal median neuropathies; however, magnetic resonance imaging can help to better localize the lesion, showing patterns of muscle denervation.

Conclusions:Proximal median neuropathies may share similar clinical features with carpal tunnel syndrome. However, nerve conduction studies and needle electromyography in conjunction with MRI can help elucidate the diagnosis of proximal median neuropathy, ensuring proper management.

ESWT Treatment for Epin Calcanei

Emre Adiguzel; Berke Aras; Mehmet Ali Tashkaynatan; Arif Kenan Tan

Goals.To define the effectiveness of extracorporeal shock wave therapy (ESWT) in people with calcaneal epinephritis.

Project:This study included 10 patients (6 women, 4 men) with calcaneal epin with a minimum history of 12 weeks. The mean age was 46.8 ± 7.6 years. The mean number of treatment sessions was 3.6±0.8 sessions with a mean interval of 10.3±3.4 days. The procedure was administered with 1800 impulses per session at a pressure of 2.0 bar and a frequency of 15 hertz. Pre-treatment patient data was obtained retrospectively from the patients' medical records. The complaints of the patients in the third month after the treatment were questioned by telephone calls. A 100-mm analog scale for pain level was used to measure pain; To assess the severity of the disease of the patients, the interval of pain-free walking, the distance traveled, the frequency of use of analgesics and orthoses, and night pain were requested. Patient satisfaction after ESBT treatment was assessed with a Likert scale. For the statistical analysis, the SPSS 15.0 program was used.

Results:After ESWT treatment, we observed a 58.5 ± 27.0 mm decrease in pain scores. There was an increase of 2,250.0 ± 1,687.3 m in distance walked and an increase of 2.9 ± 2.5 hours in pain-free walking interval. There was a statistically significant improvement in pain scores, distance, and walking interval after treatment. Nighttime pain decreased in 8 (80%) patients, the frequency of analgesic use decreased in 9 (90%) patients, and the frequency of foot orthotic use decreased in 7 (%70) patients. There were no complications. 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 dissatisfied.

Conclusions:ESWT can be an effective and safe option for the treatment of epin calcanei.

Fabrication of a prosthetic foot using 3D printing technology

brand F.Megerian; Shannon Wheeler, Bachelor of Science; Dr D Casey Kerrigan

Goals.

Background:In the United States, there are approximately 1.9 million people living with the loss of a limb, and 185,000 amputations are performed each year, primarily as a result of trauma, vascular disease, and diabetes. Approximately half of all major lower limb amputations are transtibial. Materials, components, and functional specifications greatly differentiate the many prosthetic feet available today. However, a single high-quality prosthetic foot can cost up to $5,000, which is prohibitively expensive for many amputees. The use of 3D printers to fabricate lower limb prosthetic components has been proposed due to cost, speed of fabrication, simplicity of fabrication, and improved access in underserved or third world healthcare settings.

Purpose:Design and manufacture a lower limb prosthetic foot using 3D printing technology.

Project:Using Autodesk Fusion 360 CAD software, a non-articulated flexible prosthetic foot was designed. The design incorporated a rigid connection to a prosthetic stem. The prototype was intended to provide stability at mid-support, as well as store and return energy throughout the gait cycle. One of OESH's 3-D fabrication printers, specifically designed to print strong and flexible material composites for shoe components, was used to print the prosthetic prototype using a blend of nylon filaments.

Results:The impression of the prosthetic foot prototype, made with the medial aspect of the prosthesis resting on the construction platform, took approximately 11 hours with a material cost of less than 15 dollars. The finished prototype was cosmetically sanded and tested to fit various types of shoes. Vertical compression load testing demonstrated that the rigid prosthesis compressed under loads during simulated initial stance, provided adequate stability in intermediate stance, and regained its rigid shape when unloaded.

Conclusions:A lower limb prosthetic foot was successfully designed and fabricated using 3D printing technology. Further analysis of the functional performance of the prototype is needed to further assess the 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; Dr. Susan Stickevers

Diagnosis of the case:Femoroacetabular pinch (FAI) causing adhesive capsulitis of the hip (ACH).

Case description:A 54-year-old obese prediabetic woman reported right-sided groin pain radiating to the midthigh several months after landing on the right hip. Examination demonstrated reduced range of motion of the hip, weakness in hip flexion, and pinpoint tenderness over the right inguinal ligament. MRI of the right hip revealed a collapsed joint capsule with reduced volume and a cyst in the obturator canal measuring 1.6 cm x 1.2 cm x 0.8 cm. Small cysts were identified in the anterior femoral head and anterior acetabular spine with mild CAM-type FAI. After CT-guided aspiration of the obturator canal cyst, the patient reported a 50% pain reduction lasting one week. An attempted fluoroscopy-guided injection into the right hip failed to penetrate the joint. A “rubbery” sensation was noted after repeated attempts to enter the joint capsule. CT-guided intra-articular corticosteroid injection was successful, but there was significant resistance to contrast and medication flow. The patient reported complete relief of symptoms immediately after the injection. Improvement in hip range of motion was seen within one week of injection. The diagnosis of ACH was made on the basis of the findings of reduced hip range of motion, reduced joint volume, and "rubbery" consistency of the joint capsule observed upon attempting intra-articular entry.

discussions:ACH has rarely been described in the literature. This condition is associated with a reduction in the active and passive range of motion of the hip. An arthrogram demonstrates a joint volume of less than 8 cc. ACH is typically seen in obese and diabetic women with a history of prior trauma or FAI. Hip joint cysts are commonly identified in patients with this condition. Intra-articular therapeutic injection is recommended, followed by aggressive range of motion.

Conclusions:Adhesive capsulitis has been described most frequently in the shoulder and has rarely been identified in the hip. More research is needed to determine the best course of treatment for patients with this condition.

Flipping the Classroom: A New Approach to the Musculoskeletal Curriculum

Dixie R. Aragaki, MD; Kristine Cachola, MD; Timoteo Cushing, MD; Sood Radhika, DO; Quynh Pham, MD

Goals.US medical schools are increasingly demanding musculoskeletal (MSK) curricula and clinical internships, but competency in basic MSK medicine can be enhanced with more innovative teaching strategies. The purpose of this study was to assess the effectiveness and perceived student satisfaction of a traditional lecture-based curriculum versus a flipped-classroom MSK curriculum for first-year medical students.

Project:Retrospective cohort study of two classes of first-year medical students enrolled in an MSK core curriculum at an urban university-sponsored medical school in academic years 2014 and 2015. The 2014 cohort was taught using a based on MSK in lectures, while the cohort The 2015 cohort experimented with a "flipped" classroom approach that placed more responsibility on students for learning through student-centered activities, interactive discussions, clinical vignettes, in problems, strategies oriented to the investigation and debates generated in group. Primary outcome measures were academic performance on a multiple-choice final exam and student perception of the course, as measured by an online survey. These results were compared between the two classes.

Results:The mean number of correct answers in 2014 (traditional curriculum) was 154.18 with a SD of 23.28 and in 2015 (flipped classroom) the mean was 149.57 with a SD of 26.26. There were no statistically significant differences (P value = 0.2081) in 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 differences were found for academic performance between the two classes, students in the flipped classroom format in 2015 expressed more satisfaction with the MSK course in 2015. This teaching approach may serve as an option for colleges of medicine improve education at MSK.

Functional Electrical Stimulation in the Long-Term Treatment of Bell's Palsy: Case Report

David Gutierrez, MD; Huma Naqvi, MD; Dr. Katherine Power

Diagnosis of the case:bell's palsy

Case description:A 62-year-old man with a significant medical history of hypertension has had chronic right-sided facial weakness for approximately 1 year secondary to Bell's palsy. Extensive work has been carried out over the last year, including labs, MRIs and multiple brain scans to rule out any other causes of weakness. On physical examination of the patient, the patient showed flattening of his right nasolabial fold and right-sided facial asymmetry, including an inability to wrinkle his forehead or forcefully close his eyes, consistent with Bell's palsy. His pupillary reflexes and extraocular movements were intact. The patient was scheduled for facial muscle rehabilitation with Functional Electrical Stimulation. After four therapy sessions, the patient showed improvement in VAS scores, increased right-sided facial muscle strength, and subjective gains in 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 decline in daily and social function. Regarding the treatment of Bell's palsy, various treatments, including steroids, antivirals, and electrical stimulation, have been shown to have a positive effect on 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. The addition of FES to the already established therapy in these cases may result in better results in terms of facial muscle weakness.

Conclusions:Functional Electrical Stimulation is a modality with a relatively low side effect profile that may be useful in the treatment of chronic or refractory cases of Bell's Palsy.

Functional improvement after resection of choroid plexus carcinoma: case report

Elizabeth A. Barton, MD; Dr. Peter Hwang

Diagnosis of the case:Choroid plexus carcinoma

Case description:A 24-year-old woman with a 6-month history of left 6th cranial nerve palsy presented to an intensive care hospital with new-onset right hemiparesis, incoordination, urinary urgency, dysphagia, slurred speech, and headaches. . Nuclear magnetic resonance (NMR) revealed a pontine mass. The patient underwent extreme lateral infrajugular transcondylar resection of the mass, which required displacement of the temporomandibular joint. Postoperative MRI showed no evidence of residual tumor. The pathological examination revealed choroid plexus carcinoma (CPC). The patient required tracheotomy and placement of a percutaneous endoscopic gastrostomy tube and was later referred to a rehabilitation unit with the aim of improving strength, functional independence, and nutritional status prior to the start of chemotherapy and radiotherapy. Over the course of seven weeks, the patient received intensive therapy for balance and strength deficits, dysphagia, and trismus. Neuromuscular electrical stimulation was used for dysphagia and the patient was monitored with videofluoroscopic swallowing studies. The diet was upgraded from full tube feeding to a mechanical soft diet with ground meats and light liquids, and she gained 10 pounds. The patient was able to walk 200 feet with the aid of a 4-wheeled walker at the modified level of independence at discharge. The measure of total functional independence increased from 81 on admission to 116 on discharge. The patient was discharged to her home and began chemotherapy.

discussions:After seven weeks of in-hospital rehabilitation, the patient was discharged home with significant functional and nutritional improvement. A literature search did not reveal similar cases describing the outcome of rehabilitation in patients with this diagnosis.

Conclusions:Despite the poor prognosis associated with CPC, inpatient rehabilitation can be an important part of post-acute care to improve functional independence, endurance, and nutritional status. These factors may contribute to desired high status in the community and, more importantly, improve tolerance to subsequent cancer interventions that may have a positive impact on survival.

Gabapentin-induced fever: a case report

Kevin M. Berry, MD; Eun Kwang Byun, MD; Mooyeon Oh-Park, MD

Diagnosis of the case:Gabapentin-induced fever after bilateral total knee arthroplasty.

Case description:A 66-year-old man with bilateral knee osteoarthritis and type 2 diabetes without diabetic neuropathy was admitted for comprehensive rehabilitation after bilateral total knee arthroplasty. On admission to the rehabilitation unit, the patient was using gabapentin for postoperative pain control. While in the rehabilitation unit, he presented fever on the 4th day after surgery and the investigation found no attributable cause; His surgical site was clean, no signs of infection, no leukocytosis, urinalysis was negative, urine and blood cultures showed no growth, chest x-ray was negative for infiltrate, and no DVT was found on ultrasound. He had no mental status changes. After 4 days of persistent fever, gabapentin-induced fever was suspected as a diagnosis of exclusion. The fever resolved without recurrence the day after stopping gabapentin. He completed his rehabilitation course without major medical problems and was safely discharged home.

discussions:Gabapentin is a commonly prescribed medication for neuropathic pain and is also increasingly used by orthopedists after joint replacement surgery. To the best of 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 costly and extensive investigation. Although gabapentin is often prescribed for postoperative and neuropathic pain, clinicians should be aware that gabapentin is a possible cause of fever.

Dystrophinopathic genotypic and phenotypic characterization in Puerto Rico: a cohort study

Manuel F. Mas Rodriguez, MD; Rafael E. Arias-Berrios, MD; Eduardo Ramos, MD

Goals.Duchenne and Becker muscular dystrophies (DMD and BMD, respectively), commonly known as dystrophinopathies, are common forms of inherited muscle disease. Information on the epidemiology of these conditions, including genotype and phenotype characteristics, is still scarce. We collected data from all Muscular Dystrophy Association (MDA) clinics in Puerto Rico to describe the prevalence, genotype, and phenotype of these patients.

Project:The data was collected from the medical records of the four MDA clinics on the island. Selected patients were those with a recorded diagnosis of dystrophinopathy along with a confirmatory muscle biopsy and/or molecular test, creatine kinase levels ten times the normal value, or a positive family history. Data collected included the results of the molecular study and the patient's history of disease progression.

Results:142 patients met the inclusion criteria, with 58% and 29% categorized as DMD and BMD, respectively. The estimated prevalence of DMD and BMD in Puerto Rico was calculated at 4.67 and 2.33 per 100,000 men, respectively. Deletion was the most common form of mutation (67%) in the dystrophin gene, with exons from segments 45 to 47 being the most frequently affected. Patients diagnosed with DMD tend to be confined to the wheelchair earlier than DMD patients, as expected.

Conclusions:This is the first study that describes the dystrophinopathic population in Puerto Rico. This population is similar to others described in other geographic areas.

Guillain-Barré syndrome (GBS), acute motor axonal neuropathy (AMAN) variant diagnosed during acute hospital rehabilitation: case report

Haresh Sampathkumar, MD; Artin Minaeian, MD; dr. Eduardo Lopes

Diagnosis of the case:Guillain-Barré syndrome (GBS), variant of acute motor axonal neuropathy (AMAN)

Case description:A 78-year-old woman with a history of asthma who consulted for acute respiratory failure secondary to pneumonia. The patient's medical condition improved, but she stands out for the complicated admission to the intensive care unit (ICU). Finally, she entered acute rehabilitation due to functional impairment secondary to prolonged immobility. The patient's slow functional progress in ambulation and persistent lower extremity weakness after two weeks of admission to the rehabilitation unit prompted further investigation. Spinal images ruled out spinal aetiology. The diagnosis of Guillain-Barré syndrome (GBS), variant of acute motor axonal neuropathy (AMAN) 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 to the acute rehabilitation unit, the patient demonstrated improvement in strength and function evident on physical examination and improvement in FIM scores, respectively. . The patient was finally discharged to her home.

discussions:The GBS AMAN variant is a rare condition in the United States, accounting for an estimated 5-10% of all GBS cases. It is commonly seen after a previous infection. Patients with axonal variant respond well to immunoglobulin if treatment is started within 4 weeks of symptom onset, followed by aggressive rehabilitation to maximize functional outcome. Acute paralysis after a prolonged ICU stay is most often due to critical illness polyneuropathy (CIP) or critical illness myopathy (CIM) or rhabdomyolysis and should be ruled out first, followed by screening for GBS AMAN variant, since that timely diagnosis can alter the course of the patient. and reduce disability.

Conclusions:Patients admitted with acute paralysis after a prolonged ICU stay should be evaluated for any underlying acquired neuromuscular disease if they do not progress through rehabilitation, as this may change management. In addition to routine testing for MIC, ICP, and rhabdomyolysis, clinicians should be alerted to the possibility of the AMAN variant.

Heroin-induced mononeuropathy

Dr. Jane Hwang; Julie E. Witkowski, B.S.; Dr. Marilyn Pacheco

Diagnosis of the case:Heroin-induced mononeuropathy

Case description:A 26-year-old Caucasian male with a medical history of multiple substance abuse and depression presented with a 1-day history of weakness and numbness of the left lower extremity following intravenous heroin use 12 hours earlier. On initial physical examination, the patient had 1/5 hip flexor strength and 0/5 knee extensor strength on the left side. Sensory examination of him was significant for pinprick numbness 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 troponin leak (2.20). A comprehensive infectious disease examination including a lumbar puncture was essentially negative. Electromyography performed seven days after presentation was significant for a decreased left femoral axonal motor response. After a week's stay in our acute rehabilitation unit, the patient's strength had improved to 3/5 hip flexor and 2/5 knee extensor.

discussions:Heroin-induced neuropathy is a poorly reported or studied phenomenon. Its etiology is unknown, although current hypotheses include nerve compression, an immune response, or the toxic effects of heroin. Most cases in the literature have reported plexopathy or neuropathy together with rhabdomyolysis without significant improvement in patients' symptoms over time. Treatment with corticosteroids has been suggested, but has not resulted in improvement in recent cases. Physiotherapy was reported to demonstrate an improvement in motor strength in one case report.

Conclusions:Heroin-induced neuropathy is a little-studied phenomenon. Our case study reports a slight improvement in strength within one week of admission to an acute rehabilitation unit. Patients with heroin-induced neuropathy may benefit from an acute rehabilitation stay.

Herpes Zoster in a world-class triathlete: case report and evaluation of training programs in relation to immune status

John S. Georgy, MD, MBA; Lawrence Lai, MD, MS; Dr. A.S. Jeffrey Shilt

Diagnosis of the case:Herpes Zoster in a World Class Triathlete

Case description:We present the unique case of a world-class triathlete who developed a painful dermatomal rash after a particularly intense period of training, travel and competition. His training program for three months after the illness and return to competition is documented. The subsequent period of poor performance and profound fatigue in the athlete suggests an inadequate recovery period.

discussions:Although the specific triggers and state of immune dysfunction that allow for a shingles outbreak are still unknown, it is clear that changes in the immune system play a role in the progression of this disease. In addition, extremely strenuous exercise and stress have been shown to 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 find a balance between the risk of decreased immunity from overexertion and maximizing their training to increase their level of performance. The literature has no recommendations on return to training activities or endurance events for athletes with Herpes Zoster.

Conclusions:Immunological markers can be useful to determine patients at risk of Herpes Zoster reactivation. Cell-mediated immunity may be diminished with an enzyme-linked interferon-γ-linked immunosorbent spot-forming cell assay (ELISPOT), even if vaccinated 6 to 10 years earlier. This suggests that cellular immunity is diminished in certain patients and that reactivation of herpes zoster can occur even if these patients have not been susceptible to the virus. Investigations of this immune marker for latent herpes zoster can help determine the existence of the virus in an affected athlete and help clinicians guide these athletes to return to competitive sports.

Central pontine myelinolysis induced by hyperglycemia in the setting of uncontrolled diabetes

Craig Van Dien, MD; Laurent Delavaux, MD; Dr. Iqbal Jafri; Dr. Sara Cuccurrullo

Diagnosis of the case:Myelinólisis Pontina Central

Case description:A 41-year-old man with a history of uncontrolled diabetes mellitus (HBA1C > 16%), lack of adherence to medication, and alcohol abuse who was admitted for acute hospital rehabilitation due to functional deficits secondary to central pontine myelinolysis (CPM) induced by hyperglycemia. The patient initially sought an outside medical center after a long history of progressively worsening generalized weakness, with additional complications of decreased mobility and dysarthria. Hospital laboratory evaluation revealed hyperglycemia greater than 700 mg/dL with concomitant renal failure and normal sodium levels (sodium corrected for hyperglycemia, 142 mmol/L). Initial physical examination findings included more pronounced generalized weakness on the left side. Head CT scan did not show acute intracranial hemorrhage. However, MRI identified a bilateral symmetrical confluent T2 signal abnormality in the central pons consistent with CPM. After medical stabilization, the patient was transferred to acute inpatient rehabilitation for functional deficits, including dysphagia and gait and ADL dysfunction. Pertinent examination findings included decreased proprioception, decreased lower extremity reflexes, and increased bilateral lateral sway with gait analysis. The patient achieved his functional goals, demonstrating improvement in ambulation, ADL, and transfers upon completion of inpatient rehabilitation.

discussions:Although commonly associated with rapid correction of chronic hyponatremia, CPM cases are rarely demonstrated in the setting of hyperglycemia in the absence of sodium abnormalities. One proposed mechanism for demyelination involves disruption of the blood-brain barrier due to the rapid appearance of a hypertonic extracellular space, at a rate that exceeds the brain's compensatory mechanisms. This allows passage of inflammatory mediators, resulting in subsequent nerve damage and vasogenic edema. The prognosis is variable and improves with early detection and treatment.

Conclusions:This is a rare case of hyperglycemia-induced CPM in the setting of uncontrolled diabetes mellitus with successfully completed acute inpatient rehabilitation. Early detection and management of CPM can improve functional outcome and overall prognosis.

Unilateral iatrogenic accessory nerve palsy and keralgia paresthetica as complications of intensive care hospitalization

Phuong U. Le, DO; Sparr A. Steven, MD

Diagnosis of the case:Unilateral iatrogenic accessory nerve palsy and keralgia paresthetica as complications of intensive care hospitalization

Case description:A 49-year-old woman presented with pain in her left shoulder and thumb for 6 weeks. Three months earlier, she underwent surgery for a myomectomy complicated by an intra-abdominal abscess that caused sepsis and a prolonged stay in the intensive care unit (ICU), requiring intubation. At discharge, she experienced burning pain in her 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 a superiorly and laterally displaced left scapula. There was decreased sensation on the dorsal surface of the left thumb and on the left trapezius.

Electrodiagnostic study revealed left spinal accessory neuropathy and left distal radial sensory neuropathy corresponding 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 paresthetic smear pain, is a rare diagnosis and is usually due to trauma to the wrist. In this case, the probable etiology was the insertion of an intravenous line. Isolated spinal nerve palsy is usually the result of a mechanical injury, such as tension, traction, or compression. Internal jugular vein (IVJ) central line insertions or aggressive manipulation of the neck may have been the cause in this case.

Conclusions:Common ICU procedures, including neck manipulation during IVJ insertion and peripheral line placement, can lead to traumatic neuropathies. This patient is unique in that she appears to have suffered two minor nerve injuries while she was in the ICU. Treatment to control neuropathic pain, intravenous steroids, and occupational therapy can improve pain, function, and quality of life.

Acute idiopathic brachial neuritis presenting as unilateral shoulder pain and weakness with remarkably rapid recovery after immediate steroid treatment: a case report

Mustafa Khan, MD; Danny Wilkerson, MD; Johnathan Goree, MD; Noojan Kazemi, MD; Alexandra M. Rivera Vega, MD

Diagnosis of the case:Acute brachial neuritis or Parsonage-Turner syndrome

Case description:A 59-year-old right-handed male presented with sudden left shoulder weakness with inability to abduct or flex the arm forward. Preceded by 1 week of shoulder pain. Influenza vaccine was given 1 month ago. He denied recent trauma, surgery, illness, fever, or chills. The strength was 2/5 for the deltoid, biceps, and rotator cuff muscles with scapular wing. Cervical MRI showed severe foraminal stenosis and compression of the left C5 nerve root and bilateral C6 and C7 nerve roots. The patient received a cervical epidural steroid injection the same day, oral methylprednisolone, and aggressive physical therapy. MRI of the shoulder did not show significant intrinsic pathology of the shoulder. Brachial MRI showed 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 after symptom onset.

discussions:This is the first reported case, to our knowledge, in which a patient received an epidural injection, in addition to oral steroids and physical therapy, immediately after the onset of symptoms. Full recovery can take 1-3 years, however, in our patient, it only took 2 months for near-baseline improvement.

Conclusions:Early recognition of Parsonage-Turner Syndrome is important in order to provide prompt and appropriate treatment, which consists of steroids and aggressive rehabilitation. Epidural steroid injections are a minimally invasive procedure that can be considered as a treatment.

Impact of acute inpatient rehabilitation after liver transplantation in patients scoring high in the model for end-stage liver disease (MELD)

Sheena Bhuva, MD; Megan C. Reynolds, MS; Giovanna Saracino, MS; Sumeet Asrani, MD, MSC; Jacob Christiansen, Licenciado en Ciencias; Simón Driver, PhD

Goals.People who undergo liver transplantation (LT) are overall older, sicker, have higher Model for End-Stage Liver Disease (MELD) scores, and more comorbidities in the current era. The impact of acute post-LT rehabilitation is not well studied. The aim was to compare the outcomes of LT patients with a MELD score ≥25 who received and did not receive acute inpatient rehabilitation.

Project:Adult subjects with a MELD biological score ≥25 who underwent LT in a large transplant program (2004-2014) were identified using a prospectively collected database of liver transplants, including inpatient, outpatient, and rehabilitative care. Demographic, diagnosis-related, and outcome variables were analyzed.

Results:262 high-risk patients underwent LT: 194 were discharged home, 68 to an intensive care rehabilitation unit (IRF). Patients were predominantly male (64%) and Caucasian (67%). 34% had the Hepatitis C virus; 15% had cirrhosis/cryptogenic cirrhosis due to non-alcoholic steatohepatitis (NASH). Between groups, patients admitted to IRF likely received ICU care immediately before transplant (44% vs 21%, p = 0.002), have higher MELD score (METRO=33 vs. 30, p=0.002) and experience a longer total ICU stay (METRO= 9 days vs. 4) and acute care LOS (METRO= 21 days versus 12, p= < 0.001). There were no significant differences in mortality at one year between the groups (95% vs. 94%, p = 0.69). Of the 68 patients admitted to IRF, 53 were at an affiliated institution with records available for review and demonstrated a significant difference in Functional Independence Measure (FIM) scores between admission and discharge (p=<0, 0001).

Conclusions:Although patients admitted to IRF post-LT were (1) more severely ill before transplantation, (2) had a worse prognosis based on MELD scores, and (3) had longer hospital stays, significant functional gains were achieved and rates of One Annual mortality was ultimately similar between groups. These preliminary findings are clinically significant and validate the incorporation of post-LT rehabilitation among the most critically ill patients.

Incidence of sleep disorders in military personnel with head trauma

Justin L. Weppner, DO; Ryan West, MD

Goals.The aim of this study was to determine the prevalence and consequences of somnolence and disturbed sleep in military personnel after traumatic brain injury (TBI).

Project:People aged 18 years or older who had been at least 3 months since a traumatic brain injury were prospectively recruited for the study. One hundred male subjects with TBI were assessed with polysomnography (PSG), multiple sleep latency test (MSLT), Epworth Sleepiness Scale (ESS), psychomotor alertness test (PVT), profile of mood state (POMS), and questionnaire. of functional sleep results (FOSQ). .

Results:Abnormal sleep studies were found in 47 (47%) subjects, including 35 (35%) with obstructive sleep apnea (OSA), 5 (5%) with post-traumatic hypersomnia (PTH), 2 (2%) with narcolepsy, and 5 (5%) with periodic limb movements during sleep (PLMS). Among all subjects, 28 (28%) had objective excessive daytime sleepiness with an MSLT score < 10 minutes. There was no correlation between the ESS score and the MSLT. There were no differences in injury severity or time after injury between sleepy and non-sleepy subjects. Sleepy individuals had a higher body mass index (BMI) than non-sleepy individuals. OSA was more common in subjects with a BMI ≥30. There is a high prevalence of sleep disturbances (47%) and excessive daytime sleepiness (28%) in people with TBI.

Conclusions:Patients with TBI should undergo comprehensive sleep evaluations. Sleepy people with TBI have more impaired cognitive function than other people with TBI. Daytime sleepiness with some of the neuropsychological deficits of people with TBI 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

Diagnosis of the case:We present the case of a man with paraplegia who presented an asymptomatic ischemic fasciitis lesion in the left gluteus medius.

Case description:The patient is 43 years old with a history of thoracic syrinx and uses a wheelchair for locomotion. Recently, routine imaging tests have resulted in a negative investigation for malignancy. However, it was noted that he had two small lesions on the left gluteus medius with increased uptake on the PET image. On contrast-enhanced MRI, the lesions showed peripheral enhancement with surrounding edema. The patient had no pain and no palpable mass at the site. The biopsy was compatible with ischemic fasciitis. The development of the lesion was attributed to localized pressure from the increased use of a wheelchair. Since then he has received a new pad.

discussions:Schematic fasciitis, also known as atypical decubitus fibroplasia, is the finding of a deep subcutaneous lesion, generally located on a bony prominence and subjected to chronic intermittent pressure. It is described in elderly patients with reduced mobility or weakness. Unlike pressure sores, the overlying skin remains intact. Microscopically, the lesions are notable for an organized structure with central fibrinoid necrosis surrounded by reactive fibroblasts and a chronic inflammatory infiltrate. The differential diagnosis of these lesions includes soft tissue sarcoma; however, the hypercellularity, atypical mitoses, and endothelial cell stratification more typically seen in sarcoma are not present in ischemic fasciitis.

Conclusions:Ischemic fasciitis is a benign subcutaneous lesion that is usually located over a bony prominence and is associated with chronic intermittent pressure. It is a rare diagnosis that can be found in patients with reduced mobility at risk of pressure ulcers. It is important for physiatrists to be aware of the diagnosis and its similarities to soft tissue malignancies in order to manage their patients.

Increased glial activation in vivo in patients with primary lateral sclerosis (PLS) evaluated with [11C]-PBR28 positron emission tomography

Sabrina Paganoni, MD, PhD

Goals.Multiple lines of evidence implicate the neuroimmune system in the pathology of amyotrophic lateral sclerosis (ALS). We recently demonstrated increased glial activation in vivo in the motor cortices of people with ALS using [11C]-PBR28 positron emission tomography (PET). Glial activation was correlated with disease severity and upper motor neuron load scores. These findings suggest that [11C]-PBR28 may be a potential marker of upper motor neuron dysfunction in ALS. Therefore, it may also represent a candidate biomarker for motor neuron disease that primarily affects upper motor neurons, such as primary lateral sclerosis (PLS). However, the binding of [11C]-PBR28 has not been studied in PLS so far. In this study, we evaluated the binding of [11C]-PBR28 in people with PLS.

Project:Five PLS patients and five healthy volunteers with binding affinity for age and [11C]-PBR28 completed a PET scan with [11C]-PBR28. Standardized uptake values ​​were calculated from 60 to 90 minutes post injection and normalized to the whole brain mean.

Results:Whole-brain voxel analysis showed increased [11C]-PBR28 binding in motor cortices in PLS patients compared to healthy controls (Z > 2.3, group corrected at p < 0.05). The binding pattern of [11C]-PBR28 in people with PLS was similar to that observed in a previous study in ALS.

Conclusions:Increased glial activation in vivo is present in the motor cortices of PLS ​​and ALS patients. These results suggest that glial activation may be involved 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 coactivation of the hamstrings on the measurement of knee extensor strength in older adults with or without risk of knee osteoarthritis

Robert Wellborn; Neil Segal, MD, MS; Laura Frey-Law, MPT, Masters, Ph.D

Goals.Weakness of the knee extensors is a known risk factor for radiographically progressive osteoarthritis (OA) of the knee and is associated with increased pain and disability. Therefore, accurate measurement of knee extensor force is important for clinicians involved in the diagnosis and treatment of knee osteoarthritis. Apparent force deficits may reflect actual decreases in agonist force or increased antagonist muscle coactivation, which reduces the net measured torque. The aim of this study was to determine whether hamstring coactivation during quadriceps strength testing is greater in those with lower measured net torque.

Project:The mean level of hamstring coactivation was assessed by surface electromyography during maximal isokinetic strength testing of the knee extensors. The relationships between coactivation and quadriceps specific torque (net torque per unit muscle mass of the thigh) were assessed by linear regression, adjusted for age, sex, knee osteoarthritis (grade KL), and knee pain (WOMAC).

Results:A total of 1139 knees (431 male, 708 female) met the 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 coactivation was significantly associated with quadriceps specific torque (R²= 0.04, p When adjusting for age and sex, hamstring coactivation remained a significant predictor (p < 0.0001);

Conclusions:The coactivation of the antagonist muscle probably contributes to the reduction of the net specific force of the quadriceps. However, this relationship is attenuated when adjusting for knee pain and OA, indicating that coactivation may mediate the pathway between pain and reduced force.

Inpatient rehabilitation for the management of lymphedema before total knee replacement (TKR)

Marjorie Maye S. Mamsaang, DO; Marilyn S. Ramos-Lamboy, MD; Bridget M. von Jeetze, MS, PT

Diagnosis of the case:Inpatient rehabilitation for the management of lymphedema before total knee replacement (TKR)

Case description:A 76-year-old woman with bilateral stage II lymphedema in the lower extremities and left upper extremity secondary to endometrial cancer and left breast cancer. Her prior medical history was significant for Type 2 Diabetes Mellitus, morbid obesity, rheumatoid arthritis, and severe degenerative disease of the knee joint affecting her mobility and activities of daily living, requiring total knee replacement (TKR). Orthopedics was concerned about postoperative complications due to the extent of lymphedema and TKA was postponed until swelling had been minimized. The patient received outpatient complete decongestive therapy (CDT) in a lymphedema clinic 4 times a week for 3 weeks, each session lasting 90 minutes, including complete bilateral manual lymphatic drainage of the leg, secondary sequences, and compression bandaging. She also received home care education consisting of compression, exercise, skin care, and self-massage. All outpatient treatment options were exhausted and failed to reduce the volume of the knee. Subsequently, the patient entered the Inpatient Rehabilitation Unit, where she received a modified protocol with intense lymphedema therapy 7 days a week. This included 24-hour compression with lymphedema knee wraps and CompressoGrip thigh sleeves during the day, and custom JoViPak overnight compression with CompressoGrip sleeves for night and night. After two weeks, knee circumference measurements showed a 20% decrease in volume, allowing him to continue ATK. The patient tolerated the procedure well. On the 3rd postoperative day, she required a transfusion of 1 unit of packed red blood cells. She was followed for 3 months and no other surgical complications were reported.

discussions:Lymphedema is swelling of the extremities due to the accumulation of protein-rich fluid caused by impaired lymphatic flow, most commonly due to cancer in developed countries. The rate of complications after TKA with cases of lymphedema compared to patients without lymphedema is higher than 30%, the most frequent complication being wound infection associated with risk factors such as diabetes, rheumatoid arthritis, obesity, use of immunosuppressants and use of corticosteroids. Additional complications include thrombosis, cellulitis, and worsening edema. Preoperative management is traditionally outpatient physiotherapy, including DTC and patient education on manual techniques. In this patient's situation, outpatient attempts failed to reduce the edema. Subacute rehabilitation may not be an option for everyone, as few facilities have dedicated lymphedema therapists. In this case, the hospital rehabilitation treatments managed to reduce the limb, which allowed the patient to undergo TKA without postoperative complications associated with lymphedema. The patient's postoperative transfusion was not a lymphedema-mediated complication, as the number of red blood cell transfusions required after routine joint replacements for all patients ranges from 21% to 70%.

Conclusions:In severe cases of lymphedema that do not benefit from outpatient treatment, it is advantageous to consider inpatient rehabilitation for volume control prior to surgical intervention.

Intractable rectal pain unresponsive to escalation of opioid therapy in men with rectal adenocarcinoma responds to Impar ganglion block leading to reduced hospital stay: a case study

Chau Uong, DO; Dr. Raj Uppal

Diagnosis of the case:Man with a history of rectal adenocarcinoma with rectal and perineal pain.

Case description:A 65-year-old man with a medical history of pT4bN0 rectal adenocarcinoma after neoadjuvant chemoradiation, abdominoperineal resection, urethroplasty, and suprapubic catheterization is admitted to the hematology/oncology department with increased rectal pain for 6 months without relief with hydrocodone/acetaminophen 10 /325 two tablets every 4 hours. The pain from him is localized in the rectal and perineal region; characterized as burning and cutting; relieved to be at 0/10; and worse when he sits at 10/10. He started morphine 1 mg IV every 3 hours and subsequently a fentanyl patch that was titrated up to 50 mcg/hr. Despite these efforts, his pain remains intractable; for which he consulted the pain intervention service on the 10th day of hospitalization. Topiramate 25 mg twice a day was started and ganglion impar block was performed with a 2-inch 25-gauge needle with 1 cc of 40 mg triamcinolone acetonide and 5 cc of 0.5% bupivacaine. After that, the patient's pain decreased to 2/10 and he was discharged from the hospital 2 days later. At the 2-week follow-up, the patient continues to have excellent relief from the injection and can sit without pain.

discussions:The ganglion 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 the vagina. As such, a lymph node block rare for this patient led to significant relief from rectal and perineal pain.

Conclusions:Patients with intractable rectal and perineal pain from rectal adenocarcinoma unresponsive to opioid therapy may benefit from a ganglion of Impar block and possibly lead to a shorter hospital stay.

Starch iodine test for evaluation of hyperhidrosis in amputees

Benjamin E. Wayment, MD; Colby Hansen, MD; Bradeigh Godfrey, DO; Dr. William L. Wagner

Goals.The starch-iodine test is a method widely used in dermatology to determine focal areas of sweating in palmar, plantar, and axillary hyperhidrosis. Using this test in amputees presents unique challenges, as sweating occurs on the skin covered by a prosthesis. To date, there is no described method for using the starch-iodine test to assess focal areas of hyperhidrosis in the residual limbs of amputees. The purpose of this study was to determine a preferred method of administering the starch-iodine test in amputees in order to better guide treatment.

Project:We recruited 8 amputees with hyperhidrosis and used different methods to apply the starch-iodine test. We applied betadine and cornstarch, then covered the limb with plastic wrap before placing the prosthesis. The participants were then instructed to walk in 5- or 10-minute intervals. At the end of each interval, the prosthesis was removed and the reaction to sweat, skin irritation, discomfort, and staining of the limb lining were assessed. The tests were repeated with a prosthetic sleeve and then with a thick sock.

Results:The plastic wrap quickly produced sweat after a short break. There was no skin discomfort, but the sweating quickly became too diffuse to read. The application was messy and the plastic casing would sometimes slip, causing the liners to leak. The cover was comfortable, with noticeable sweating after 10 min of walking, without discomfort to the skin and easier to apply. It stayed in place with minimal leakage in the liners. Socks were least preferred, considered the most uncomfortable and highly absorbent, making it difficult to assess reaction to sweat. Trials with socks were discontinued after repeated complaints.

Conclusions:Of the 3 methods, the introducer is the most comfortable, easiest to apply, and does not cause discomfort or irritation to the skin, making it the preferred method for applying the starch-iodine test to stumps.

Isolated teres minor atrophy presenting as shoulder pain: a case report

Tyler D. Hedin, MD; David J. Petron, MD; Dr. Daniel M. Cushman

Diagnosis of the case:As one of the four rotator cuff muscles, the teres minor function 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, in part because it is rarely injured on its own and is probably 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 about 3% to 5.5%, although it is often considered clinically insignificant. This case describes a patient who had a chronic history of shoulder pain previously diagnosed as rotator cuff syndrome. After evaluation including MRI and electrodiagnostic studies, he was found to have isolated teres minor atrophy and denervation with no other involvement of the rotator cuff or muscle supplied by the axillary nerve.

Case description:A 39-year-old man presented to a sports medicine clinic complaining of an approximately 5-year history of relatively constant right shoulder pain that had previously been diagnosed as rotator cuff syndrome. A previous examination, including assessment and plain radiographs, was reported as normal. He initially noted shoulder pain while lifting weights, but had no recollection of a traumatic shoulder or neck injury. His pain was mainly exacerbated by lifting objects and was worse at night while he was lying on the affected side. On physical examination, there was no atrophy or deformity in his right shoulder, but he did have significant stiffness and myofascial tenderness throughout the scapular area on the right side. His strength test was noted for subtle weakness with shoulder external rotation, documented as a 4+/5. He had a positive Neer's sign, Hawkin's sign, speed test, and crossed arm sign, all of which recreated his typical pain. Sensation and reflexes normal. Initially, he was prescribed a course of anti-inflammatory medication and physical therapy, including isometric stretching, eccentric rotator cuff strengthening, and scapular stabilizer strengthening, all of which exacerbated his symptoms over the course of a month. A posterior MRI of his right shoulder was ordered due to lack of improvement, which showed severe teres minor atrophy with no other structural abnormalities. He was referred for neuroconduction and electromyography (EMG) studies, which showed a low-amplitude single motor unit action potential in the teres minor muscle during maximal effort in external rotation of the shoulder, with no 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, the patient was recommended to continue with physiotherapy focused on strengthening external rotation and strengthening the shoulder girdle. In addition, dry needling of the periscapular muscles has been added in an effort to alleviate some of the myofascial pain. He was started on a nightly dose of gabapentin to relieve shoulder pain that was interfering with his sleep. At a 4-week follow-up visit, her physical examination was largely unchanged, although gabapentin was helpful for nocturnal pain in her right shoulder and improved her sleep. It was recommended that she also take this medication during the day for pain relief. As of this writing, she continues her physical therapy regimen and takes gabapentin three times a day.

discussions:The axillary nerve originates from the posterior cord of the brachial plexus and traverses 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 supplies 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 rami of the axillary nerve. Quadrilateral space syndrome, as first described in 1983, marked the surgical observation of "fibrous bands" causing compression of the axillary nerve. However, more recent case studies have found other etiologies for nerve compression around the quadrilateral space, including space-occupying injuries, trauma, muscle hypertrophy, and overuse. Although rare, other minor injuries have been described, such as in volleyball players with repetitive overhead movements, external impaction of cysts, and bone abnormalities. Neuralgic amyotrophy has also been shown to affect the axillary nerve somewhat selectively, with relative sparing of some muscles while affecting others.

Conclusions:Given the considerable anatomic variation in the nerves that innervate the teres minor muscle, there are several points at which the axillary nerve or its posterior branch may be vulnerable to impingement or injury. Patients presenting with activity-related posterior shoulder pain and/or weakness without evidence of involvement of other rotator cuff muscles that do not improve with physical therapy should receive advanced imaging. In these cases, careful examination of the teres minor musculotendinous unit should be performed on MRI. EMG can further elucidate the acuity and extent of teres minor atrophy, although ultrasound-guided localization may be necessary.

Learning-related changes in fMRI response to fear conditioning after acute medical trauma

Edward Ference, Bachelor of Science; Nathaniel Harnett, BA; Muriah Wheelock, BA; Kimberly Wood, PhD; Martin Setliff, MD; Peyton Thetford; David Caballero, PhD; Amy Knight, PhD; Amy Knight, PhD

Goals.Little research has investigated changes in fear learning after acute trauma (ie, <1 month after the event). These changes may be important in understanding susceptibility to post-traumatic stress disorder (PTSD). The current study investigated the relationship between brain measures, behavioral measures, and PTSD symptom expression after acute medical trauma. We hypothesized that trauma exposure would be associated with self-reported elevated psychosocial risk factors and PTSD symptoms, as well as impaired Pavlovian fear conditioning.

Project:12 participants recruited from the university's acute trauma unit completed self-reported surveys on 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 6 months after trauma (p < 0.05) and psychosocial risk factors within 1 month after trauma (p < 0.01). During fear conditioning, healthy controls showed a higher expectation of threat during warning than safety cues. In contrast, people exposed to trauma showed threat expectations equivalent to warning signs and safety. Functional magnetic resonance imaging revealed increased activation of alerting and safety signals in the dorsomedial prefrontal cortex (dmPFC) in trauma-exposed subjects compared with healthy control subjects (p < 0.01). Individuals exposed to trauma exhibited learning-related activity in the left amygdala (p < 0.01), which was modulated by symptoms of anxiety and depression. Finally, greater alert activity than safety signals was observed within the hippocampus for healthy controls; the opposite occurred in individuals exposed to trauma (p < 0.01).

Conclusions:These data suggest that early psychosocial risk factors and PTSD symptom severity may predict future PTSD development. The trauma-exposed group showed increased activity in the dmPFC, which is important for emotion regulation, but expected threat after warning and safety signals. Group differences in the amygdala and hippocampus suggest that trauma may 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. Cortes, MD; Brian D. McMichael, MD; Matthew Dawson, physician

Diagnosis of the case:A 53-year-old man was diagnosed with HTLV-1-associated adult T-cell leukemia and developed methotrexate-induced leukoencephalopathy after intrathecal methotrexate treatment for leptomeningeal involvement. The rapid progression of leukoencephalopathy has limited the efficacy of rehabilitation, illustrating the importance of determining the stability of disease progression before setting rehabilitation goals in patients with methotrexate-induced leukoencephalopathy.

Case description:Ten weeks prior to admission (PTA), a 53-year-old man presented with nausea and headaches and was subsequently diagnosed with HTLV-1 adult T-cell leukemia associated with leptomeningeal involvement on MRI. Due to leptomeningeal involvement, he started intrathecal methotrexate, cytarabine and dexamethasone (4 cycles) with alemtuzumab after the first cycle. He had completed cycle 7 of alemtuzumab when he experienced near syncope and dizziness after two weeks of ATP. Nuclear magnetic resonance imaging demonstrated extensive irregular and confluent areas of T2/FLAIR hyperintensity in the periventricular and frontal parietal regions. Brain biopsy showed reactive astrogliosis. Cerebrospinal fluid analysis on two occasions was negative for malignant cells. Electrodiagnostic studies excluded acute demyelinating peripheral polyneuropathies. The patient was referred to the oncology rehabilitation service for rehabilitation of mild cognitive impairment and bilateral leg weakness due to methotrexate-induced leukoencephalopathy. After brief functional improvement over several days, the patient deteriorated markedly within a week and was again transferred to oncology.

discussions:Methotrexate-induced progressive leukoencephalopathy is a rare complication of treatment for HTLV-1-associated adult T-cell leukemia and has limited treatment options. This patient continued to deteriorate during rehabilitation, even after corticosteroid treatment. The prognosis after methotrexate leukoencephalopathy can range from acute and fulminant to chronic and will affect rehabilitation considerations.

Conclusions:Methotrexate-induced leukoencephalopathy may not be amenable to rehabilitation during the active phase, as progression may outpace rehabilitation progression. Neurological symptoms must be stabilized before rehabilitation potential can be successfully predicted and a plan successfully executed.

Brain abscess due to Listeria monocytogenes: a rare complication of dermatomyocytitis

Dr. Alex B. Behar, ATC/L; Andre Joon. Park, B.S.; Jonathan VandenBerg, DO; Dr. Chirag D. Shah, Juris Doctor

Diagnosis of the case:A 40-year-old woman with a pathological history of resistant amyopathic dermatomyositis diagnosed 1.5 years before admission by EMG. She was previously on chronic immunosuppression and now she has progressive R side weakness and headache for the last month.

Case description:The patient presented to the county hospital, where an MRI showed a left-sided enhancing annular lesion in the left frontoparietal lobe. The closed biopsy attempt failed due to intraoperative bleeding and was converted to an open biopsy. Pathological anatomy and cytology of the lesion compatible with Listeria Monocytogenes, the etiology being chronic immunosuppression due to its dermatomyocytosis. Postoperatively, the patient presented with dense right hemiplegia, severe expressive aphasia, and dysphagia caused by Candida esophagitis, which led to G-tube placement.

discussions:Patients with dermatomyositis, a connective tissue disorder, are at increased risk and incidence of infection, usually due to the disease itself or as a consequence of treatment side effects. In this patient, due to her history of chronic immunosuppression due to dermatomyocytosis, she developed a large brain abscess that caused right hemiparesis and expressive aphasia. As one of the main complications of connective tissue disorders, patients should always be monitored for unusual infections due to their immunocompromised state. Although rare, listeriosis occurs in 5.4 cases per 1,000,000 people, with 1% of all brain abscesses associated with Listeria Monocytogenes. Listeria should be part of the differential working diagnosis of hemiparesis with annular lesion in patients with dermatomyocytosis.

Conclusions:In conclusion, due to the size, location, and comorbid complications of listeria brain abscess, patient rehabilitation will be very demanding for any patient while combating the debilitating disease of dermatomyocytosis, the symptoms of which include severe erythema of the skin, proximal muscle weakness and pain.

Low back pain secondary to Baastrup disease in a patient with inflammatory myopathy: case report

Abir Naguib, MD; Yumei Wang, MD; Athar Saad, M.D

Diagnosis of the case:A 48-year-old woman 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, years before, proximal muscle weakness and fatigue manifested in difficulty getting up from a chair, climbing stairs, and combing her hair. CPK levels were elevated, and electromyographic examination revealed diffuse myopathic units and denervation potentials in all extremities, lumbar paraspinal, and thoracic, consistent with inflammatory myopathy. Muscle biopsy confirmed the diagnosis. She started on steroids and immunosuppressants. During the course, she began to complain of severe low back pain of unknown etiology. The pain worsened with extension of the lumbar spine, and she did not respond to conservative measures. She did not radiate to the legs and she denied sensitive symptoms. She had weak abdominal and back muscles and she was referred to rehab for physical therapy with an emphasis on core strengthening. Her pain did not improve, but it worsened with exercise and was associated with an increase in CPK levels. Images of the spine revealed normal disc spaces, but showed diffuse narrowing of the lumbar interspinous spaces with "kissing shins," a condition known as Baastrup disease.

discussions:Baastrup disease is a condition of unknown etiology, characterized by close approximation of the adjacent spinous processes, usually occurring at L4-5. Symptoms include low back pain with a midline distribution that is worse on extension and relieved on flexion. It usually presents after the age of 70, secondary to degenerative changes in the spine and, therefore, it is not frequent to present at younger ages without degenerative changes in the spine. Paraspinal muscle involvement in inflammatory myopathy with resultant weakness may predispose to increased lumbar lordosis, which may eventually lead to approximation of the spinous processes characteristic of Baastrup disease.

Conclusions:It is important to assess and maintain core muscle strength in patients with low back pain. Management can be especially challenging in patients with progressive muscle weakness. Low back pain in Baastrup disease may be resistant to conservative treatment and not compatible with interventional treatment, such as epidural injections, and may require surgical excision of the spinous processes. So far, there are no 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 a single SI joint injection

Kelsey S. Neufeld

Diagnosis of the case:A 50-year-old patient with proximal lower extremity muscle weakness, decreased ROM, and gait/flexibility abnormalities secondary to sacroiliac joint dysfunction after a fall 6 months earlier.

Case description:The patient presented to the PM&R clinic with difficulty moving from a squat to a standing position without using the UE as a secondary force. He had a fall 6 months prior to his R side with no evidence of acute pathology on the initial single film image completed at the time of the fall. She continued to have right lumbar/hip pain with progression to proximal R lower extremity weakness, difficulty climbing stairs, and inability to sit for more than 10 minutes. In addition, her transfers from sitting to standing were difficult and she had an altered gait. After the initial exam, she completed a 4-month physical therapy regimen for back pain with mild relief before the exam at the PM & R clinic, but her weakness persisted. She denied bladder or bowel incontinence, LOB, or paresthesias. On physical exam her SLR was negative, proximal muscle strength 4/5 bilateral hip flexors, FABRE+ in R and R SI joint pain, her Gaenslen test was b/l negative. Due to her continued weakness and pain pattern of low back/R buttock pain radiating to the R buttock: A lumbar MRI was obtained and there was no evidence of herniated disc, spinal stenosis, or foraminal involvement. His weakness and pain patterns continued and he underwent an EMG study of the RLE which demonstrated normal motor and sensory NCV of the RLE and needle studies with normal recruitment and MUAP patterns, the study did not demonstrate evidence of radiculopathy, plexopathy or neuropathy to explain it. . LE weakness. Given her normal MRI and EMG and ongoing pain and weakness in the R SI joints, she decided to try a diagnostic injection into the SI joint as a therapeutic measure to improve the pain. She was given an injection in the R SI joint (40 mg kenalog with 2 ml lidocaine 1% and 2 ml bupivcaine 0.25%) under fluoroscopy with no complications and well tolerated procedure. She was instructed to continue her physiotherapy course and follow up in 4 to 6 weeks. At therapy/follow-up, she reported significant relief of pain symptoms and reported feeling stronger in her lower extremity. His transferability improved and he was able to transition from kneeling to standing without symptoms or needing UE support (while leading with LE). She also had improved tolerance for standing and sitting time, as well as car transfers, stair climbing, and ambulation.

discussions:Four weeks after injection into the right sacroiliac joint, the patient was able to improve functional ability with respect to ambulation, transfers, and pain control. He had increased muscle strength in the 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 a single SI joint injection under fluoroscopy.

Conclusions:SI joint dysfunction may be associated with proximal lower extremity weakness contributing to functional limitations, but it may also be reversible with injection of the SI joint under fluoroscopy.

Maggot Debridement Therapy (MDT): A Case Study Using MDT in a Non-Healing Traumatic Upper Extremity Amputation

Lawerence Kelleher, DO; Jennifer Hankenson, BA

Diagnosis of the case:Traumatic upper extremity amputation resulting in a chronic non-healing wound

Case description:A 22-year-old man was admitted for comprehensive rehabilitation after multiple trauma and resulting traumatic right transhumeral amputation. On admission, the patient presented with a chronic post-traumatic wound and was initially treated with hyperbaric oxygen therapy, MIST treatment and followed up by the wound care team. He showed little improvement and subsequently underwent larval debridement therapy (MDT). The wound was cleansed with Dakin's solution, rinsed thoroughly with normal saline, dried and sterile larvae applied. A “cage” was made to prevent the larvae from escaping and a bandage was placed on the wound. Bandages were changed daily or as needed to prevent moisture from drowning the worms. After 3 days, the larvae were removed and the wound was treated with ultrasound MIST therapy for 6 minutes, followed by dressing with Santyl and Dakin solution. The wound dimensions were reduced from 11 x 5.5 x 5.5 to 10 x 3 x 3.5 cm. He then underwent successful wound closure, fully healed, received a prosthesis, and is now undergoing OT.

discussions:Chronic wounds are defined as those that do not follow an orderly form of healing and subsequently fail to close. In the amputee population, chronic wounds are a barrier to progress towards the use of prostheses. MDT is known to be effective in the treatment of diabetic and pressure related wounds, while also showing benefits in wound detachment. It provides a more precise debridement, less laborious and slow than traditional methods because only necrotic tissue is ingested. MDT has three main benefits: debridement, disinfection, and advanced healing.

Conclusions:We believe this is the first case of MDT promoting wound healing in a traumatic UE amputation. Future studies should be conducted to observe the benefit of multiple applications of MDT in improving wound healing in the amputee population.

Marsupialization of the cranial flap as an infrequent cause of meralgia paresthetica: a case report

Just N. Walker, MD; Dr. A.S. Kirk Lercher

Diagnosis of the case:Meralgia Parestésica

Case description:A 66-year-old woman with a history of right middle cerebral artery infarction with hemorrhagic conversion status after right decompressive hemicraniectomy and marsupialization of the cranial bone flap in the right lower quadrant of the abdomen, who was admitted to an acute rehabilitation unit two months after surgery. beginning. infarction due to a mechanical fall resulting in a posterior right temporal intracranial hemorrhage posterior to the existing hemicraniectomy site. During her acute rehabilitation stay, she reported burning pain that began at the marsupialization site and radiated to the anterolateral thigh. Physical examination revealed that the marsupialized skull had migrated to the right groin. Hip radiography ruled out heterotopic ossification, acute fracture, periosteal reaction, or bone destruction, but showed mild bilateral hip osteoarthritis. She was clinically diagnosed with meralgia paresthetica. An ultrasound-guided lateral femoral cutaneous nerve block was attempted. However, the nerve could not be visualized on ultrasonography because 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 for neurosurgery for cranial bone flap removal and cranioplasty three months after the hemicraniectomy date.

discussions:Meralgia paresthetica is neuropathic pain described as burning, tingling, and/or numbness in the anterolateral thigh due to compression of the lateral femoral cutaneous nerve. It is usually 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 cranial 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. Furthermore, it underlines the importance of monitoring the sites of recent surgical interventions which are seen in a large proportion of patients admitted to acute rehabilitation centers.

Mass mortality risk is not a barrier to acute rehabilitation

Atira H. Kaplan, MD; Francis Lopez, MD, MPH

Diagnosis of the case:Pelvic crush injury

Case description:A 57-year-old man struck by a truck sustained multiple injuries, including an open fracture of the pelvic ring, a tear injury from the lower left pubic bone to the left knee, and a urethral injury. The patient underwent pelvic external fixation, placement of a suprapubic catheter, debridement of necrotic tissue in the left lower extremity, placement of a split-thickness graft, formation of a loop colostomy, and removal of the pelvic external fixator. The patient's hospital course was complicated by sepsis, acute renal failure, respiratory failure requiring tracheostomy, necrotizing fasciitis of the left foot, adrenal insufficiency, and pericardial tamponade. After nearly four months in the ICU, he was transferred to acute inpatient rehab, where he required the assistance of two people to move in bed, maximal assistance to hold the short sitting static position, and maximal assistance for pivot transfer from sitting to sitting Getting up from bed to bed. chair. Upon discharge from acute rehab nearly six months after the initial trauma, he was able to transition from supine to sitting with a brace in waiting position, sit and stand using a walker with supervision, walk 175 feet using a walker with a protector in waiting position and portable oxygen.

discussions:Pelvic crush injury is often associated with multiple medical complications and a high mortality rate. Despite the patient's tenuous medical stability, she completed an extensive course of acute rehabilitation and achieved 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 prevent providers from offering the full range of rehabilitation services, as the outcome may exceed expectations.

Maximizing independence in a 40-year-old woman with multi-minicore disease in hospital acute rehabilitation: a case report

dr. Rishi Shah; Padma Srigiriraj, MD

Diagnosis of the case:Multi-Minicore disease was diagnosed through a muscle biopsy.

Case description:A 40-year-old woman with a significant medical history of Marfan syndrome, multi-minicore disease, scoliosis, mitral valve repair, and chronic obstructive pulmonary disease who presented to hospital intensive care with left leg swelling and pain for two days . Evaluation revealed DVT and the patient received anticoagulation. The patient was noted to have significant weakness and was subsequently transferred to acute inpatient rehabilitation for functional improvement. On patient admission, the 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 submaximal exercise. To ensure submaximal exercise, creatine phosphokinase (CPK) was closely monitored and analyzed. The patient was noted to have unsteady gait along with an inability to independently laterally rotate the neck.

discussions:Multi-minicore disease is a rare autosomal recessive congenital myopathy. Patients are diagnosed with a muscle biopsy showing multiple nuclei. Genetic testing will reveal a mutation in the selenopretein N gene (SEPN1) and the ryanodine receptor gene (RYR1). These patients suffer from early scoliosis, distal weakness, muscle atrophy, and respiratory compromise.

Conclusions:There is no standard treatment for rehabilitation in patients with multi-minicore disease. We suggest that these patients undergo acute rehabilitation after hospitalization. In addition, we recommend that a comprehensive rehabilitation program be initiated with therapies administered at a submaximal level and close monitoring of CPK levels and trends. We can see significant gains when this patient was discharged with a high FIM of 75 motor and 34 cognition for a total of 102 and a FIM of 23.

May-Thurner syndrome: a rare cause of a common problem

Thomas Lione, do; Silvia Juan, M.D.

Diagnosis of the case:May-Thurner syndrome (MTS) is a rare cause of deep vein thrombosis (DVT) due to an anatomic variant in which the right common iliac artery compresses the left common iliac vein against the lumbar spine, resulting in DVT of the left lower limb. This anatomical variant has been shown to exist in up to 20% of the population, but is generally not 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 woman with MS, hypothyroidism, and Graves' disease admitted to an acute rehabilitation clinic after an exacerbation of MS developed acute edema of the left lower extremity five days after admission. Venous Doppler ultrasonography revealed DVT in the common femoral, popliteal, and left saphenous veins. Noncontrast abdominal MRI 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 was consulted and anticoagulation was started with subsequent endovascular intervention after discharge from the rehabilitation unit.

discussions:MTS is a progressive disease with the potential to cause long-term disability and fatal sequelae. Diagnostic accuracy is important to guide appropriate treatment, including anticoagulation, endovascular intervention, or surgical thrombectomy. Chronic cerebrospinal venous insufficiency (CCSVI) is also known to be related to the pathogenesis of MS and clinicians performing CCSVI venography in patients with MS have suggested that there is a higher incidence of TMS in this population, although there is evidence of a connection. limited.

Conclusions:Although this variant is rare and diagnosis can be challenging with early detection and treatment, TMS can be a well-controlled disease and should be considered a rare etiology of DVT, especially in patients with elevated risk factors, such as MS. .

Middle finger entrapment neuropathy caused by tophaceous gout of the first metatarsophalangeal joint

Ayesha Khan, MD; Phuong U. Le, DO; Se Won Lee, MD; Dr. Dennis Kim

Diagnosis of the case:Neuropathy of the middle toe caused by tophaceous gout

Case description:We present the case of a 36-year-old man with a 10-year history of gout who consulted due to worsening pain in the first right metatarsophalangeal joint.

The pain was localized to the medial aspect of the right first metatarsophalangeal joint. It worsened with prolonged standing and improved with rest, ibuprofen, and topical analgesics. The patient took allopurinol, colchicine, and has also received several steroid injections for foot pain in the past. The pain was burning in nature and radiated to the medial foot and ankle and also distally to the ball of the big toe. On physical examination, there was minimal effusion of the first metatarsophalangeal joint. Ultrasound examination of the joint showed a characteristic double-contour sign representing accumulated urate crystals in the hypoechoic hyaline cartilage with a "snowstorm" appearance with joint effusion. The patient's symptoms (burning pain with radiation) were reproduced (Valleix's sign) on sonopalpation of the medial alucal nerve on the medial side of the right first metatarsophalangeal joint.

The patient was advised to wear roomier shoes, with a donut-shaped pad for the trapped right medial tearing nerve over the tophaceous joint.

discussions:Entrapment and compression neuropathies of the upper extremity caused by tophaceous gout are widely reported, however, entrapment neuropathy of the foot is poorly recognized. Hallux neuropathy is a well-known complication of hallux valgus surgery (bunion surgery). Taking into account the proximity of the middle finger nerve to tophaceous gout, compressive neuropathy due to tophaceous gout can be included in the differential diagnosis of tophaceous neuralgia.

Conclusions:This case illustrates the usefulness of a complete history, physical examination with spot ultrasound in the assessment of midforefoot pain. Chronic tophaceous gout should include entrapment neuropathy of the middle finger as a possible cause of forefoot pain.

Metabolic expenditure during exoskeleton-assisted walking in a person with multiple sclerosis

Taimur Afzal, PhD; Marcie Kern, PT, MS; Shih-Chiao Tseng, PT, PhD; Dr. A.S. John Lincoln, Doctor of Medicine; Shuo-Hsiu Chang, physiotherapist, Ph.D

Goals.Wearable exoskeletons are designed and can be used to facilitate walking in people with neurological problems, such as spinal cord injuries. However, the amount of assistance provided during exoskeleton-assisted gait is unclear. Therefore, the aim of this study was to investigate the feasibility and efficacy of using an exoskeleton for walking in people with multiple sclerosis (MS).

Project:A subject with an Expanded Disability Status Scale (EDSS) score of 6.0 received 12 sessions of exoskeleton-assisted walking training using a wearable exoskeleton (EKSO®, Ekso Bionics, Richmond, CA). Outcome measurements were made at the end of training. Metabolic expenditures were measured during the up-and-go test (TUG), the 25-foot walk test (25FTWT, self-selected fast speed), and the 6-minute walk (6MWT) and compared between exoskeleton-assisted walking and not assisted. Muscle activation profiles were also recorded and analyzed using surface electromyography (sEMG) in key upper and lower extremity muscles.

Results:Preliminary data showed that maximal oxygen uptake (VO₂max) and heart rate (HR) during the 6MWT (approximately 7.5% and 6%, respectively) were lower in exoskeleton gait than in unassisted gait. During 25FTWT at high speed, VO₂max and HR were higher (approximately 3% and 10%, respectively) in exoskeleton-assisted gait than in unassisted gait. For sEMG, all lower extremity muscles except the semitendinosus showed less activity during 25FTWT at self-selected speed and 6MWT in exoskeleton-assisted gait than in unassisted gait. Similar to the pattern observed in metabolic cost, muscle activities were greater during 25FTWT at high speed in exoskeleton-assisted gait than in unassisted gait.

Conclusions:Walking with an exoskeleton may allow MS patients to walk more efficiently, reducing metabolic output and muscle activity, especially when walking long distances. The wearable exoskeleton can provide enough assistance to perform activities of daily living, leading to a better quality of life.

Metastatic Horner and brachial plexopathy: a case report

Julie Larson, MD; Wilson Chang, MD, MPH; Dr. Reza Taher; Dr. Michael Larson; S.Kamal Fetouh, MD

Diagnosis of the case:Metastatic Horner and brachial plexopathy due to metastatic breast cancer in a patient with a history of breast cancer.

Case description:A 41-year-old woman with significant HMP for breast cancer with known spinal and lung lesions with persistent left shoulder and neck pain and associated numbness of the left arm. The patient failed multiple pain therapies, including shoulder joint steroid injections, physical therapy, topical ointments, and chiropractic therapy before being referred to the oncology rehab clinic.

discussions:The patient's history and physical examination were consistent with C8-T1 radiculopathy. She was scheduled for an epidural steroid injection. However, prior to the injection, she returned to the clinic with worsening symptoms and noted that she had right-sided ptosis and miosis. She confirmed anhidrosis on the right side. Chest computed tomography, brachial plexus MRI, brain MRI, and cervical spine MRI were requested. The official radiology report was initially negative for acute pathology or a new mass within the brachial plexus, brain, or chest. The patient continued to present C8-T1 paresthesias and myalgia with progressive worsening, similar to a C8-T1 radiculopathy. Imaging exams with the radiologist. In a retrospective review, nodular enhancement was noted at the vertex edge of the right lung with clearer enhancement outside the C8, T1, and T2 neural foramina. Official radiology reports have been added to flag previous findings with concern for new metastatic disease. The patient was diagnosed with Horner's Syndrome secondary to a metastatic mass in the right brachial plexus.

Conclusions:In patients with a known history of malignancy, metastatic lesions presenting with new pain, weakness, and/or altered sensation should always be considered. To our knowledge, this is the first documented case of a single metastatic lesion causing brachial plexopathy and Horner's syndrome. This case reiterates the importance of a physical examination. If the patient had presented to a pain clinic that relied on the imaging results without emphasizing the physical examination, her other symptoms might have been missed and the cancer might have progressed.

Middle back pain as an initial symptom of Klippel-Feil syndrome in an adult woman: case report

Matthew G. Hadilaksono, DO; Borna Kavousi, MSc, MD; Sanjeev Agarwal, MD

Diagnosis of the case:Klippel-Feil syndrome in a 37-year-old woman

Case description:This case presents a 37-year-old obese woman who was seen in the clinic for persistent mid-back pain for months. Initial x-rays of her showed mid-thoracic spondylosis. The patient eventually developed neck discomfort along with radicular symptoms, at which point further imaging was obtained. MRI of her cervical spine revealed C3-C4 and C5-C6 vertebral bodies and posterior element fusion, as well as multilevel degeneration and foraminal/spinal canal stenosis with spinal cord signal abnormalities. This anomaly is compatible with the diagnosis of Klippel-Feil Syndrome. Subsequently, the patient was treated conservatively with physiotherapy and pain control; in addition, the patient was instructed on cervical spine precautions.

discussions:Klippel-Feil syndrome (KFS) is a rare congenital condition characterized by the fusion of two or more cervical vertebrae due to interruption of proper fetal bone development, which has been associated with mutations in the GDF6, GDF3, and MEOX1 genes. The incidence of KFS is approximately 1 in 42,000 births with a female predilection. Although deformities are present from birth, KFS patients can present with various symptoms at different ages. This case highlights an atypical early symptom of KFS that deviates from the usual cervical spine complaints. The initial presenting symptom in this case was pain in the thoracic spine, probably as a result of impaired vertebral motion mechanics below the level of congenital fusion. Other deficiencies in KFS that can coexist with cervical spine fusion include hearing loss, torticollis, genitourinary, and cardiovascular abnormalities.

Conclusions:Patients with Klippel-Feil syndrome often have neck pain due to congenital cervical spinal fusion. Although the anatomic abnormality exists from birth, clinical symptoms may not present or be discovered until later in life. Knowledge of the presence of other clinical symptoms associated with KFS can help with early diagnosis and treatment.

MNGIE syndrome: Implications of acute inpatient rehabilitation for a rare neuromuscular disorder

Anish A. Mirchandani, DO; Jesuel Padro-Guzman, MD; Dr. Katherine Yao

Diagnosis of the case:A 58-year-old woman with mitochondrial neurogastrointestinal encephalopathy syndrome (MNGIE) is admitted for acute rehabilitation after stem cell transplantation.

Case description:A 58-year-old woman with mitochondrial neurogastrointestinal encephalopathy syndrome (MNGIE) 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 earlier with genetic testing and muscle biopsy. Her symptoms, which progressively worsened, included: abdominal pain, diarrhea, weight loss, hearing loss, ptosis, ophthalmoplegia, and painful peripheral neuropathy associated with loss of sensation in the hands and feet, as well as bilateral foot drop requiring ankle braces. walking. foot foot orthosis 🇧🇷 Prior to admission, she was ambulating at home with her orthosis and using a walker for community ambulation. She entered the inpatient rehabilitation unit (IRU) 23 days after SCT. Her hospital course was complicated by intestinal obstruction, cardiac arrest, sepsis, graft-versus-host-disease (GVHD), recurrent C. difficile infection, anemia, and malnutrition requiring prolonged total parenteral nutrition. Her impairments at the time of admission to the IRU included balance impairments, distal lower extremity weakness, sensory impairments, decreased stamina, and coordination problems. After her initial evaluation, the patient required substantial assistance with most of her activities of daily living. After a total of 15 days of therapy, the patient was discharged from the URI with home therapy services. At the time of discharge from the URI, the patient had 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 features, including: gastrointestinal dysmotility, cachexia, episodic abdominal pain, diarrhea, ptosis, ophthalmoplegia, hearing loss, peripheral demyelinating neuropathy, and muscle weakness. To our knowledge, this is the first reported case of a patient with MNGIE syndrome who was treated in acute rehabilitation. This case highlights the clinical and functional challenges faced by 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 functional recovery in these rare cases of MNGIE syndrome.

Conclusions:This case illustrates the clinical challenges and functional decline in patients with the rare diagnosis of MNGIE syndrome and the importance of an in-hospital rehabilitation program for favorable outcomes.

Cognitive motor risk syndrome in Korean elderly: the KLoSHA cohort study

Goo Joo Lee, MD; Hyun-Kyung Do; Jea-Young Lim, MD, PhD

Goals.The association between cognitive function and physical performance has been reported several times. Recently, a study documented that the prevalence of dementia in older adults with normal cognitive function and low physical performance is higher than in older adults with normal cognitive and physical function. The objective of this study is to determine if low physical performance affects the deterioration of cognitive function in older adults.

Project:One participant of 1,118 elderly Koreans was randomly selected from among local residents aged 65 and over residing in Seongnam, Korea. Self-report surveys, face-to-face interviews, and physical and psychological assessments were conducted on 714 volunteers. Cognitive function was assessed using the Korean version of the Consortium to Establish a Registry for Alzheimer's Disease Assessment Package (CERAD-K) and the Korean version of the Hasegawa Dementia Scale (HDS-K). Physical functions were assessed using the SF-36, the Specific Activity Balance (ABC) Confidence Scale, Tinetti's Performance Oriented Mobility Assessment (POMA), Inbody, isokinetic knee muscle strength, and the measurement of body composition. Follow-up surveys were conducted using the same methodology after 5 years. In the first wave, the exclusion criteria were patients with dementia or mild cognitive impairment according to the DSM-IV diagnostic criteria and older than 75 years. In the second wave, people who had a stroke, Parkinson's syndrome, death, or loss to follow-up were excluded. Finally, data from 203 participants, 104 men and 99 women, were used for linear regression analysis.

Results:The incidence of motor cognitive risk syndrome (MCI) was 5.9% in this study. High second-wave MMSE-KC scores were observed in women with high knee extensor strength and low first-wave BMI, regardless of primary MMSE-KC score and years of education. However, there were no statistically significant variables to predict MMSE-KC score decline in men.

Conclusions:Cognitive motor risk syndrome was verified in a cohort of elderly Koreans. Physical performance and body composition affect cognitive function in older women.

Non-invasive MRI allows visualization of immediate changes in tissue composition after manual lymphatic drainage therapy

Paula Donahue, PT, DPT, MBA; Rachelle Crescenzi, PhD; Allison Scott, BA; Shelia Ridner, PhD, BSN; Dr. Manus J. Donahue

Goals.Breast cancer treatment-related lymphedema (BCRL) is a lifelong condition that results from lymphatic dysfunction following anticancer therapies. Manual lymphatic drainage (MLD) is a component of comprehensive decongestant therapy used to control lymphedema; however, studies using limb volumetry to assess the benefit of MLD are inconclusive, leading to more variable clinical use despite subjective benefits reported by patients and therapists. Our goal was to apply more sensitive internal MRI measurements of tissue composition to quantify hypothesized deep tissue changes before and after MLD.

Project:Controls (n=19; age=22-74 years) and patients with unilateral BCRL (stage 0-2; n=12; age=33-77 years) were scanned using a non-invasive multi-echo magnetic resonance imaging protocol. . non-MRI measurements of limb volume, bioimpedance, and dielectric constant. Patients received repeat MRI after 50 min of MLD and a subset of controls (n = 5) were scanned twice to assess reproducibility.T₂relaxation time, a known surrogate marker of tissue composition, was quantified in the upper arm and axilla. Pearson Correlation Test,t-stats and two-tailed matchmakingpag-values ​​and linear regression analyzes were performed.

Results:Measurements without MRI were strongly correlated before and after MLD (R=0,87-0,99;p<0.001). tissue waterT₂was less correlated (R=0,56;pag=0.06) and elevated in patients vs. check S (pag=0.044), compatible with increased edema.T₂post-MLD unaffected arm enlargement (p < 0.001) consistent with fluid being redirected to the healthy axilla during MLD; affected arm T₂changed more variably and depended on the location and stage of the BCRL, withT₂increasing range of controls for patients with BCRL Stage 0 and Stages 1–2.

Conclusions:Internal MRI measurements of deep tissue composition provided evidence of structural tissue changes after MLD in BCRL undetectable using conventional measurements of limb volume, bioimpedance, and dielectric constant. The results provide a foundation for more sensitive internal mechanistic investigations of MLD and its use in condition management.

Remarkable Electrodiagnostic Findings of the Peripheral Nervous System in the Context of Multiple Sclerosis

Larry B. Guinto; Brian Anderson; Adrian Christian, MD

Diagnosis of the case:Peripheral lesions in multiple sclerosis

Case description:A 58-year-old right-handed man with a history of multiple sclerosis presented to our office complaining of pain, weakness, and tingling in the right upper extremity. He denied recent trauma, speech or swallowing problems, infections, or symptoms in the contralateral extremity. A recent MRI of the spine showed a central disc bulge causing a left-sided C4-C7 cord deformity, and an MRI of the brain showed extensive cerebral white matter pathology consistent with MS. On examination, he felt pain in the range of the right shoulder. Fromnet's sign was positive with marked thenar and hypothenar atrophy of the right hand. An electrodiagnostic study was performed to determine the cause or origin of the pain. After extensive electrophysiological evaluation, conventional peripheral nervous system lesions were not easily identifiable.

discussions:Multiple Sclerosis is characterized as a demyelinating disease of the central nervous system. However, in rare cases, electrodiagnostic findings suggest that peripheral nerve pathology may occur. There are several documented cases describing such findings in patients with a history of multiple sclerosis. EMG results obtained from this patient were inconsistent with right-sided radial, median, or ulnar neuropathy, brachial plexopathy, cervical radiculopathy, motor neuron disease, myopathy, or peripheral neuropathy. Such findings may be caused by, among others: altered supernormality, manifestations of postinfectious inflammatory polyneuropathy, 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 myelin in the peripheral nerves of MS patients can be affected and should be watched.

Conclusions:Although EMG is commonly performed to rule out other causes of neuropathy, the possibility of peripheral nerve findings is worth considering when evaluating patients with a history of MS.

Nutritional status of dysphagic patients who died in hospital

Mitsumasa Yoda, MD, PhD; Kyoko Sato; Nobuyuki Kawate, MD, PhD

Goals.Our hospital is an intensive care unit with 1,014 beds. Dysphagia rehabilitation is discussed in rounds conducted by a multidisciplinary team that includes a physiatrist, dentist, dental hygienist, nurse, and nutritionist. This multidisciplinary team usually cares for more than 40 dysphagic patients. Despite these efforts, some of the patients die in the hospital. This study aimed to determine the predictors of death in dysphagic patients.

Project:A total of 337 patients with dysphagia hospitalized 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 the hospital were analyzed.

Results:A total of 45 patients died in the hospital. The underlying diseases varied; the most frequent were inflammatory respiratory diseases (n = 15). Twenty-two patients died due to progression of an underlying disease, such as malignancy. More than half of the patients died due to the deterioration of their general conditions in relation to complications such as pneumonia. Mean baseline serum albumin levels for those who died (2.3 ± 0.5 g/dl) were significantly lower (p < 0.01) than for the 70 patients who achieved sufficient oral intake after initiation of the intervention (2.8 ± 0.6 g/dl) . After the intervention, the mean serum albumin levels of those who died decreased to 2.0±0.4 g/dl, while the mean serum albumin levels of those who achieved oral intake increased to 3.2± 0.6g/dl.

Conclusions:The results of the present study showed that the majority of deaths were attributed to deteriorating general condition, including nutritional status, and not to fatal diseases such as malignant neoplasms and severe cerebrovascular accidents. Dysphagic patients who died were malnourished even after the intervention, suggesting the importance of nutritional intervention.

Oncological etiology of hip pain without a history of AC

Eduardo Chen, MD; Dr. Kevin Trinh; Emily N. Gray, MD; Dr. Craig H. Rosenberg

Diagnosis of the case:After osteoporosis, metastatic disease is the most common cause of pathologic fractures. 60% of patients with an identifiable primary tumor may already have metastases. 61% of all pathologic fractures occur in the femur. Our patient presents an isolated worsening of pain in the left hip in the last 5 months, not related to a triggering event. A complete history and physical examination was performed to investigate the inconsistent pain that led to the diagnosis of pathologic metastatic fracture of the femur.

Case description:67-year-old Caucasian female initially referred for evaluation for pain management secondary to persistent left hip pain that has progressively worsened over the past 5 months. The symptoms began in early 2015 with no clear triggering event. Hip pain was refractory to conservative measures, including acupuncture, steroid tapering, muscle relaxants, and oral analgesics. Initial radiography of the hips showed mild bilateral degenerative changes of the hip. Pain was described as pain, 7/10 on the VAS, localized to the gluteal/inguinal/proximal anterior region of the left thigh. She reported that she was unable to bear weight on her left lower extremity. She described the pain as worsening with activity and better with rest. She denied associated bowel or bladder incontinence.

On physical examination, he presented pain with RPM in the left hip; Passive MRI of the right hip was limited and caused significant concomitant pain in the left gluteal region. The left HF of strength 3-/5 was limited by pain. Special tests included SLR, Fabers, Gaenslens, and Yoemans, all negative. Gait and posture were painless and he walked with a RW. Subsequently, the patient was scheduled for an intra-articular injection of the left hip. She was sent for an MRI of her left hip prior to the injection to assess for a possible labral tear. MRI results showed a pathological subcapital fracture of the left femoral neck and a tumor.

The central biopsy revealed an adenocarcinoma compatible with primary lung cancer. CT C/A/P revealed an irregular mass in the right upper lobe, highly suspicious for primary pulmonary malignancy, mediastinal and right hilar adenopathies. Subsequently, the patient underwent a proximal arthroplasty of the left femur and she was discharged to acute hospital rehabilitation, where she tolerated the therapy well. She was subsequently discharged to her home.

discussions:The diagnosis of hip pain can be challenging, since its presentation can be due to multiple etiologies. A study by Decroisette reports that lung cancers can often metastasize to bone. As for our patient, despite having no history of primary malignancy, the investigation revealed an oncological etiology for her hip pain. Hip fracture not detected on radiography is estimated at 3-4% and up to 9% in some cases. Intra-articular hip injection in a missing hip fracture has rarely been reported in the literature. To the best of our knowledge, one case was reported in 2015 after a stress fracture of the femoral neck. Due to the inhibition of bone healing, corticosteroid injections are contraindicated in the presence of joint fractures. As in our case, this was avoided with an adequate study. Not all cases of hip pain are related to arthritis, other differential diagnoses should be considered in patients with minimal radiographic OA.

Conclusions:The etiology of hip pain can come from many different sources, making a full H&P/EF imperative. We hope this case highlights the importance of proper history taking and examination to avoid misdiagnosis, delays in AC treatment, and unnecessary/contraindicated procedures (intra-articular injection).

Oropharyngeal muscular dystrophy in a 32-year-old woman: case report

Michael A. Bush-Arnold, MD; Dale Strasser, MD

Diagnosis of the case:Oropharyngeal muscular dystrophy in a 32-year-old woman: case report

Case description:A 32-year-old woman with no medical history and a significant family history in her father and great-grandfather of oropharyngeal muscular dystrophy presented to the outpatient clinic with muscle pain, fatigue, and occasional dysphagia. Muscle pain was associated with activity and was localized to bilateral thighs and calves. The physical examination was pertinent due to weakness in the orbicularis oculi muscle and bilateral proximal lower extremities of strength 4+/5. The patient was referred for genetic testing and tested positive for the 13GCN repeat allele in the PABPN1 gene. The patient's symptoms have progressed over the past three years to worsening ptosis, increased bilateral upper limb weakness from 4+ to 5-/5, bilateral lower limb weakness from 4 to 4+/5, and worsening dysphagia. She currently walks with a cautious step and uses a Lofstrand crutch on the right side of her.

discussions:Oculopharyngeal muscular dystrophy is caused by mutations in the PABPN1 gene and is characterized by muscle weakness that usually begins after the age of 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 to walk. 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 people with a strong family history and perform early testing to detect the disease.

Osteoporosis and compression fractures in a patient with ulcerative colitis and ankylosing spondylitis: a case report

Joshua Minori, DO; Edward Park MD

Diagnosis of the case:Patients with ulcerative colitis (UC) and ankylosing spondylitis (AS) develop complications of osteoporosis.

Case description:The patient was a 58-year-old man who presented to the clinic complaining of pain throughout the spine that began at age 20. He had a history of diabetes, high blood pressure, ulcerative colitis (UC), ankylosing spondylitis (AS), osteoporosis, and polyarticular joint pain. Chart review revealed chest compression fractures at 48 years, dual-energy X-ray absorptiometry (DXA) T-score −3.12 and Z-score −2.7 at 50 years, and bilateral sacroiliitis on imaging at 48 years. 53 years. Initial investigation showed DXA T-score −2.5 and Z-score −1.9, human leukocyte antigen B27 (HLA-B27) negative, and estimated sedimentation rate of 60. He was referred to Rheumatology and Endocrinology for treatment of spondyloarthropathies and chronic osteoporosis symptomatic.

discussions:AS is common 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 42% in IBD and 62% in AD. In AS, anteroposterior DXA is limited in monitoring osteoporosis due to syndesmophyte formation and often shows pseudoimprovement in T and Z scores. AS is diagnosed by a history of inflammatory back pain with imaging showing signs of sacroiliitis. Early diagnosis is difficult due to the slow onset of bone 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 the early stages of the disease, defined as <10 years from onset, to avoid late diagnosis and treatment.

Conclusions:Physiatrists who frequently care for patients with chronic back pain should be aware of the correlation between UC and AS and the risk of osteoporosis so that debilitating and life-altering complications can be avoided.

Outcomes of patients with benign versus malignant cancer in an acute care rehabilitation unit

Ashish Khanna, MD; Giuseppe Amore, MPH, CPH; Wali Jahangiri, Bachelor of Science; Yulia Revelis, BA; Adrian Christian, MD; Dr. A.S. Marc K. Ross

Goals.To compare the outcomes of patients with benign and malignant cancer in an Inpatient Rehabilitation Unit (IRF)

Project:Five-year retrospective review of the medical records of 144 patients admitted to rehabilitation with a diagnosis of cancer, of whom 42 were benign and 102 malignant.

Results:The types of benign neoplasms consisted of 91% CNS, 7% bone/soft tissue, and 2% hematologic. The types of malignancies consisted of 43% CNS, 17% GI, 15% bone/soft tissue, 9% lung, 4% each urogenital and hematologic, 3% each breast and endocrine, 1% each cutaneous and immunological. The mean age was 58.22 years for patients with benign cancer and 65.87 for malignant ones. The mean scores of the Functional Independence Measure (FIM) at admission were 54.98 for benign and 57.34 for malignant. FIM's gains were 22.69 and 16.27 respectively. Hospital stay (LOS) was 17.05 days for benign and 15.34 for malignant. The efficiency of the FIM was 1.71 for benign and 1.42 for malignant. The discharge placement for both groups was home (benign 64.3%, malignant 55.9%), subacute nursing unit (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 that of CNS origin. The average ages were analogous. Patients with benign and malignant cancer had similar results in LOS, FIM admission, FIM gain, and FIM efficiency. The location of the discharge was also similar, except that the malignant patients had more than twice the rate of acute discharge. This research demonstrates that patients admitted to an IRF with malignant cancers can have similar functional gains at a similar rate to benign cancers and have similar locations after discharge. However, increased surveillance may be warranted for malignant patients given the higher rate of acute discharges.

Results of acute rehabilitation in patients undergoing hemodialysis

Raj D. Murthy, MD, MPH; Hossam Adham, MD; Adrian Cristian, MD; Jemmry Pantin

Goals.To evaluate comorbidities, complications, discharge destinations and functional independence measure (FIM) of acute rehabilitation in patients on Hemodialysis (HD).

Project:Retrospective study.

Results:The mean age of patients on HD was 64.5 years, while the mean age of patients without HD was 69 years. The mean FIM scores on admission were 63.8 for patients on HD and 60.11 for patients without HD. The mean FIM scores at discharge were 78.6 for patients on HD and 81.08 for patients without HD. The total mean FIM gains were 14.4 for HD patients 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. Patients without HD had cognitive gains on average 5.22 and motor gains on average 15.74. The hospital stay of HD patients was 15.4 days and 16.4 days for non-HD patients. 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%. Reasons for acute discharge of HD patients included: gout, recent-onset AF, sepsis, mediastinal biopsy, transmetatarsal amputation, and electrocardiogram changes.

Conclusions:Compared with non-HD patients, HD patients had lower FIM gains, primarily in the motor domain as well as the cognitive domain. They also had a shorter hospital stay and a higher rate of acute discharge. This research shows that HD patients hospitalized in acute rehabilitation obtain functional gains and can be discharged to the community. However, due to the complexity of their medical condition, they require a longer hospital stay, very close follow-up, and a personalized, individualized program during rehabilitation. The physical rehabilitation of HD patients is more complex due to the severity of their disease, but the adoption of routine counseling and promotion of physical rehabilitation has the potential to improve physical functioning, optimize quality of life and health. general of dialysis patients.

Sorrowful Garrod Nodes

Edward A. Dolomisiewicz, MD; Christopher J. Forster, MD; Aaron W. Pumerantz, DO

Diagnosis of the case:Dorsal Dupuytren's nodes, sometimes described as Garrod's nodes, are subcutaneous fibromatoses that cover the dorsal proximal interphalangeal (PIP) joints. These injuries are usually painless and, if severe, can interfere with the function of the extensor tendon in the hand. We present the case of an active military man who presented progressively painful Dupuytren's nodules.

Case description:A 34-year-old Caucasian Army female airman was referred for non-surgical treatment of multiple painful nodules involving PIPs on her hands. Postcontrast fat-suppressed T1-weighted axial MRI revealed increased signal and more marked enhancement over the extensor surface of 5^ºPIP joint, compatible with fibromatosis. An extensive rheumatological evaluation was carried out and, after ruling out other diseases, a diagnosis of Garrod's node associated with Dupuytren's disease was made. He postponed invasive treatments in favor of topical and oral pain relievers.

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 doctor until 23.1 months after symptom onset, and only 9% received a Dupuytren's diagnosis. Nearly half were advised to "wait and see" or received no treatment. This information suggests that patients do not receive an accurate diagnosis with subsequent timely interventions that may affect long-term outcomes. Treatment consists of maintaining or restoring hand function or, in this case, pain control. The level of disability and the impact on quality of life should be used to guide the therapeutic approach.

Conclusions:This case highlights an atypical presentation of painful Garrod's nodules associated with Dupuytren's disease. Unfortunately, the underlying pathophysiology remains unclear and therefore no definitive interventions are currently available to prevent disease progression. In addition, early diagnosis and treatment are important to maintain optimal hand function and track other manifestations of disabling diseases that can interfere with quality of life.

Paraneoplastic necrotizing myopathy secondary to nasopharyngeal cancer

Tony CT Lo, DO, MS; Bi-Ying Yeh, MD; Kenten Wang, DO, MS

Diagnosis of the case:Paraneoplastic necrotizing myopathy secondary to nasopharyngeal cancer

Case description:A previously healthy 58-year-old Chinese woman developed profound and progressive weakness of proximal muscles, which prevented her from walking, swallowing, or holding her head up in a matter of weeks. The creatine kinase level rose to 11513 U/L. She was started on steroids and methotrexate on suspicion of polymyositis. Although creatine kinase improved to 422 U/L, it did not make significant progress in inpatient rehabilitation. Muscle biopsy revealed atrophy and necrosis without an inflammatory infiltrate. Symptoms of drug-refractory nasal congestion eventually led to the discovery of nasopharyngeal basaloid squamous cell carcinoma. After radiation and chemotherapy were started, his strength improved with exercise therapy.

discussions:Autoimmune necrotizing myopathy (ANAM) belongs to the family of inflammatory myopathies, including polymyositis and dermatomyositis. NAM also has symmetrical proximal weakness but is distinguished by the histologic appearance of marked necrosis and a predominance of macrophages rather than inflammatory cells. Although nasopharyngeal carcinoma has been associated with dermatomyositis, its relationship to necrotizing myopathy is unknown. The effectiveness of exercise therapy in downregulating inflammatory genes in other myopathies is well described in the literature, but not in NAM. In our patient, CK levels improved significantly after exercise therapy and medical treatment. Our patient's progress was likely initially limited by her underlying malignancy, but she regained sufficient strength to walk short distances after treating her cancer and undergoing additional rehabilitation, demonstrating the benefits of exercise therapy .

Conclusions:Although the link between nasopharyngeal carcinoma and necrotizing myopathy is not well understood, suspicion should remain high for malignancies. A more aggressive evaluation is indicated in patients who do not improve. Although there is little evidence to support physical therapy in NAM, studies have shown the safety and efficacy of exercise in other inflammatory myopathies. We assume a similar effect in NAM once the underlying causes are addressed, although more research is needed to validate this point.

Parsonage-Turner syndrome: an unusual presentation of weakness and acute unilateral pain in the upper extremities

Yogen Patel, DO; Joy Bhat, M.D.

Diagnosis of the case:A 76-year-old woman presented with a 2-day history of acute onset of pain, weakness, and numbness in the right upper extremity.

Case description:The patient felt her weakness progressively worsen; she now she has difficulty raising her arm. She denied any recent trauma, overuse, or illness. Given concerns about a possible stroke, she had a noncontrast head CT scan completed and it was negative for any acute intracranial abnormalities. Radiculopathy was ruled out with a CT scan of the cervical spine. Given the physical examination findings of proximal muscle weakness, an MRI of the right shoulder was performed, which showed diffuse edema in the supraspinatus, infraspinatus, and proximal deltoid without atrophy, being diagnosed with Parsonage Turner Syndrome. The patient was referred to outpatient physical therapy for range-of-motion exercises and strength training. Using modalities like TENS, she noted an 80% improvement in proximal muscle pain and weakness over the next month.

discussions:PTS is a rare inflammatory disease of the brachial plexus of uncertain pathophysiology with an incidence of 1.64 cases per 100,000 inhabitants. Many patients reported a triggering event such as infection, surgery, pregnancy, exercise, or vaccination. It usually presents with an acute onset of shoulder girdle pain that progresses to weakness and numbness. The diagnosis is usually made clinically; however, detailed electrodiagnostic and imaging can help confirm the diagnosis. In 97% of cases, the suprascapular nerve is involved. Therefore, the muscles most frequently involved are the supraspinatus and the infraspinatus, followed by the deltoid. Treatment focuses on pain control. Modalities such as TENS and acupuncture, along with physical therapy, have been shown to improve functional outcomes.

Conclusions:Parsonage-Turner syndrome should be considered in the differential diagnosis for someone with acute onset of pain and unilateral weakness in the upper extremities when the diagnosis is unclear. Early diagnosis can help guide pain management and physical therapy to improve functional outcome.

Patellar subluxation after below knee amputation

John R. Frampton, MD; Shanti M. Pinto, MD; Dra. Mary Ann Miknevich

Diagnosis of the case:Patellar subluxation after below-knee amputation.

Case description:The patient is a 48-year-old female with a history of right transtibial amputation (Syme procedure) performed at age 5 due to neurofibromatosis who presented to our amputee clinic with knee pain associated with the use of her endoskeletal knee support prosthesis. knee. her patellar tendon (PTB) that she had used for the past two years. She was noted to have knee pain, patellar instability, and patellar suluxation on physical examination, probably as a result of years of prosthetic use. She had been seen by an orthopedic surgeon who recommended a surgical correction, which she hoped to avoid. Subsequently, she received a new prosthesis with modified supracondylar and suprapatellar lines of fit that resolved her problems of patellar subluxation and knee pain, improving ambulation and eliminating surgical correction.

discussions:Patellar instability and subsequent subluxation are the result of abnormalities in knee joint geometry, limb alignment, ligament stability, and muscle strength. People with below-knee amputations and long-term use of PTB-type prostheses are at increased risk of developing patellar instability associated with patella alta, shallow trochlear notch, and patellar hypoplasia due to added stress on the patellar tendon. This is particularly true when the amputation was performed in childhood. This is poor evidence to guide best practice in the management of chronic patellar instability (Level –IV) with respect to conservative versus surgical therapy, especially as it relates to below-knee amputees. Only one similar case report was found describing successful results in the prevention of chronic patellar luxation by simple modification of the prosthesis instead of surgical intervention.

Conclusions:Chronic patellar instability is often seen in people with below-knee amputations, and evidence on management is lacking. Few case reports discuss prosthetic modification in relation to patellar instability, indicating a need for increased awareness of this problem and its possible solution.

Piriformis Syndrome Confirmed by NCS, with Prolonged H Reflex During FAIR Maneuver

Dr. Reza Taher; Wilson J. Chang, MD; Michael Fediw, MD; Dr. Michael Larson; S. Kamal Fetouh, MD; Dra. Julie Larson

Diagnosis of the case:Piriformis syndrome confirmed by NCS, with prolongation of the H reflex during the FAIR maneuver

Case description:This is a sixty year old woman who presented to the pain clinic with a primary symptom of pain in the left buttock radiating back to the left thigh. The pain in her buttocks was burning and intermittent. The pain was exacerbated by prolonged sitting and walking and improved by stretching exercises and analgesics. Physical examination included positive FAIR and Mirkin tests. Evaluation included NCS illustrating asymmetry in H reflexes with abnormality in the left lower extremity while the patient was in the FAIR position.

discussions:After conservative treatment, including NSAIDs, formal physiotherapy followed by steroid injection into the left piriformis muscle, the patient showed improvement in pain symptoms, function, quality of life, and increased pain-free walking distance. .

Conclusions:Piriformis syndrome was originally described by Dr. Robinson in 1947. It is believed to be responsible for up to 8% of cases of low back and gluteal pain, with or without radiation to the ipsilateral lower limb. A common misconception is that piriformis syndrome is just pain in the muscle itself, which due to trauma or strain can occur in any muscle in the body. Piriformis syndrome is an irritation or hypertrophy of the piriformis muscle which, in turn, can cause compression/irritation of the sciatic nerve. Many prominent MSK physicians disagree with the existence of piriformis syndrome. This case sheds light on the importance of a good history and physical examination that can be supported by NCS with objective findings and recordings, including prolongation of the H reflex during the FAIR test beyond 1.86 ms of the mean at 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, M.D.

Diagnosis of the case:Inflammatory enthesitis in Osgood-Schlatter disease

Case description:A 27-year-old woman 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 fracture of the right tibia treated conservatively. She recently had recurrent urinary tract infections (UTIs) prior to the onset of acute bilateral knee pain.

Physical examination revealed warmth in the right pretibial region and tenderness at the bilateral tibial tuberosities/patellar tendon attachments without joint effusions.

MRI of his right knee revealed a nondisplaced subacute tibial fracture extending to the tibial spine and tibial tuberosity and chronic patellar tendinopathy with fragmentation of the tibial tuberosity. According to his orthopedic surgeon, the MRI findings suggested a healed fracture and did not explain his current symptoms.

Point-of-care ultrasound examination of her bilateral infrapatellar knees demonstrated bilateral infrapatellar enthesopathy; and hyperemia along the right ossicles that correlates with the patient's maximum pain, consistent with inflammatory enthesitis. The differential diagnosis included reactive arthritis and OSD reactivation.

Treatment included tapering prednisone and aggressive bilateral knee physiotherapy. He now walks without assistive devices.

discussions:OSD is a cause of adolescent knee pain that is usually diagnosed clinically and confirmed by plain radiographs. OSD reactivation in adults is rarely reported. The use of ultrasound to evaluate for apophysitis, enthesopathy, and hyperemia has been described as a useful adjunct to confirming SOD in adolescents, but there are no studies describing the use of ultrasound in adults with SOD; the patient's infectious history raises concerns about possible reactive inflammatory arthritis.

Conclusions:OSD can lead to significant morbidity and disability in adolescence and early adulthood if management is suboptimal. Ultrasonography may be helpful in differentiating between mechanical pain and pain associated with inflammation and may alter treatment management. More studies are needed to evaluate the value of ultrasound in these patients.

Polymositis: a case report of the interaction between disease severity and iatrogenic disability

Daniel A. Goodman, MS, MD; Toledo Santiago, MD

Diagnosis of the case:39-year-old woman with polymyositis

Case description:A 39-year-old female patient with corticosteroid-dependent polymyositis and pulmonary fibrosis, who initially presented weakness in the proximal extremities, diffuse pain, and dyspnea, leading to successive diagnoses of fibromyalgia, seronegative rheumatoid arthritis, and mixed connective tissue disease. She began oral prednisone and was finally diagnosed with polymyositis 1 year after a muscle biopsy. Multiple steroid-sparing drug treatments failed over the next 5 years and she remained on oral prednisone. Long-term use of corticosteroids and reduced mobility have led to a number of side effects, including obesity, osteoporosis, and bilateral cataracts. She was diagnosed with obesity-related obstructive sleep apnea requiring overnight CPAP and she underwent bilateral cataract surgeries. His obesity and osteoporosis were implicated as the cause of multiple skeletal complications, including bilateral hip osteoarthritis and 4-foot fractures, as well as degenerative changes in the spine, including cervical and thoracic spine disc bulges with central and foraminal stenosis and spondylolisthesis. L5-S1. radiculopathy. She received corticosteroid injections in both hips, microdiscectomy at L5-S1, and multiple surgeries for fractures of the right 3rd and 4th metatarsals and 2 sequential fractures of the left 5th metatarsals. The patient is weight bearing on her lower extremity for most of the past 2 years and she is unable to perform her duties as a real estate agent.

discussions:His chronic limitations due to poor mobility, poor stamina, and dyspnea are further complicated by additional impairments, including weakness, a non-weight-bearing limb, and obesity, which are related to long-term use of corticosteroids. The chronic side effects of corticosteroids resulted in a cascade of complications and functional decline superimposed on marked functional deficits secondary to the primary disease process, leading to aggravated disability.

Conclusions:Iatrogenic adverse effects of chronic corticosteroid use can lead to worsening disability in steroid-dependent inflammatory diseases and should be considered in refractory cases, such as this one with polymyositis.

Posterior Dislocation of Total Knee Arthroplasty with Cross Retention Prosthesis during Rehabilitation: Case Report

Matthew G. Hadilaksono, DO; Ana M. Garcia, M.D.;

Diagnosis of the case:Total knee arthroplasty posterior dislocation

Case description:We present the case of a 75-year-old obese woman who underwent elective total arthroplasty of the left knee due to severe tricompartmental osteoarthritis with valgus deformity. A prosthesis of unrestricted design (cross-retention) was used in this procedure. On the second postoperative day, the patient was transferred to the inpatient rehabilitation floor and started a course of physiotherapy. On the seventh postoperative day, the patient developed spontaneous pain and swelling in the left lower extremity. The left knee radiograph revealed a total posterior dislocation of the knee. The patient was immediately taken to the operating room for emergency closed reduction under anesthesia. After reduction, she placed the patient in a knee brace and was given an unweight-bearing state in the left lower extremity. The patient continued to show some swelling in 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 at around 0.15 to 0.5%. TKA dislocations can occur with any of the available prosthetic designs, but are generally more common with the posterior cruciate ligament (PCL) retention design. In this situation, neurological and vascular involvement should be evaluated. Immediate reduction of the dislocated knee is indicated. The patient should also be evaluated for possible further review.

Conclusions:Sometimes total knee replacement rehabilitation can be complicated by a dislocated knee. Although it is a rare occurrence, awareness and recognition of this complication during the rehabilitation process is crucial to prevent future neurovascular complications.

Posterior interosseous neuropathy after IV line placement

Aarón J. Yang, MD; Dr. Eric P. Sturos

Diagnosis of the case:Posterior Interosseous Neuropathy

Case description:A 40-year-old man with a medical history of type 1 diabetes mellitus presents to the electrodiagnostic clinic with a chief complaint of a dropped right wrist. He says that about 2 weeks earlier he was admitted to the hospital with high blood sugar levels and during his hospitalization an IV was placed in the ventral part of his right forearm. Shortly thereafter, he developed swelling involving the entire forearm and fingers, followed by weakness with extension of the wrist and fingers. He was soon released from the hospital with residual weakness and told that his symptoms would go away in a few days. The swelling in the forearm and hands finally disappeared a few days after discharge. He continued to have persistent symptoms and went to his primary care clinic after 2 weeks and was rushed to the electrodiagnostic clinic for further testing. At the time of presentation, he continued to complain of weakness in his right wrist and painful finger extension along his right forearm. He denied any associated numbness. He stated that this situation was causing great anguish in his life due to his customer service job at a computer company and he could not type or have all the functions of his right hand. In addition, he was taking classes at the university and it was difficult for her to complete his assignments. As for the rest of his medical history, he was diagnosed with Diabetes 13 years ago and is currently taking Metformin. He denies any significant medical or surgical history other than hernia repair. Focused physical examination revealed a well-nourished man with no apparent complaints. On inspection it was notable for symmetrical muscle mass in the forearm and hand. There was no tenderness throughout the bilateral upper extremities. Hand muscle testing was remarkable for total strength in the extremities, except for 4/5 extension of the right wrist and 2/5 extension of the fingers. Sensation was intact in the extremities, and reflexes were symmetrical and present. Electrodiagnostic testing confirmed the presence of a severe right posterior axonal interosseous neuropathy as well as a mild large-fiber polyneuropathy consistent with his previous history of diabetes. The patient planned to follow up with his primary care physician and begin physical and occupational therapy.

discussions:Posterior interosseous neuropathy (PIN) is a pure motor branch of the radial nerve that innervates the extensor carpi ulnaris, abductor pollicis longus, and extensors digitorum and thumb. Entrapment neuropathy occurs most often in the radial tunnel or Arcade of Frohse. Other reported causes of PIN include forearm fractures, lipomas, bruises, and ganglion cysts. Patients often have weakness in the extension of the fingers and thumb with a slight drooping of the wrist. Patients may extend the wrist with radial deviation due to weakness of the extensor carpi ulnaris muscle. The patient may experience pain in the forearm, as the nerve has deep sensory fibers that innervate the interosseous membrane. Diagnosis is usually made with electrodiagnostic studies where radial motor studies may show reduced amplitude in the extensor index muscle proper. Needle electromyography is most useful in demonstrating denervation of the muscles supplied by this nerve. Treatment consists of anti-inflammatories, splints and focal exercises. With progressive weakness or treatment failure after 3 to 6 months, surgery should be considered. Kaplan found that 80% of PIN patients had symptom resolution within 5 years when treated conservatively.

Conclusions:This is an atypical case, since due to the intravenous infiltration and subsequent swelling of the forearm, the patient could have suffered a PIN due to compression of this nerve in the Arcade of Froshe or radial tunnel. As the swelling resolved, the patient continued to have residual deficits due to his PIN.

Postoperative hematoma resulting in airway compromise after anterior cervical spine surgery

Janice Lau, Bachelor of Science; Tony CT Lo, DO, MS; Michelle Thai, M.D.

Diagnosis of the case:Postoperative hematoma after cervical spine surgery

Case description:A 76-year-old woman with a history of upper extremity DVT and metastatic breast cancer presented for rehabilitation after undergoing uncomplicated anterior cervical decompression and fusion surgery for cervical stenosis. Three days after surgery, she was restarted on therapeutic anticoagulation because of her history of DVT. One 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 satisfactorily, achieving functional gains higher than the initial evaluation.

discussions:Postoperative airway obstruction due to hematoma is a serious complication of anterior cervical spine surgery, with an incidence of 0.2 to 1.9%. Due to its rapid onset, short intervention period, and difficult location for airway control, cervical hematomas are life-threatening. Chemoprophylaxis after spinal surgery is controversial due to the need to weigh the risks of life-threatening pulmonary embolism against life-threatening bleeding. Spinal surgeries performed through the anterior approach have a higher incidence of VTE. Furthermore, it is known that patients with malignant tumors are at increased risk of developing VTE. Therefore, anticoagulation of this population becomes essential. However, there are no clear guidelines as to when therapeutic or prophylactic anticoagulation should be initiated. Although most surgeons start chemoprophylaxis within 3 days, little is known about the timing of therapeutic anticoagulation. As observed in our case, attention should be paid to monitoring the formation of hematomas after the start of anticoagulant treatment. Signs of hemorrhage include drainage, tracheal deviation, and swelling of the anterior neck and submandibular region. Alternatively, superior vena cava filters can be used, but their benefit and safety remain questionable.

Conclusions:Postoperative hematoma resulting in airway compromise is a life-threatening complication of anterior cervical spine surgery. Anticoagulation should be initiated in high-risk patients with close monitoring for hematoma development in the rehabilitation setting. Further studies are needed to determine the optimal periods to start anticoagulation in high-risk groups.

Prismatic Therapy for Pain and Distortion of Body Consciousness in an Orthopedic Patient: Case Report

Pavli S. Demian, DO; Cristin McKenna, MD, PhD

Diagnosis of the case:Left hip and gait dysfunction

Case description:A 57-year-old woman presents with chronic left hip pain and gait dysfunction. She states, "Sometimes I don't know where my left hip is." She has had several bilateral hip surgeries since childhood due to congenital dysplasia of the hip. She has had a bilateral hip replacement with multiple revisions. Her left hip at this point is a DuPuy hip that was later found to be leaking cobalt and chrome. Hip pain at presentation was described as aching, sharp, throbbing, sharp, burning, numb, continuous, worst: 9/10, best: 2/10, exacerbated by: standing, sitting, walking, carrying. The patient came for pain control in the left hip and the desire to improve walking. She also wanted to minimize oral medication. Wearing wedge prism glasses, she performed repetitive upper and lower body line bisection exercises. She experienced changes in both pain and body awareness immediately before and after treatment, as measured by the Likert scale. Changes in body awareness and pain lasted for about 24 hours and were reproducible over a period of months of daily prism treatment. She increased the community pilgrimage of her.

discussions:Visuospatial neglect is a lack of attention or response to stimuli on the opposite side of a brain lesion. The effect of chronic pain and anatomical abnormality secondary to multiple surgeries on brain remodeling in the developing brain compared with injury in the adult brain has not been explored. The patient's description of remarkably "neglect-like" symptoms on her left side, along with a condition of chronic pain in an extremity and a desire to avoid medication, provided a confluence of medical conditions for which prismatic therapy, used both in neglect as in pain, it could have clinical effects. to benefit.

Conclusions:The use of the prism for coexisting disorders of body perception and pain offers a low-risk intervention that can affect pain and increase body awareness.

Prognostic indicators of functional recovery in patients with brain tumors

Meghan E. Cochrane, DO; Dr. Eric Leung; Dra. Heidi Fusco

Goals.In the US, 74,000 new cases of brain tumors are diagnosed annually and create barriers to functional independence and quality of life. Patients with neoplastic brain injury undergoing acute rehabilitation showed improvements in recovery equal to those of patients with traumatic brain injury. Few studies have evaluated prognostic indicators and modifiable risk factors for outcomes in patients with brain tumors; however, several have shown that severity at presentation, tumor type, presence of pain, and radiation affect recovery and outcome. Objectives of our study: To assess rehabilitation outcomes for patients with brain tumor injury at a tertiary rehabilitation center and to identify prognostic indicators for favorable rehabilitation outcomes based on initial presentation and tumor-related comorbidities.

Project:This is an IRB-approved retrospective review of 93 patients admitted to an acute rehabilitation unit from July 2012 to July 2014. We assessed demographics, admission and discharge FIM, discharge site, demographics social status, tumor type, tumor location, treatment history, and various comorbidities. 66 patients met the inclusion criteria for admission to acute rehabilitation secondary to brain tumor.

Results:The FIM data reflected a positive gain in all areas, with an average gain of 28.4 FIM per patient. Linear regression with FIM motor change demonstrated independent prognostic indicators for favorable rehabilitation outcome, including younger age (each 20-year increase decreased FIM motor change by 5), surgical resection (no surgery reduced FIM by 12 ) and the type of tumor (primary brain tumors). FIM decreased by 10). Although not statistically significant, bivariate analysis showed that chemotherapy, radiation, antidepressants, and high relative risk suggested a poor outcome. The initial presentation with high functionality, headache and pain suggestive of favorable evolution.

Conclusions:Acute hospital rehabilitation of patients with brain tumor produces a functional improvement. Younger age, surgical resection, and metastatic tumors are independent prognostic indicators for a favorable rehabilitation outcome. Future studies with larger sample sizes should be conducted to identify other prognostic indicators that predict favorable rehabilitation outcomes.

Prophylactic efficacy of ulnar shift: report of a case and review of the literature

Richard C. Swedarsky, DO; Mateo Miller, MD; Dr. Walter J. Faillace

Diagnosis of the case:Left ulnar neuropathy in elbow secondary to firearm

Case description:A 30-year-old man, shot in the left arm in May 2014, underwent surgical repair of a distal humerus fracture in Europe. After repair, symptoms of ulnar neuropathy developed. Physical examination in October 2014 revealed an ulnar claw hand, decreased sensation in the ulnar distribution, and no abduction of the fingers in the ring and little fingers. Electrodiagnostic findings showed severe left ulnar axonal injury and ultrasound evaluation showed focal flattening of the nerve around the scar tissue and subcutaneous transposition. The patient underwent an ulnar nerve scan 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 the flexor digiti minimi and adductor digiti minimi; ROM reinnervation was observed in a limited EMG study.

discussions:This patient had a prophylactic subcutaneous transposition due to an orthopedic injury. He has had weakness and numbness since the time of the injury with no improvement. Scar formation was assessed by ultrasound and intraoperatively. The patient underwent neurolysis and submuscular transposition. The current literature on submuscular versus subcutaneous ulnar transposition for compression-mediated ulnar neuropathy shows that the two are ambiguous, however, in more severe cases, submuscular transposition is preferred as less stress is placed on the nerve during the procedure; however, submuscular transposition has a greater tendency to lead to scar tissue formation. A more advantageous option would be an in situ decompression, since the risks are very low and the efficacy of the procedure does not differ significantly from transposition. Furthermore, when considering prophylactic transposition in relation to elbow contracture release, there is consensus that the patient is symptomatic or has positive electrodiagnostic findings before prophylactic decompression or ulnar transposition is considered. Furthermore, ulnar transposition to prevent neuropathy has only been suggested for severe deformity. Here we report ultrasound and electrodiagnostic studies demonstrating scar tissue formation leading to ulnar neuropathy after subcutaneous transposition and intraoperative findings causing other adverse effects of the procedure.

Conclusions:Prophylactic ulnar transposition should only be considered if severe deformity occurs due to trauma, tumor, or other etiologies. If the procedure is sought, the patient should be evaluated for symptoms or electrodiagnostic findings. Submuscular transposition places less stress on the nerve; however, if the surgeon is not properly trained, scar tissue is more likely to form.

Propranolol for the treatment of tremors induced by tacrolimus in a patient undergoing rehabilitation: case report

Joseph W. Frye, do; Respecting Robes, MD

Diagnosis of the case:Tacrolimus-induced tremors

Case description:A 73-year-old man, 17 months after bilateral orthotopic lung transplantation, was admitted for acute rehabilitation after a severe prolonged Clostridium Difficile infection. On admission, the patient exhibited significant resting and intention tremors that worsened during the initial course of his rehabilitation. His anti-rejection therapy included prednisone, azathioprine, and tacrolimus. The patient's tremors significantly affected his rehabilitation progress in activities of daily living. He required minimal assistance with feeding, grooming, and bathing and maximum assistance with dressing. At this point, a literature search for treatment options related to tacrolimus-induced tremors was completed. We identified a single case report successfully using propranolol at a dose of 10 mg every eight hours for tacrolimus-induced shivering in a single-lobe orthotopic lung transplant patient undergoing acute rehabilitation. After obtaining the patient's consent, a trial of propranolol for possible amelioration of tremors and subsequent optimization of rehabilitation was instituted. At that time, the patient's medication regimen included metoprolol 25 mg every 12 hours for hypertension. This was discontinued and changed to an equivalent dose of propranolol 20 mg twice daily. After approximately 36 hours, the patient reported a subjective improvement in his tremors. Two weeks after initiation of propranolol, the patient's functional status had improved to standing assistance with eating and grooming and minimal assistance with dressing and bathing. At discharge 1 week later, the patient received assistance with feeding, hygiene, dressing, and minimal assistance with bathing. Three months after discharge, a chart review revealed that the patient's antiregional regimen was changed by the transplant team and tacrolimus was discontinued. Subsequently, the patient's tremors disappeared and propranolol was discontinued.

discussions:Tacrolimus is a macrolide antibiotic with immunosuppressive qualities through 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 nervous tissue and binding of these proteins is thought to cause sympathetic hyperactivity. Propranolol works as a beta-adrenergic receptor antagonist and is widely used in the treatment of essential tremor. Research on the effects of propranolol has found that, in addition to blocking peripheral beta receptors, it probably also functions as a central depressant and this may explain its tremor-attenuating effects. There are currently no studies examining the efficacy of propranolol for tacrolimus-induced tremors, however there is one case report identifying its utility.

Conclusions:Tremors are a common side effect experienced by patients receiving immunosuppressive regimens including tacrolimus. These tremors can significantly affect the recovery and function of these patients. Propranolol appears to be an effective treatment option for tacrolimus-induced tremors in situations where tacrolimus must be used and cannot be discontinued. Continued research and possible clinical trials are needed to further investigate this treatment.

Use of prosthesis in a patient with osteogenesis imperfecta and new transfemoral amputation

Bryndon B. Escotilla, MD; Drag. Karen L. Andrews

Diagnosis of the case:Prosthetic adaptation to a patient with new transfemoral amputation and Osteogenesis Imperfecta (OI)

Case description:A 73-year-old woman with peripheral vascular disease status after multiple revascularization procedures, osteoporosis, and OI with 13 fractures before age 4 years, but no additional fractures until after menopause, presented with left lower extremity pain and fever due to to an infection. of the vascular graft that extends from above to below the knee. Popliteal and distal artery TcPO2 levels were < 30 mmHg two months previously, but at presentation had risen to 55 mmHg in the proximal foot with adequate healing for distal amputation, but amputation indicated transfemoral due to graft infection. The physiatrist was consulted by the vascular surgeon to assess whether she would be a candidate for the safe use of a prosthesis for OI and osteoporosis. We reassured the patient and surgeons that we anticipate that she would be a successful prosthesis user and instructed her in postoperative recovery. She delayed the healing of the wound that prevented the placement of the prosthesis for five months. She underwent prosthetic fitting and training without fracture or other complications (more follow-up data will be available at the time of the AAP conference) with an anticipated ambulation level of K2.

discussions:OI is a congenital bone disorder caused by deficiency or abnormality of type I collagen, leading to abnormal bone formation and predisposing to pathologic fractures. The severity of the disease can be highly variable.

In this case, the patient was determined to have OI type I (mild) due to her history of fractures only in early childhood and after the menopause. Although the literature on the use of lower limb prostheses in OI patients is extremely limited, case reports have shown good recovery of OI patients undergoing joint replacement surgeries. Due to her milder form of OI, she was expected to successfully wear a prosthesis.

Conclusions:The use of prostheses is possible in patients with milder forms of Osteogenesis Imperfecta.

Rare case of Flatbush syndrome as a cause of critical illness polyneuropathy

Dra. Carrie McShane; Clinton Faulk, MD; Joshua Brown, MD; Siena Ona, MD

Diagnosis of the case:Flatbush syndrome leading to critical illness polyneuropathy.

Case description:A 21-year-old woman with a 2-month history of polyuria and polydipsia was admitted 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 multi-organ dysfunction syndrome requiring hemodialysis. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. The remaining investigation for the origin of sepsis included lumbar puncture, abdominal ultrasound, chest/abdomen/pelvic computed tomography, and echocardiogram. All images were negative for infection. It was noted that she had general weakness. After treatment in our Level One Trauma Center intensive care unit, she was admitted for rehab for critically ill polyneuropathy (CIP). Originally it was thought that she had undiagnosed type 1 diabetes. However, anti-glutamic acid decarboxylase antibodies were negative. She did not need supplemental insulin. She consulted the endocrinology service again and was diagnosed with Flatbush Syndrome.

discussions:Flatbush syndrome, or type 2 diabetes with a tendency to ketosis, is a rare disease that usually affects middle-aged patients. Patients with Flatbush syndrome do not have a medical history of diabetes. After a period of stress, they often arrive at the hospital with a blood glucose level of around 600 and require treatment for CAD. Only half of patients will need insulin after a DKA episode.

Concussions:The patient's proximal weakness improved with therapies and close follow-up for systemic inflammatory response syndrome. Bilateral necrosis of the toes from peripheral vasopressors was treated with open orthoses. At discharge, he was independent to walk and perform activities of daily living after completing inpatient rehabilitation. Clinicians should be aware of Flatbush Syndrome as a source of sepsis that can result in ICP and subsequently require extensive rehabilitation.

Rare case of late-onset central hypoventilation syndrome (Ondine's curse): case report

Hannah M. Garcia, MD; Matthew G. Hadilaksono, DO; Sanjeev Agarwal, MD; Tariq Hilal, DO; Tsai Chao, MD

Diagnosis of the case:Late-onset central hypoventilation syndrome (Ondine's curse).

Case description:A 57-year-old woman with HMP, well-controlled DM, and hypertension, who consulted for sudden-onset respiratory failure. She was intubated and treated in the ICU. After extubation, she was wheezing during the day and unable to breathe during sleep. She was eventually released with a CPAP machine at her home to help her breathe at night and she was referred to rehab for a pulmonary rehab and diaphragm strengthening exercise program. After further examination and careful evaluation of the possibility of a late-onset central hypoventilation syndrome, formerly known as Ondine's curse, secondary autonomic dysfunction of the phrenic nerve was considered. After a course of pulmonary rehabilitation and an exercise program to strengthen the diaphragm, the patient showed improvement in her breathing patterns and ventilatory function.

discussions:Congenital central hypoventilation syndrome, formerly known as "Ondine's curse," is more common in newborns. Late-onset cases are well described up to the age of 10 years, with only two documented cases of adult-onset central hypoventilation syndrome. This condition should be considered when adults have 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 may help 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

Diagnosis of the case:Recurring students

Case description:A 41-year-old woman was admitted to the acute rehabilitation hospital for lupus-related autoimmune sensory ganglionopathy. She had been diagnosed with lupus in 2004 and she had Raynaud's phenomenon, for which she was taking amlodipine. She was also taking high doses of prednisone (30 mg daily) and hydroxychloroquine for her autoimmune conditions, as well as carvedilol for high blood pressure. The social history was significant for her smoking 1/2 pack a day. Her rehabilitation course was progressing as expected when she suddenly developed a fleshy, erythematous distal tip on her left index finger that was cold and numb, suggesting ischemia. Subsequent questioning revealed that she had a history of developing delinquents and she suffered minor trauma to her finger the previous week. The rheumatology clinic recommended daily betadine and outpatient follow-up. However, over the next two days, the patient continued to worsen the finger until the distal portion of it finally turned black and it began to emit a foul odor, suggesting necrosis and dry gangrene. Orthopedic consultation was obtained and the finger was finally amputated.

discussions:Raynaud's phenomenon is a common condition that causes blood vessels to spasm, restricting blood flow to the fingers. When secondary to an autoimmune condition (eg, lupus), it is associated with a more severe restriction of blood supply and has a higher risk of causing complications such as ulcers, scarring, and gangrene. Management of early ischemic changes consists of avoiding cold temperatures, stress, caffeine, nicotine, beta-blockers, and treatment with vasodilators and calcium channel blockers. These approaches have been shown to prevent amputation in up to 86% of patients.

Conclusions:Raynaud's phenomenon can cause severe ischemia and dry gangrene, for which early conservative treatment is often successful. However, some cases still require partial amputation of the finger.

Real-world gait patterns provide unique insight into functional gait outcomes after lower extremity amputation

Quinn Tate, Bart Gillespie, DPT; Krista O'Connor, PT, DPT; Teri Chou, PhD; Bradeigh Godfrey, DO

Diagnosis of the case:Depression and cognitive deficits in transfemoral amputees with a history of TBI.

Case description:A 53-year-old right-handed man sustained a traumatic brain injury and multiple orthopedic injuries resulting in a right transfemoral amputation following a pedestrian vs. automobile accident. He was admitted to inpatient rehabilitation for 8 weeks, where he participated in physical, occupational and speech therapy. Prior to discharge, he was prescribed the Modus Trex System (MTS), a wearable device that tracks walking patterns. At the initial outpatient appointment with PM&R, the MTS was placed on her prosthesis. Regular outpatient therapy included ambulation training and decreased use of assistive devices. At the one-week follow-up, the patient independently recognized the need to be more active after viewing the MTS data. In three weeks, he showed a great improvement in activity levels. However, at week 6, the data revealed that community walking had decreased. In contrast, therapists reported continued improvement in functional skills and gait mechanics. Upon questioning, the patient reported symptoms of depression, insomnia, and difficulty concentrating. Changes were made to his treatment plan to address this. Without the MTS demonstrating a drop in real-world activity, the worsening of the patient's depressive symptoms may have gone undetected.

discussions:Quantitative analysis of daily activity during the initial phase of rehabilitation for new amputees provides information about 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 use the Trex system during their 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 Rehabilitation Setting: Case Report

Kunj G. Patel, MD; Lauren Hutts, Bachelor of Science; Chaz Fausel, MD; Dale Strasser, MD

Diagnosis of the case:Recurring students

Case description:A 67-year-old woman was admitted to acute rehabilitation hospital for spinal cord injury (SCI) T4 Asia B secondary to spinal cord infarction. Prior to her SCI, she had T5-6 discitis due to methicillin-susceptible Staphylococcus aureus (MSSA) and a history of four failed left knee replacement surgeries complicated by MSSA infection. She completed a 16-week course of intravenous antibiotics prior to her arrival and, during rehabilitation, she initially demonstrated excellent participation in physiotherapy and decreased need for pain medication. However, after the first week, she suddenly began to experience increasing back pain. She did not appear seriously ill and her vital signs and scans were normal. Over the next two days, her pain progressed despite aggressive medication adjustments and she could not tolerate physical therapy. CRP and ESR were ordered, yielding >380 and 76, respectively, a significant increase from preadmission levels of 11 and 37, respectively. Intravenous antibiotics were restarted and blood cultures were obtained. Repeat imaging showed worsening T3-T6 discitis with 2 right paraspinal muscle abscesses and significant T2-T7 circumferential epidural phlegmon. Blood cultures developed MSSA.

discussions:Discitis is a serious and rare condition that can cause significant neurological damage. Discitis often presents without systemic signs, leukocytosis, or superficial signs of infection (present in only 10% of cases). Back pain and elevated ESR/CRP are the most consistent abnormalities seen in discitis. 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 for testing inflammatory markers (ESR, CRP) in patients with a history of discitis presenting with sudden unexplained low back pain, even in the absence of the usual physical or laboratory signs of infection.

Rehabilitation of fluctuating cerebellar ataxia and dementia in the context of nonvasculitic autoimmune inflammatory meningoencephalitis

Justin Choi, MD; Martin Wice, MD

Diagnosis of the case:Non-vasculitic autoimmune meningioencephalitis (NAIM)

Case description:A previously healthy 65-year-old man developed progressive ataxia over a year before developing cognitive decline over three months. After a fall, he was admitted for left frontal and left posterior parafalcinous subdural hematomas and facial fractures. He was admitted to rehab for encephalopathy until he could tolerate more testing. After extensive investigation, including EMG and brain biopsy, the patient was diagnosed with NAIM.

He returned to rehab, and his second stay was marked by fluctuating periods of functional gains relative to the pulsed steroid infusions. At worst, she was unable to sit up without support, fed herself, and was minimally verbal. After the infusions, she was able to transfer with minimal assistance, ambulate with a wheeled walker, feed herself, and speak simple sentences. Collaboration between the rehabilitation team and the neurology team guided the immunomodulatory treatment and the transition to high-dose oral steroids. This allowed progress in the functional evolution of the patient, despite his devastating pathology.

Eight months later, he is a home walker and increasingly aware of his shortcomings.

discussions:The progressive presentation of NAIM can mimic clinical entities such as Creutzfeldt-Jakob disease, Hashimoto's encephalopathy, and Sjögren's encephalopathy. Its treatable and reversible nature makes diagnosis especially important in the rehabilitation setting, should patients arrive with inconclusive etiologies.

Conclusions:Nonvasculitic autoimmune meningioencephalitis is a rare clinical entity. A Pubmed query for this diagnosis returns seven results. It remains a diagnosis of exclusion, presenting as progressive ataxia and dementia responsive to immunomodulatory agents. If diagnosed early, the symptoms may be reversible. If diagnosed late, as in this case, symptoms may stabilize at a relatively low functional level. The early diagnosis of NAIM can facilitate the efficient use of health resources in rehabilitation, as well as improve clinical outcomes.

Rehabilitation and treatment of spasticity in tropical spastic paraparesis

Frank Jackson, do; Dr. Venessa Lee; Dr. Alexandra Flis

Diagnosis of the case:This case report describes the rehabilitation and management of spasticity in a patient with tropical spastic paraparesis.

Case description:A 71-year-old man with a history of tropical spastic paraparesis (TSP) was admitted to an acute rehabilitation academic unit with significant spasticity and impairments in transference, endurance, activities of daily living, and mobility. He was infected with human T-lymphotrophic virus type 1 (HTLV-1) in Guatemala in 1976. He began developing symptoms of TSP in 1999. This progressed to difficulties getting up from a chair, climbing stairs, and carrying heavy objects. when walking In 2007 he presented to the Neurology clinic where he was diagnosed with TSP.

On acute rehabilitation admission, overnight oral baclofen was tried for significant lower extremity spasticity but caused sedation. Due to failure of oral baclofen, he underwent a trial of intrathecal baclofen (ITB) with significant improvement in spasticity. During a break in his acute rehab stay, Neurosurgery fitted him with an ITB pump. The dose was subsequently titrated in the acute rehabilitation of the hospitalized patient.

discussions:HTLV-1 infection is typically found in Central and South America, as well as Japan and Africa. There is limited literature describing the rehabilitation of TSP and, to the authors' knowledge, the management of spasticity in this population has not been described anywhere. The patient in our case failed treatment with oral baclofen twice due to spasticity, but tolerated ITB therapy. He demonstrated a significant improvement in function with ITB therapy and provides evidence for the effectiveness of this modality in managing spasticity in patients with TSP.

Conclusions:TSP affects the function of patients in settings around the world who are often underserved with acute inpatient rehabilitation and ITB therapy. In this case, we describe 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: Case Report

Ann H. Liechtenstein, DO; Michael Escalon, MD, MPH

Diagnosis of the case:A 58-year-old man with a history of familial non-ischemic cardiomyopathy after total artificial heart placement. Postoperative course complicated by respiratory failure with tracheostomy and dependence on mechanical ventilation, renal failure requiring hemodialysis, and sepsis awaiting cardiac and renal transplantation.

Case description:Rehabilitation was consulted to manage the mobilization of the patient while he was connected to the ventilator. At initial evaluation, the patient had arterial access, a central venous catheter, and a chest drain. Muscle strength tests revealed strength of 4/5 in the upper and lower extremities bilaterally, except for the absence of ankle dorsiflexors and extensor hallucis longus bilaterally. Electromyography showed decreased anterior tibial activation and gastrocnemius activity, probably secondary to critical illness myopathy. Serial casts were implemented for plantar flexion contractures. While in the ICU, the patient was able to ambulate 80 feet using a chest walker with sitting breaks and moderate to maximum two person assistance.

discussions:Patients in the ICU for prolonged periods may develop long-term physical and functional impairments due to immobility. Early intervention rehabilitation programs that focus on preventing physical deterioration, muscle wasting, and contractures, as well as improving respiratory status, are vital to patient recovery. Rehabilitation in the ICU requires a well-coordinated team consisting of doctors, nurses, physiotherapists and physical therapists. This team working together can effectively mobilize critically ill patients, which can shorten the length of stay in the ICU and improve the patient's quality of life after discharge.

Conclusions:The implementation of rehabilitation in the ICU setting is vital to prevent deconditioning. The mobilization of critical patients is possible through the coordination of medical and rehabilitation teams. This collaboration is crucial, since early rehabilitation, since an intervention can speed up the recovery of the patient.

Rehabilitation of a new bilateral amputee after frostbite injury: a case report

Dr Katherine Power; Se Won Lee, MD; Jeremy Roberts, Bachelor of Science

Diagnosis of the case:Bilateral below knee amputation (BKA) secondary to frostbite injury

Case description:A 45-year-old man with no significant medical history was admitted to an emergency room with cold and painful lower extremities after falling asleep in a work truck the night before when the outside temperature was below freezing. After rewarming and allowing sufficient time for the tissue to demarcate areas of non-viable tissue, he underwent bilateral BKA. The below-knee level was chosen because of the area of ​​tissue damage and to allow functional ambulation from there. After a normal postoperative course, he was discharged to rehab to learn how to care for his stumps, perform transfers, and use a wheelchair for transportation. He was then discharged to his home to continue healing and allow the swelling in the extremity to reduce.

At first, social issues interfered with her ability to get proper dentures, but after a while she was able to qualify for dentures. Thanks to his years of playing soccer and manual labor, his body was quite strong and fit. These factors and his need to continue working in construction helped classify him as a K-3 level prosthetic candidate. Since he was a bilateral amputee, his energy expenditure during walking would have to be higher. Additionally, his prosthetic legs would require features such as the exact same feet to allow for a more natural gait.

discussions:Although bilateral amputations are sometimes considered secondary to trauma, frostbite is a rare cause that presents unique challenges. This case demonstrates the importance of individualizing the treatment and rehabilitation plan.

Conclusions:Sustaining bilateral below-knee amputations due to frostbite is rare in this country, but offers a unique rehabilitation scenario for a patient who is in good health to now be rehabilitated.

Rehabilitation of anti-NMDA receptor encephalitis

Dara Jones, MD; Ryan Ramsook, MD; Anne Felicia Ambrose, MD, MS

Diagnosis of the case:anti-NMDA receptor encephalitis

Case description:A 31-year-old woman with a 2-month history of headache and progressive altered mental status was brought in with catatonia. Head CT and brain MRI were negative. An infectious investigation revealed significant lymphocytosis in both serum and CSF, but was negative for bacterial, viral, and fungal etiology. Anti-NMDA receptor antibodies in CSF were positive. Whole-body PET was negative for tumors. She was diagnosed with Anti-NMDAR Encephalitis and treated with IV acyclovir, IVIG, plasmapheresis, and Rituximab. She regained consciousness but was severely agitated, confused, and paranoid. She entered the rehabilitation service, where she was started on propranolol and olanzapine and reduced on steroids. This, in combination with her cognitive and behavioral remediation, helped her improve enough to be discharged home to her 2 weeks later, oriented, adequate, with better judgment, and on a modified independent level. Her antipsychotics were tapered before discharge.

discussions:Anti-NMDAR encephalitis is a relatively new condition characterized by prominent psychiatric manifestations of anxiety, agitation, delusions, and neurological manifestations of memory deficits, seizures, and dyskinesias. Infectious tests, brain imaging, and EEG are usually negative. The CSF usually shows lymphocytic pleocytosis or oligoclonal bands. The diagnosis is confirmed by the presence of IgG antibodies against the NMDAR N1 subunit in serum or CSF. Tumor resection and immunosuppression may improve outcomes, but psychiatric symptoms often thwart rehabilitation efforts. However, careful and limited use of antipsychotics can improve a patient's mood, behavior, and cognitive functioning, giving them the opportunity for successful rehabilitation.

Conclusions:Anti-NMDAR encephalitis is a serious and life-threatening condition with psychiatric, neurological, and cardiovascular manifestations with a long and often difficult course. However, it can respond to rehabilitation efforts if managed properly.

Rehabilitation of concomitant transverse myelitis and acute inflammatory demyelinating polyradiculoneuropathy

Frank Jackson, hacer; Suleiman Lapalme, MD; Dr. Jeffrey Rosenbluth

Diagnosis of the case:This case report describes the diagnosis, treatment, and rehabilitation of a patient with concomitant transverse myelitis and acute inflammatory demyelinating polyradiculoneuropathy (AIDP).

Case description:A 30-year-old male admitted to an academic rehabilitation unit for acute patients with tetraplegia and deficits in transference, mobility, and activities of daily living. Before that, he had been admitted to two community hospitals. Initially he presented to the first hospital with complaints of left lower extremity weakness, was diagnosed with transverse myelitis, and was placed on a course of steroids. However, his weakness progressed to include all four limbs, so he was transferred to the second hospital, where he was diagnosed with AIDP. Additional steroids were administered, as well as a course of intravenous immunoglobulin. Upon admission to an acute rehabilitation hospital, he was consulted to Neurology for his nebulous diagnosis. Electrodiagnostic studies were performed which demonstrated nerve conduction abnormalities of the nerve roots and peripheral nerves. Images from outside hospitals were reviewed and, along with the results of the nerve conduction study, he was diagnosed with concomitant transverse myelitis and AIDP.

Her functional independence measure (FIM) score on admission was 47. During her acute rehabilitation admission, she received additional intravenous immunoglobulin because she felt her previous course was insufficient; he was monitored and tolerated the treatment. He achieved functional improvements during a 43-day hospital stay and his FIM score at discharge was 63.

discussions:Quadriplegia can result from a dysfunction of the central or peripheral nervous system. Demyelination of the central and peripheral nervous systems usually occur as separate disease processes. The sparse literature describes concurrent transverse myelitis and AIDP, and to the best of the authors' knowledge, the course of rehabilitation has not been detailed anywhere.

Conclusions:Transverse myelitis and AIDP are generally considered separate disease processes. Here we describe the diagnosis, treatment, and rehabilitation of comorbidity.

Rehabilitation of Guillain-Barre Syndrome Tetraplegia Complicated from Pre-existing Congenital Mutism in Deafness: Case Report

Svetlana Abrams, DO; Lisanne C. Cruz, MD, MSC; Jeffrey Fine, MD

Diagnosis of the case:Guillain-Barré syndrome tetraplegia as a complication of pre-existing congenital deaf-mutism

Case description:A 57-year-old male with childhood sensorineural hearing loss and mutism, who communicates through American Sign Language (ASL), lip reading, and limited writing in Spanish. The patient developed quadriplegia due to Guillain-Barré Syndrome which impeded ASL communication and resulted in pressure ulcers on the buttocks. He was admitted to our Inpatient Rehabilitation Facility (IRF) for interdisciplinary rehabilitation treatments, evaluations for MSDs and appropriate environmental control devices, wound care, therapeutic counseling to adjust to new disabilities, and family education. OT fabricated a custom head pointing device and mounted bedside icon-based communication boards inside its functional pointing envelope. The head switch call bell allowed immediate contact with the nursing staff. This provided a respite for ASL-speaking family members who previously stayed almost continuously at the bedside for interpretation. Pressure ulcers healed, bath time prevented functional incontinence. Family members learned ergonomic techniques for bed mobility and transfers and were instructed in the proper use of DME. An appropriate personalized wheelchair and cushion is provided. The patient was safely discharged to his home with his family.

discussions:Our patient had an unusual combination of congenital and acquired disabilities that created unique challenges for him and his family. Previously, he could communicate his needs with his hands, but after developing quadriplegia, this communication option was no longer possible. This clinical presentation, coupled with the family's limited financial resources, created additional challenges that were creatively overcome.

Conclusions:Individualized patient care provided by the 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 Lymphedema in the Legs

Naveed H. Butt, MD; Muhammad dinamarquês Saleem, MD; Rummana Aslam, MD

Diagnosis of the case:A case of lymphedema and chronic leg ulcer treated successfully in our clinic

Case description:A 59-year-old obese man with bilateral leg edema since adolescence, which progressively worsened. He had grade 3 lymphedema, pachyderma, and large, oozing, foul-smelling ulcers, despite 7 months of hydrotherapy 3 times a week with wound care. We devise a management plan to treat the symptoms by treating the underlying problem, that is, the lymphedema. An ulcer dressing with a 4-ply short compression bandage covered with a self-adhesive film was used to secure the bandage. This was changed daily initially and then three times a week. As the patient showed improvement (calf circumference 52 cm), a weekly non-elastic zinc-based compression layer was added. Pachyderma was treated with lymphatic pads. Effective edema control was demonstrated by dry, drainless, odorless dressings between consecutive dressings. He was educated on his condition, treatment and exercise plan. The ulcers healed in 2 months and the edema improved in 4.5 months (circumference 42 cm) and a once daily compression pump was added to the treatment. The patient's behavior changed from hopelessness and despair to happy, complacent, and motivated. He walks every day and has started appointments for weight loss surgery.

discussions:Patients with lymphedema and ulcers require a multidisciplinary plan that includes physical medicine, wound care, and medical care. The primary goal is to correct the underlying disorder, ie, lymphedema, while managing secondary problems, such as chronic ulcers, difficulty walking, cellulitis, and sepsis. A common mistake made is to treat ulcers and cellulite without addressing the main underlying cause, which is lymphedema.

Conclusions:Chronic ulcers with lymphedema impose an enormous psychological, physical, and financial burden on patients. Personalized patient management for lymphedema, exercise, weight loss, education, and rehabilitation will ensure a successful outcome in ulcer healing, restoration of function, patient satisfaction, and quality of life.

Reliability of Two New Metrics to Assess Function in the Intensive Care Hospital Setting by Nurses and Physiotherapists in Adult Neuroscience Patients

Kara Shumock, DPT; Erik H. Hoyer, MD; Julie Kreif, PT, MBA; Michael Friedman, PT, MBA

Goals.Bed rest and immobility in the acute hospital setting have been associated with hospital-acquired complications, and there is increasing research supporting the benefits of early mobility in improving patient outcomes. To achieve this goal, it is necessary to have outcome measures that assess functional impairments and mobility status, determine patients' progress during hospitalization, and help develop a multidisciplinary plan of care. Although physical therapists (PTs) specialize in functional mobility, most mobilization in intensive care is performed by nurses (RNs). Currently, there are no reliable, viable, and valid functional metrics used routinely by PTs and RNs in the daily care of hospitalized patients. Our aim in this study was to investigate the interrater-test-retest reliability of two new mobility assessment tools currently used by nurses and physical therapists at Johns Hopkins Hospital, the Johns Hopkins Higher Level of Mobility (JH-HLM) and the abbreviated inpatient form of the Activity Measure for post-acute care (ON-PAC🇧🇷 Here, we study these metrics in a neuroscience inpatient population because they are frequently admitted for evaluation for falls, dizziness, abnormal gait, and/or weakness, or are post-state neurosurgical procedures that can result in mobility issues such as postoperative sequel.

Project:This study was carried out during 5 study sessions between May 29 and June 26, 2015 in two 34-bed neuroscience units in a large teaching hospital. A mobility event consisted of an RN (Mobility RN) assessing the patient's mobility potential and mobilizing him to the highest level on the JH-HLM scale with which he felt comfortable. An RN observer and a PT observer were also present during the mobility event. After the mobility event, the 3 study participants independently rated the patient on the JH-HLM and AM-PAC scales and served to measure inter-rater reliability. Each study session consisted of a mobility event in the morning and in the afternoon and served to measure test-retest reliability. The JH-HLM is an ordinal scale to record the achievement of mobility milestones and ranges from bed rest (score = 1) to ambulation ≥250 feet (score = 8). The AM-PAC is a functional assessment instrument with 6 questions to measure the burden of mobility limitations in activities such as sitting down and getting up from a chair or walking around the hospital room. Interobserver and test-retest reliability was calculated using Intraclass Correlations (ICC), where an ICC ≥0.6 was considered good and an ICC ≥0.7 excellent.

Results:118 neuroscience patients participated in 213 total mobility events and 68 patient study sessions, consisting of morning and afternoon mobility events. Patients had a mean (SD) age of 56.6 (15.5) years, 55% were female, 59% were Caucasian, the mean stay was 10.9 (11.8) days, and 40% They were Medicare beneficiaries. The most common diagnostic 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 degenerative nerve disease. system disturbance (6%). For interrater reliability, the ICCs between RN mobility and observing RN and observing PT were 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 morning and afternoon mobility events, based on the NB's rating of mobility, were 0.88 (95% CI, 0.82-0.93) and 0. 68 (95% CI, 0.82-0.93).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 a neuroscientific population of adult hospitalized patients. Establishing the psychometric properties of multidisciplinary functional assessment tools has the potential to have a broad impact on direct patient care. Future studies should investigate whether these results are generalisable to other patient populations.

Renal cell carcinoma and paraneoplastic weakness

dr. Ingrid Yang; Danny Bega, MD, MSCI; Dr. Steven Nussbaum

Diagnosis of the case:Weakness as a paraneoplastic syndrome in renal cell carcinoma

Case description:A 61-year-old woman with type II diabetes presented with several days of urinary retention and inability to ambulate in the context of a year of progressive lower extremity weakness and 100-pound weight loss. She described weakness in her proximal left leg, then her right leg and bilateral hands, and numbness and tingling in her feet. On examination, she had weakness and atrophy in the proximal lower extremities and intrinsic muscles of the hand. Sensation dwindled at her feet. Her lower extremity reflexes were absent. Catheterization revealed 2 liters of retained urine. Lumbar puncture revealed 175 total proteins and 1 WBC. Cytology and the paraneoplastic panel were negative. EMG/NCS demonstrated a length-dependent chronic sensorimotor polyneuropathy with demyelinating features with diffuse fibrillations in the lower extremities, possible CIDP or lumbar plexopathy. CT showed a 1.2 cm mass in the right renal parenchyma. Partial nephrectomy confirmed clear cell renal cell carcinoma. She was given steroids and then IVIG treatment once a week and she was released to a skilled nursing facility for her rehabilitation. One month after resection, she still required intermittent catheterization, but with improvement in urinary desire and was independently modified with a walker for home distances.

discussions:Paraneoplastic symptoms are estimated to occur with CRC in 10-40% of patients, but are generally endocrine or neuroendocrine abnormalities rather than neurological symptoms. Paraneoplastic neuropathy with CRC has been described in case reports, although the pathologic basis is unknown and the electrophysiologic features are not well described. In this case, demyelinating features and albuminocytologic dissociation suggested CIDP, but autonomic involvement raised suspicion of painless diabetic amyotrophy, and some features on EMG resembled plexopathy.

Conclusions:Paraneoplastic weakness in RCC is rare, and electrophysiological features are variable. This case considers the possibility that RCC causes paraneoplastic weakness with features of CIDP, as well as lumbosacral plexopathy.

Resident Quality Improvement Project: Urgent Unplanned Discharges from an Inpatient Rehabilitation Unit (IRF)

Dmitry Dvoskin, MD; Little John, MD; Deanna Holtman, NP; Margaret A. Turk, MD

Goals.IRFs admitting patients with high medical acuity and case mix rates must manage unplanned discharges of patients to higher levels of care. These discharges are not surprising, but they do interrupt the flow of patients and the routine activities of the unit. The goal of a resident-led quality improvement project is to determine risk factors that can prospectively identify these patients and develop a follow-up strategy to protect at-risk patients.

Project:A retrospective cohort (unexpected IRF discharge for intensive care from September 2014 to July 2015) had their electronic medical records extracted. Several variables were identified from published articles that evaluated urgent discharges and 30-day readmissions. Functional comorbidity index (FCI), Charlson comorbidity index (CCI), and Braden scale scores were determined. Reasons for discharge and discharge destinations were noted.

Results:There were 29 subjects with a mean age of 65 years (38-88 years). The most common rehabilitation disability category was orthopedic disorders. The most complex surrogate indicators included previous acute length of stay (LOS) (17.4 days), mean number of medications on hold (11.10), and IRF LOS (13.14 days). The average FCI was 5.2; the most common comorbidities identified were neurological disease (18) and CHF/heart disease (18). The mean ICC was 7.10; the most common comorbidities identified were Non-Metastatic Solid Tumor (22), Cerebrovascular Disease (13) and Peptic Ulcer Disease (12). The reasons for discharge were surgical (12), superior medical (12), neurological disorder (3), psychiatric (1) and miscellaneous (1). The most common discharge destinations were telemetry/ICU (13), Orthopedic Floor (5), Preoperative waiting for emergency surgery (4).

Conclusions:Common factors for patients at high risk of unplanned discharge from an IRF are high complexity of care, especially related to neurological conditions, cancer, and heart disease. Further collection and analysis of patient data using a case-control approach will be used to identify patients at higher risk of potentially preventable unplanned discharge and to develop an intervention and follow-up plan.

Return to Play Post-Operative Rehabilitation Program for Professional Soccer Athletes with Lumbar Radiculopathy

Laura M. Pilgram, BA; Mateo Matava, MD; Reggie Scott, Bachelor of Science, Master of Science; Jacob Buchowski, MD, MS; Heidi Prather

Diagnosis of the case:Postoperative rehabilitation program for sports reintegration for professional soccer players with lumbar radiculopathy

Case description:A 24-year-old professional soccer player presented with low back pain during preseason. Symptoms progressed despite conservative treatment. An MRI showed disc extrusion at L4-L5 and congenital central stenosis from L2 to L5. He opted to undergo microscopic discectomy and decompression. Immediately after surgery, he reported a decrease in the intensity of his lower back and thigh pain. He had a new lumbar dislocation. On postoperative day 5, the athlete began rehabilitation by walking on a treadmill with altered gravity at 50% of body weight while he corrected for the shift using a mirror for orientation. Active neural glides designed to reproduce the sensation of “stretching” but avoiding pain were performed. His lumbar dislocation was corrected within 3 days and 2 weeks after LBP surgery and positive signs of neural tension were removed. He progressed to walking and bicycling on a fully loaded treadmill with lumbar stabilization in the frontal and sagittal planes. Retesting of active range of motion provocation and neural tension signals was used before and after the sessions to decide when to advance activities. This provided a mechanism to guide milestone achievement with the athlete as an active decision maker. In weeks 6 and 7 he ran at 60% and progressed to 80% body weight. Log rotating activities were introduced. In weeks 8 and 9, he began position-specific exercises. He returned to play 10 weeks after surgery, completed the season and remains symptom free now, one year after surgery.

discussions:Postoperative rehabilitation for athletes with spinal disorders who intend to return to play has not been well researched or described. This case is an example of a rehabilitation protocol that allowed a successful return to play and maintenance of symptom-free one year after surgery.

Conclusions:This report provides a model for postoperative rehabilitation of the lumbar spine for athletes with return-to-play milestones. Supported by AAP RREMS (LP).

Review of major amputation of the lower limbs and independent walking in 12 months

Rebecca A. Speckman, MD, PhD; Daniel C. Norvell, PhD; José Czerniecki, MD

Goals.To determine whether revision of the same level or higher level amputation is associated with independent ambulation 12 months after the initial major disvascular amputation of the lower extremity and whether the results depend on the level of initial amputation.

Project:Two multicenter prospective cohort studies were combined. Eligibility criteria included: 18 years or older, initial disvascular lower extremity amputation (transmetatarsal (TM), transtibial (TT), or transfemoral (TF)). Walking independence at 12 months was self-reported and defined as walking without waiting or physical assistance, but allowing the use of assistive devices for walking indoors or outdoors on flat or uneven surfaces. Adjusted relative risks were obtained by Poisson regression with robust standard errors. Models included amputation level, demographic characteristics, comorbidities, premorbid walking status, and the interaction of revision amputation with initial amputation level.

Results:334 patients met the study criteria and 200 were subsequently enrolled. At follow up, 9 dropped out, eight were lost, one declined, and 25 died, leaving 157 participants. Twenty-two (14.0%) underwent amputation revision at the same level (5 MT, 13 TT, 4 TF) and 10 (6.4%) underwent revision at a higher level (4 TM, 6 TT, 0 TF). 97 (62%) were independent gait at 12 months (34 TM, 52 TT, 11 TF). Review 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). Neither was any revision associated with independence of ambulation (unadjusted RR = 0.89, 95% CI 0.64 to 1.24; adjusted RR = 0.77, 95% CI 0.51 to 1.16 ). The effect of the revision on the independence of ambulation did not depend on the initial level of amputation.

Conclusions:Revision amputation to the same or higher level is not associated with the likelihood of future walking independence. Studies with larger samples are needed to better explore this relationship.

Rheumatoid vasculitis presenting with numbness, dysesthesias, and inability to walk

Emily A. Robbins, DO; Brian D. McMichael, MD; Jeffrey D. Lemberg, MD; Gerald Nora, MD, PhD

Diagnosis of the case:Rheumatoid vasculitis presenting as predominant sensory polyneuropathy.

Case description:MB is a 38-year-old independent woman with a history of poorly controlled rheumatoid arthritis who presented to hospital unable to walk after experiencing progressive numbness and dysesthesias in her extremities. Physical examination revealed left facial weakness, decreased sensation in left V2 and V3, weakness worse than in the upper extremity, areflexia, dysmetria, profoundly impaired proprioception, and decreased sense of light touch and vibration in all four extremities. There were bruises on all four extremities from colliding with objects at home.

Diagnostic investigation revealed positive RF, antibodies against cyclic citrullinated protein, and borderline thiamine deficiency. Cerebrospinal fluid, paraneoplastic markers, Lyme, SS-A/SS-B antibodies, cryoglobulins, and hepatitis panel were normal. Sural nerve biopsy showed chronic degeneration and loss of myelinated axons with areas of perivascular reactivity containing mononuclear cells and T cells, but without overt vasculitis. Serial NCS/EMG revealed absence of all SNAPs, motor conduction velocity and preservation of F waves, and decreased CMAP amplitudes with development of fibrillations and sharp waves in 4/5 muscle groups.

MB was initially treated with thiamine and IV prednisone with mild improvement in sensation and strength, but continued to have deficits in proprioception and ambulation. She was later administered a dose of cyclophosphamide while she was hospitalized for rheumatoid vasculitis. She missed the follow up.

discussions:This case describes an atypical presentation of rheumatoid vasculitis. Classic findings of vasculitis on biopsy include necrotizing vasculitis with fibrinoid necrosis and inflammatory mononuclear cell infiltrate. Despite the absence of necrosis in this biopsy, serial EMGs are more consistent with vasculitis than with another diagnosis (eg, dorsal root ganglionopathy).

Conclusions:The diagnosis of rheumatoid vasculitis should be considered in patients with a history of rheumatoid arthritis and on physical examination and evidence of NCS/EMG polyneuropathy, even if histopathological findings do not fully correspond to the classical definition of the disease.

Rimabotulinum Toxin B (Myobloc) Injection for Focal Abdominal Muscular Skeletal Pain

Susan J. Kim, DO

Diagnosis of the case:Abdominal pain in the right hypochondrium secondary to right thoracic radiculopathy associated with diabetes vs. secondary to direct injury to the abdominal skeletal muscle itself

Case description:A 51-year-old obese man with hypertension, type 2 diabetes mellitus, hyperlipidemia, and low back pain was referred to my clinic for right upper quadrant (RUQ) abdominal pain that began after sigmoidectomy surgery for diverticulitis in 2008. He reports that the surgical wound abdominal wound became infected requiring multiple washings and finally the wound was closed by secondary intention.

He underwent extensive examinations by a gastroenterologist. During the evaluation, choledocholithiasis was found and cholecystectomy was performed in December 2010, which did not improve her right upper abdominal pain. Abdominal MRI showed pancreatic division, but no evidence of pancreatitis.

Before coming to my clinic, she had tried nonsteroidal anti-inflammatory drugs, opioid analgesics, antispasmodics, and neuropathic pain relievers such as tramadol and gabapentin, without much improvement in her right upper abdominal pain. In addition, injections of local anesthetics with and without corticosteroids into the right upper quadrant abdominal scar and muscle tissues did not improve pain.

10,000 units of Rimabotulinum toxin B (Myobloc) diluted in local anesthetics (20 ml total volume) were injected at 15 to 20 different sites (1.5 ml to 1 ml at each site) along the abdominal scar of the RUQ and skeletal muscle tissues under the guidance of electromyography and ultrasound (EMG/US). The patient was able to locate his most severe abdominal pain in the region where complex repetitive discharges (CRD) were heard on the EMG during the injections. No other abnormal findings (ie, positive sharp waves or fibrillation potentials) were observed on the EMG.

As he has diabetic distal symmetric polyneuropathy affecting his bilateral lower extremities from the 2011 Nerve Conduction Study (NCS), a needle EMG test was performed on the bilateral thoracic paraspinal muscles in October 2013, which showed no abnormal spontaneous electrical potential.

Myobloc injections performed at my clinic resulted in a 50-70% reduction in abdominal pain over 2-3 months between 2011 and 2012. The dose was reduced to 5000 units in 2013 as there was a benefit with subsequent injections . Even with a reduced dose, he experienced a 50-70% reduction in pain. Also, the benefit lasted from 3 months initially to 6-8 months after 3 years of receiving Myobloc injections. So now he gets a maintenance injection of Myobloc twice a year.

Its most painful region still correlates to where the CRDs are heard on the EMG during injections; however, CRDs are heard less frequently now than when the Myobloc injection was started in December 2011.

discussions:Complex Repetitive Discharges (CRDs) are bursts of recurrent complex muscle action potentials that begin and end abruptly. It can be seen in chronic conditions of myopathy and neuropathy.

Therefore, CRDs indicate that there has been some damage to muscle fibers, as CRDs originate from muscle fiber to muscle fiber and are time-limited (i.e., ephaptically activated), either as a consequence of trauma direct or neuropathy affecting muscle fibers.

In this particular patient, the previous direct trauma/injury to the right abdominal skeletal muscle is more likely based on a history of infection in the region than as a consequence of right thoracic radiculopathy or involvement of the right ventral thoracic rami (focal neuropathy). ) from its associated condition to diabetes.

In animal studies, botulinum toxins have been shown to block the release of substance P (a neuropeptide involved in pain transmission) and reduce the release of calcitonin gene-related peptide, both of which may reduce pain. This is an independent mechanism of pain reduction by decreasing muscle hyperactivity by blocking the presynaptic release of the neurotransmitter acetylcholine at neuromuscular junctions (NMJs).

Rimabotulinum B toxin (Myobloc) injections have been quite effective in reducing right upper quadrant 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 muscular skeletal pain who have not responded to oral analgesics (i.e., NSAIDs, opioids, neuropathic analgesics, etc.).

Myobloc is believed to have a higher affinity for sympathetic nerve endings than onabotulinum toxin A (Botox) and this may explain better pain control with Myobloc than Botox if pain is sympathetically caused.

In the future, it would be great to do a comparative study of Myobloc and Botox injections to determine which particular toxin provides the greatest benefit in this specific set of patient populations.

Furthermore, it would be good to further explore the usefulness of botulinum toxin injections to control associated visceral abdominal pain.

Role of the study of the blink reflex in acute multiphasic demyelinating encephalomyelitis: a case report

Juan Carlos Pérez, MD; Joanne M. Delgado, MD; Carmen Lopez, MD

Diagnosis of the case:Acute demyelinating encephalomyelitis (ADEM) is an immune-mediated inflammatory demyelinating disease of the central nervous system that usually affects children in a monophasic and multifocal manner. Multifocal ADEM lies in the juxtaposition of ADEM and multiple sclerosis (MS), making its diagnosis controversial. Currently, MRI studies are considered important diagnostic tools to differentiate MS from ADEM; however, iterative reports have demonstrated the utility of electrodiagnostic studies (EDX) in aiding in the diagnosis of MS, raising the question of the utility of such studies in correlating diagnosis and prognosis in ADEM patients. multiphase.

Case description:A 12-year-old female, previously diagnosed with ADEM nine months ago, with no residual functional deficits, presents with new neurologic findings, including left hemiparesis and left facial palsy. Magnetic resonance imaging studies showed the development of intervals of demyelinating lesions of the left hemipon and central pons/medulla oblongata. The patient was treated with high-dose intravenous corticosteroids and IVIG with clinical improvement of facial paralysis and, to a lesser extent, of left hemiparesis. Blink reflex studies performed three weeks after treatment showed no abnormalities in ipsilateral and contralateral R1 or R2 latencies, nor abnormalities in facial nerve amplitude or latency.

discussions:As reported in the MS literature, electrodiagnostic studies, such as blink reflex studies, have been used to correlate neuroimaging studies with clinical findings and to support diagnosis across time and space when the trunk brain is involved. In our case with demyelinating lesions of the pons and medulla oblongata and clinical facial palsy, we would have expected abnormal blink reflex results (R1/R2 latencies). However, given the resolution of the presentation after the study, normal results may indicate improvement after treatment.

Conclusions:Given their cost-effectiveness and accessibility, neurophysiological tests such as the study of the blink reflex should be considered as a complementary method to establish prognosis and recovery in multiphasic ADEM.

Saphenous nerve entrapment case series

Dr. A.S. Thomas J. Malbrough, MA; Jessica M. Hasak, MPH, RN; Heidi Prather, DO; Susan Mackinnon, MD; Andrew Yee, Bachelor of Science

Diagnosis of the case:We describe the clinical symptom complex of seven patients with saphenous compression neuropathy confirmed by successful saphenous nerve release.

Case description:In a retrospective chart review, we obtained data from seven patients referred for plastic surgery to release the saphenous nerve. Our subject population primarily developed pain after surgery (3) or trauma (3). They had a variable distribution of pain, but were predominantly concentrated on the medial aspect of the knee or along the medial aspect of the leg from the distal thigh extension to the ankle. Three people had undergone knee surgery prior to our evaluation in an attempt to improve their symptoms. All subjects underwent a saphenous nerve release, while some underwent additional procedures that typically involve other nerve decompressions.

discussions:The saphenous nerve is the largest sensory nerve that branches off the femoral nerve. It travels medially through the adductor canal, or Hunter's canal, bounded by the vastus medialis, abductor longus, and adductor magnus muscles. Saphenous nerve entrapment most commonly occurs at the exit of the adductor canal when the nerve pierces the fascia between the sartorius, vastus medialis, and adductor magnus muscles. Although saphenous nerve injury from surgery is reported in as many as 50-70%, less than 1% of adults presenting with lower extremity pain are reported to have saphenous neuropathy. Our case series demonstrates the successful treatment of saphenous vein compression neuropathy resulting from saphenous nerve release. Three patients had a complete resolution of symptoms, while another three had a modest improvement after surgery.

Conclusions:Saphenous nerve entrapment is probably an unrecognized cause of pain in the medial knee and lower extremities. A history of surgery involving the knee prior to symptom onset or persistent symptoms despite surgery likely contributes to the diagnosis of saphenous neuropathy.

Satisfaction with a Formal Orientation Program in Physical Medicine and Rehabilitation

Mithra Maneyapanda, MD; Dra. Leslie Rydberg

Goals.To assess satisfaction with a formal mentoring program in a Physical Medicine and Rehabilitation residency program.

Project:Research-based prospective study. Anonymous surveys with Likert-type items were distributed to all program participants. Surveys were completed at the beginning and end of the school year. Responses were scored from 1 to 10, with 10 being the most valuable/satisfied. Participants met with their assigned mentor/mentee 4 times during the year.

Results:The response rate of treating physicians was 25 of 25 (100%) for the baseline survey and 20 of 25 (80%) at follow-up. The resident response rate was 28 of 36 (77.8%) for the baseline survey and 25 of 36 (69.4%) at follow-up. The most important program goals for residents were career planning (mean 9.37, standard deviation 0.84), resident support/wellness (8.00, 1.71), and networking (7, 77, 2,27). The most important goals for attending physicians were career planning (8.48, 1.06), resident support/wellness (8.08, 1.35), and networking (7.00, 1.77). At follow-up, residents were more satisfied with resident support/well-being (7.80, 2.21), organizational knowledge (7.71, 2.29), and career planning (7.56, 2.29). 2, 58). Physician assistants were more satisfied with resident support/well-being (8.15, 1.75), career planning (8.10, 1.55), and organizational knowledge (7.85, 1.55). 63) . At follow up, residents felt that people 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 mentoring program. After a year in the program, residents felt that people were more available to address their concerns. These results demonstrate that a formal mentoring program can address goals that are important to the participants. These results can help tailor counseling programs to improve their effectiveness.

Seronegative neuromyelitis optica (NMO) after L5-S1 laminectomy: case report

Sean A. Lacey, BSC; Estevao Alcinto. Guirand, MD; Douglas Sohn, MD

Diagnosis of the case:Seronegative neuromyelitis optica (NMO)

Case description:A 54-year-old man of mixed Native American and Caucasian ancestry was admitted to a tertiary hospital two weeks after an L5-S1 laminectomy with discectomy with a primary complaint of lower extremity and sacral paresthesias associated with limb weakness. lower. His hospital course was complicated by progressive weakness, optic neuritis of the left eye, bowel and bladder incontinence, drowsiness, and intractable vomiting.

MRI of the skull revealed hydrocephalus. Whole spine MRI revealed T2-weighted hyperintensity from the obex level to the T9 level, along with a 5-mm incidental mass along the first lumbar nerve. Lumbar nerve biopsy was consistent with schwannoma. Frontal leptomeningeal biopsy did not reveal malignant cells. IV dexamethasone was started and a ventriculoperitoneal (VP) shunt was placed. After VP shunt placement, there was an exacerbation of the above symptoms and a new weakness in the right upper extremity. Autoimmune testing, including serum anti-AQP4 antibody, was negative, however CSF anti-AQP4 was positive. Treatment with rituximab and five cycles of plasmapheresis were performed over the following two weeks, with improvement in optic neuritis, weakness, and constitutional symptoms.

discussions:AQP4 expression is known to be increased in the context of tumors and trauma. The history of recent spinal instrumentation in this patient, associated with the initial development of symptoms and the finding of an incidental schwannoma, suggests the possibility of triggering the disease through a tumor and/or surgery.

Conclusions:In patients with NMO, symptoms may manifest after spinal surgery or in the presence of tumors of the nervous system.

Severe statin-induced autoimmune necrotizing myopathy (SINAM) resulting in functional tetraplegia

Marissa L. Dombovy-Johnson, BA; Erin M. Conlee, MD; Dr. Jeffrey A. Strommen

Diagnosis of the case:Severe statin-induced autoimmune necrotizing myopathy (SINAM)

Case description:A 62-year-old woman with hyperlipidemia developed progressive axial and proximal limb weakness over a 6-week period, 11 months after starting statin therapy. Evaluation revealed creatine kinase (CK) levels greater than 10,000, electromyography (EMG) showed diffuse myopathy, and muscle biopsy showed necrotic and regenerating fibers without prominent inflammation.

EMG and muscle biopsy were compatible with SINAM and the diagnosis was confirmed with positive anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) autoantibodies. Aggressive immunosuppressive therapy consisting of prednisone, rituximab, methotrexate, and IVIG was started. The hospital course was complicated by pneumonia against the background of weakness of the respiratory muscles and severe dysphagia.

Serum CK levels decreased, but debilitating muscle weakness persisted, and the patient was admitted for inpatient rehabilitation to optimize functional status. The patient currently drives a motorized wheelchair.

discussions:Statins are commonly prescribed lipid-lowering agents that are used in the prevention of cardiovascular disease. Although well tolerated, musculoskeletal complications range from an asymptomatic increase 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. Features of SINAM include rapid-onset proximal muscle weakness, elevated CK, irritable pattern on EMG, and myonecrosis with minimal inflammation on biopsy. The newly discovered anti-HMGCR antibody is highly specific for diagnosis. Various immunosuppressive agents have been used with favorable responses in functional improvement. Antibody levels correlate with CK levels and clinical severity; therefore, the trend of anti-HMGCR levels can provide treatment recommendations. Current literature suggests that recovery may be prolonged, taking 9 to 12 months to regain functional strength.

Conclusions:This case illustrates the debilitating consequences of this serious disease. Knowledge of this condition is vital, since these patients are optimally cared for by physiatry and the multidisciplinary rehabilitation team.

Short-term bisphosphonate-induced atypical femoral fracture

Saiyun Hou, MD, PhD; Monica Verduzco-Gutierrez, MD

Diagnosis of the case:Short-term bisphosphonate-induced atypical femoral fracture

Case description:A 73-year-old woman was admitted with a femoral shaft fracture of the left thigh. She reported that she tripped and fell off 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. The radiograph showed an oblique fracture of the femoral shaft displaced to the left and an atypical fracture of the right femoral shaft. Her previous history revealed osteoporosis for which she was taking alendronate for 10 months and discontinued after 2-3 years prior to this fracture. She underwent bilateral closed reduction of the femur and internal fixation with cephalomedullary nailing. The patient began to walk the day after surgery and can walk with a walker without any problem.

discussions:Bisphosphonates reduce the overall risk of fractures in patients with osteoporosis. However, since bisphosphonates inhibit bone remodeling, they may increase the formation and propagation of microcracks over time, and therefore patients may be prone to atypical stress fractures. The risk of atypical fracture among women increased progressively with duration of use. Additionally, for each year since last use, the risk was 70% lower. The consensus now is to take into account the increased risk of atypical fractures when bisphosphonates are continued beyond 5 years. To date, few reports have described atypical femoral fractures induced by the use of short-term bisphosphonates (<1 year). Our data showed that an atypical fracture of the femoral shaft occurred 2 to 3 years after receiving bisphosphonates for 10 months. We recommend that the patient taking bisphosphonates request bone scans at regular intervals to detect fractures.

Conclusions:Despite the overall beneficial effect of bisphosphonates, bone scintigraphy is routinely recommended for the detection of atypical fractures. Also, more research is needed to avoid this significant complication.

Significant truncal/abdominal lymphedema with minimal involvement of the extremities in a patient with breast cancer

Jessica Engle, DO; Dr. Jack Fu

Diagnosis of the case:Significant truncal/abdominal lymphedema with minimal involvement of the extremities in a patient with breast cancer

Case description:A 60-year-old woman with a history of type II diabetes and carcinoma of the left breast (postresection and chemoradiotherapy status) who is currently disease-free presented to the PM&R Cancer Clinic complaining of new asymmetric abdominal wall swelling. left . She underwent a segmental mastectomy of the left breast with left axillary sentinel node dissection and reduction mastopexy of the right breast for symmetry 1.5 years earlier. The pathology study showed stage IIa T2 N0 M0 invasive ductal carcinoma of the left breast. After starting radiation to enlarge the tumor and left breast 6 months later, she complained of decreased range of motion of the left upper extremity and lymphedema. She received treatment for left upper limb lymphedema with improvement. At the follow-up clinic, she has gained 4 to 5 pounds in weight in the past 3 months, despite her lifestyle changes. The patient referred a remote history of hysterectomy and bladder suspension surgeries. She denied changes in bowel or bladder function. On examination, the patient was found to have significantly greater abdominal pannus and lymphedema on the left side compared to the right. The left breast and left lateral trunk were significant for lymphedema. The affectation of her arm was minimal. Ultrasonography revealed benign postoperative and postradiation changes in the left breast. CT was negative for hernia and showed diffuse thickening of the skin in the left breast. She failed conservative treatment and was referred to plastic surgery for possible liposuction.

discussions:Lymphedema is typically seen in the ipsilateral upper extremity in patients with breast cancer. There is a lack of literature on truncal and abdominal lymphedema in patients with breast cancer who have not undergone reconstruction with donor abdominal tissue. To the best of our knowledge, this is the first case report of a breast cancer patient with this type of presentation.

Conclusions:Early identification and treatment of lymphedema improves the quality of life for cancer survivors. Unusual presentations are not to be overlooked.

Smoking and degenerative cervical disc disease seen on computed tomography

Mitchell Leavitt, MD; Dr. William Beckworth

Goals.This study seeks to assess the association between smoking and cervical degenerative disc disease (DDD) through advanced imaging using computed tomography (CT). This has been reported in the lumbar spine but not in the cervical spine, except for one X-ray study which suggests that smoking has no effect.

Project:A radiologist with subspecialty training in neuroradiology along with a physiatrist reviewed 182 consecutive CT scans that were performed at a university hospital for various reasons. Documentation regarding the severity of cervical DDD was performed. Each disc was classified as normal, mild (0-33% disc height loss), moderate (33-66% disc height loss), or severe (>66% disc height loss or void disc). ). Scores from 0 (normal) to 3 (severe) were given for each disc. A cumulative cervical DDD score for the entire cervical spine (C2-7), with a range of 0 to 15, was provided. Other health information was collected, including age, smoking, pack-years, BMI, hypertension , dyslipidemia and diabetes. A linear regression model was used to assess the correlation with cervical DDD, considering age.

Results:Of the 182 patients, 61 were smokers (34%) and 103 were women (57%). Age was correlated with worsening of cervical DDD (correlation coefficient 0.636, p < 0.0001). Current smokers had more severe cervical DDD after controlling for age (p = 0.0203). Active smokers had a cumulative cervical DDD score worse by one point on average. There was no statistical significance for the years of packaging (p=0.164). Comorbidities including diabetes, hypertension, hyperlipidemia, and BMI did not correlate with worsening of 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 after bilateral hip arthroplasty

Diana Barayeva, DO; Yu-Jen Lai, MD

Diagnosis of the case:A 50-year-old man with headache secondary to intracranial hypotension after spinal anesthesia for bilateral hip arthroplasty.

Case description:A 50-year-old man underwent bilateral total hip arthroplasty under spinal anesthesia. Entering acute rehabilitation on the second postoperative day, he reported a severe nauseating headache that was aggravated by upright posture. Cranial computed tomography revealed a hypodense area in the posterior parasagittal convexity, suspicious for subarachnoid hemorrhage. Anticoagulation was discontinued. IV fluids, caffeine, and bed rest were ordered. Contrast-enhanced brain MRI revealed diffuse enhancement of the dural parenchyma in both cerebral convexities and cerebral sinus vein thrombosis. The patient's headache was thought to be secondary to cerebrospinal fluid leakage, resulting in intracranial hypotension. He started on methylprednisolone. On the seventh postoperative day, the patient's headaches decreased and his FIM score improved 33 points in ten days.

discussions:Spinal anesthesia may be indicated for surgeries of the pelvis and lower limbs. Lidocaine is injected into the intrathecal space at L2-L3, providing sensory and motor block. Postanesthetic spinal headache and intracranial hypotension are seen more frequently when large-bore spinal needles are used, resulting in CSF leakage and decreased CSF pressure. Initial treatment includes bed rest, fluids, caffeine, and steroids. An epidural blood patch can be used to treat this condition with 80% effectiveness when initial treatment fails.

Conclusions:Severe intracranial hypotension after 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 deserves review as it describes a rare and serious neurological complication of a commonly used anesthetic procedure, which must be immediately recognized by rehabilitation professionals in order to administer timely and effective treatment.

Connective tissue elongation: do porcine fibroblasts increase cross-sectional area in response to shear stretch?

Mairin A. Jerome, MD; Nicole A. Bouffard, Bachelor of Science; Rhonda L. Maple, AS, BS; Gary J. Badger, MS; Dra. Helene M. Langevin

Goals.In mouse areolar connective tissue, fibroblasts respond to tissue stretching shear by actively remodeling their cytoskeleton and increasing in size. This response has been associated with purinergic signaling and may be important for local sensory modulation, in addition to affecting the viscoelastic properties of connective tissue. As porcine tissue architecture is more human-like than mouse-like, we sought to determine 1) whether or not a stretch-like fibroblastic response occurs in porcine tissue and 2) whether this response is altered when altered. movement of the animal in vivo. We hypothesized that the mean cross-sectional area of ​​fibroblasts would increase in stretched versus non-stretched tissue and that this difference would decrease in movement-restricted (lame) pigs compared to controls.

Project:Postmortem porcine tissue was collected from three lame animals and three controls. Bilateral samples spanning dermis to skeletal muscle were collected, half of which were shear stretched for 2 hours, fixed with paraformaldehyde, microdissected, phalloidin stained, and visualized under confocal microscopy. Cell body area measurements were obtained using MetaMorph analysis. An analysis of variance was performed comparing the mean areas of stretched versus unstretched tissue and the differences between control and lame pigs.

Results:There was a significantly greater cell area in the stretched tissue compared to the unstretched tissue (F = 31, p < 0.01). There was also a significant interaction between the effect of stretching and treatment group (F=8.4, p < 0.05) with a greater increase in cell cross-sectional area in piebald pigs.

Conclusions:These preliminary data demonstrate that ex vivo porcine connective tissue responds to shear stretch with a significant increase in mean fibroblast cell area. This is consistent with what has been previously seen in mice but never before seen in pigs. We found a striking increase in stretch responsiveness in lame pigs, which has so far not been explained and needs to be confirmed with a larger group of animals.

Study of the effects of onabotulinum toxin injection on needle electromyography of the lumbar paraspinal muscles

Adam J. Susmarski, DO; Kevin F. Fitzpatrick, MD; Min Ho Chang, MD

Goals.Injection of botulinum toxin A into the lumbar paraspinal muscles has been shown to have beneficial effects on pain in patients with chronic low back pain. Injection of botulinum toxin A into muscle can cause abnormal spontaneous activity on the EMG needle, regardless of denervation.

Project:Patients with chronic mechanical low back pain for more than six months were evaluated by EMG using the MiniPM technique. They were further treated with botulinum toxin A injections into the lumbar paraspinal muscles, followed by reassessment of the paraspinal musculature 1 month later using the same MiniPM technique.

Results:At the 1-month follow-up, all three patients exhibited a significant increase in the MiniPM EMG score, representing abnormal spontaneous activity in the treated lumbar paraspinal muscles.

Conclusions:Injection of botulinum toxin A into the lumbar paraspinal muscles results in abnormal spontaneous activity, creating a confounding variable in the evaluation of lumbosacral radiculopathy.

Subacute-onset chronic inflammatory demyelinating polyneuropathy (CIDP) with CNS involvement initially diagnosed as Guillan-Barré syndrome

Anand M. Navarasala, DO; Dr. Vasilios Stambolis

Diagnosis of the case:Subacute-onset chronic inflammatory demyelinating polyneuropathy (CIDP) with CNS involvement diagnosed as Guillan-Barré syndrome

Case description:A 50-year-old man with a medical history of hypertension and diabetes presented to the emergency department with balance problems, a diffuse burning sensation, and stiffness in his legs and arms. The symptoms progressed more than 12 hours after the patient fell asleep and woke up with worsening symptoms. MRI showed moderate areas of T2 hyperintensity and FLAIR signal scattered throughout the periventricular and subcortical white matter, suspicious of a demyelinating process. Analysis of the cerebrospinal fluid showed ambuminocytological dissociation, elevated IgG, and the absence of oligoclonal bands. The patient was diagnosed with Guillan-Barre syndrome and administered a five-day course of IVIG followed by plasmapheresis. The patient was stabilized and transferred to an acute rehabilitation hospital. Examination findings included horizontal nystagmus, unilateral tongue atrophy, poor phonation, tetraparesis, and symmetric patellar hyperreflexia. The patient had a minimal evolution for one month and was discharged for subacute rehabilitation as complete care. After three months in subacute, the patient was readmitted for acute rehabilitation hospitalization and maintained full care.

discussions:Approximately 15% of patients diagnosed with CIDP have a subacute onset, often initially diagnosed as Guillan-Barre syndrome. The CIDP diagnosis is given to patients after eight weeks of continuous symptoms that are refractory to treatment. Although this patient continued subacute rehabilitation therapy, he may have benefited from once-weekly pulsed steroids for 1 to 3 months, followed by IVIG if ineffective.

Conclusions:Patients affected by CIDP require close monitoring due to neuronal demyelination along with axonal degeneration associated with the disease. If not aggressively treated throughout the course of the disease, axonal degeneration can lead to irreversible damage. Guillan-Barre and subacute-onset CIDP have similar presentations, and both duration and frequency of treatment change depending on the transition from acute to chronic inflammatory demyelinating polyneuropathy.

Superior gluteal neuropathy after breast reconstruction with superior gluteal artery flap (SGAP): case report

Alan Schleier, DO; dr. Eric Wisotzky

Diagnosis of the case:Superior gluteal neuropathy after breast reconstruction with superior gluteal artery flap (SGAP)

Case description:We describe the case of a 53-year-old woman who attended outpatient rehabilitation services due to a history of breast cancer. She had undergone a right mastectomy 11 months prior to presentation and she had a superior gluteal artery perforator (SGAP) flap reconstruction 4 months prior to presentation. At her first visit, she described pain in the right lateral buttock that began immediately after the reconstruction. She noted a “tight” pain that worsened with walking and sometimes progressed to numbness, tingling, and burning. Initially a clinical diagnosis of sciatica was made, however further investigation was carried out. MRI of the lumbar spine did not reveal significant narrowing of the central or neuroforaminal canal, but did demonstrate asymmetric fatty denervation of the right gluteus medius muscle. Closer 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 lesion in the superior gluteal nerve.

discussions:An increasing number of breast cancer survivors who undergo mastectomy are opting for SGAP reconstruction because of the positive results associated with this method. Given the history and clinical findings related to this patient, it is most likely that her superior gluteal neuropathy was a direct result of her SGAP flap procedure. Although this surgical approach tends to preserve important neurovasculature, this case identifies the possibility of damage to important structures.

Conclusions:This case demonstrates that although donor site morbidity is considered very low in SGAP flap reconstructions, superior gluteal neuropathy can occur. This case is of great importance in highlighting this potential adverse effect, and physiatrists treating breast cancer survivors who have undergone SGAP reconstruction will benefit from learning about this potential complication.

The Case of Mr. K.: Electrodiagnostic studies saved the patient from unnecessary neurosurgery

Rupali Kumar, MD; Lauren Eichenbaum, MD; Dr. A.S. Richard Keyme; Min Kim, DO; Dr. A.S. Roger Climate

Diagnosis of the case:lumbosacral radiculoplexopathy

Case description:The Lord. K. is a 53-year-old male with a previous C3 AIS C TSCI due to a 1984 diving accident, 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 suggested cervical spondylitic myelopathy, although unchanged from the previous three years. Considering cervical spondylitic myelopathy as the potential source of her problems, they planned an anterior corpectomy with ACDF C6-7. However, several days before the planned surgery, an electrodiagnosis was requested to clarify the weakness of the RPE.

EMG/NCS revealed electrodiagnostic evidence of acute denervation in the right L2-S2 myotomes, with no abnormalities in the 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 the suspicion of right lumbosacral radiculoplexopathy, suggesting a more distal cause for the patient's symptoms. The EMG showed that the triceps and pronator teres abnormalities were chronic, probably as a result of his original spinal cord injury.

As a direct result of these electrodiagnostic findings and discussion with our neurosurgical colleagues, the decision was made not to proceed with cervical spine surgery that was scheduled to take place later in the week, in favor of further investigation of lumbosacral radiculoplexopathy. that to date. It is of obscure etiology.

Conclusions:Electrodiagnostic tests are often difficult to draw meaningful conclusions unless they are used to support a strong clinical suspicion. This was a case where electrodiagnosis played a key role in influencing management decisions and sparing the patient unnecessary invasive surgery.

The effect of a mirror on the preferential loading of the lower extremities during a two-legged squat: a pilot study

Monica Rho, MD; Franz Nigl, MS; Steven Makovitch, D.O.

Goals.The double leg squat is a regularly used exercise and rehabilitation tool. While common practice is to perform squat exercises in front of a mirror to get feedback on form and positioning, some believe this has detrimental effects. There are no studies evaluating squat performance based on the use of mirrors. The purpose of this study was to examine the effect of a mirror on lower extremity preferential loading during a two-legged squat exercise in multiple standing positions (fixed, mixed, self-selected) and during a deep squat.

Project:Ten healthy subjects (5 men, 5 women) performed 5 squats to a fixed height of a chair in 3 different foot positions and 5 deep squats with and without a mirror. Mean preferential load displacement for the dominant leg was analyzed along with maximum knee and hip flexion angles during the deep squat (α = 0.003).

Results:There was no significant difference in the mean preferential load change between the mirrored and non-mirrored conditions in either type of squat.

The comparison between the fixed and mixed positions of the feet in the condition without a mirror showed a statistical difference (p = 0.001), while in the condition with a mirror there was no difference (p = 0.247). All comparisons of maximum angle of knee and hip flexion were not significant.

Conclusions:The presence of a mirror during a two-legged squat exercise did not change the preferential loading of the lower extremities. Athletes should select a comfortable foot position during an equivalently loaded squat exercise.

The effect of BNP testing on cardiac rehabilitation outcomes in patients after cardiothoracic surgery.

Adeepa D. Singh, MD; ShaEssa L. Wright, DO, MBS; Dr. Iqbal Jafri; Lei Lin, MD; Dr. Sara Cuccurrullo

Goals.Brain natriuretic peptide (BNP) is a cardiac hormone secreted by myocytes within the ventricles in response to pressure changes due to volume expansion and overload. Serum BNP levels correlate with the severity of cardiac decompensation. Compared to an echocardiogram as an assessment method to monitor cardiac function, the BNP test as a diagnostic tool provides rapid results, is operator independent, and reduces the likelihood of lost therapy time. Studies show that elevated BNP levels during the first few days after coronary artery bypass grafting (CABG) have 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 for cardiac rehabilitation monitored by acute internal telemetry.

Project:This case-control study was conducted in an acute care telemetry-monitored cardiac rehabilitation program in an academic setting. All 47 subjects were patients admitted to cardiac rehabilitation undergoing coronary artery bypass grafting and valvuloplasty involving the aortic, mitral, or tricuspid valves. The experimental group (16 patients) performed serum BNP measurements in the first twenty-four hours of hospitalization and the control group (31 patients) did not. Patients with elevated BNP levels received immediate interventions, including administration of diuretics and/or medication dose adjustments, and these levels were closely monitored for the first two to five days of hospitalization. This protocol was carried out in conjunction with close follow-up and medical management led by cardiology consultants.

Both groups were assessed on Functional Independence Measure (FIM) and Length of Stay (LOS) scores. Each group received an electrocardiogram, chest X-ray, and cardiology consultation within 24 hours of admission as part of routine care. All patients in this study underwent a comprehensive intensive care rehabilitation program for three hours per day for five days per week in a telemetry-monitored cardiac rehabilitation program.

Results:This study reveals a reduction in the length of hospital stay of 2.11 days and greater daily gains in the FIM score in the BNP group compared to the control group. This suggests a reduction in the total cost of medical care due to shorter hospital stays. The greater FIM gains were attributed to more efficient and effective therapy time and less time lost 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 have recently undergone cardiac surgery results in rapid recovery and greater daily FIM gains as a result of early intervention to prevent postoperative complications. There is a paucity of literature describing the correlations between biomarker levels with clinical and functional status outcomes of patients after CABG or valve repair in telemetry-monitored cardiac rehabilitation programs of acute hospitalization. more research. This study identifies the utility of BNP testing in the field of physiatry as a method to improve general medical care and functional outcomes for cardiac patients in acute inpatient rehabilitation programs.

The effectiveness of online learning with postgraduate medical education in PMR for the evaluation of dysphagia

Dr Noel Rao; Susan Brady, MS, CCC-SLP, CCC-SLP; Letha Williams, PhD, FACHE; Mark Hakel, PhD, CCC-SLP; Teresa Pape, DRPH, MA

Goals.Develop, implement, and evaluate the effectiveness of an interactive, online, interprofessional course designed to increase the ability of PMR residents and speech therapists to accurately interpret fiberoptic endoscopic examination of swallowing (FEES) results.

Project:This educational intervention was developed with the underlying theoretical concepts of Adult Learning Theory and Social Cognitive Theory (SCT). In the SCT, self-efficacy and its relationship with the interpretation of the FEES procedure were evaluated. A non-randomized, quantitative research study design was used to assess the efficacy of this course. Key outcome measures include the FEES Interpretation Knowledge Test (40 points) and the FEES Self-Efficacy Questionnaire.

Results:Participants who completed the FEES online training course (norte= 30) demonstrated significant improvements in their ability to interpret the results of the FEES procedure based on pre-course (28.47, SD = 3.92) and post-course (35.47, SD = 2),40) (t=−9,37,d.f.=29,pagt = 3849,d.f.=28,pag=.001); however, both groups had similar scores after the course (PMR=35.67; PFS=35.27; t=−0.450, df=28, p=0.657). PMR group(norte= 15) demonstrated a significantly greater change in knowledge (9.46, SD = 4.06) compared to the SLP group (norte=15) (4.53, SD=2.26), suggesting that this online course is an effective educational intervention for PMR residents. Self-efficacy scores related to the interpretation of the FEES procedure on a 5-point Likert scale for the entire study sample increased from 2.28 before the course to 4133 after the course (pag=.0001).

Conclusions:PMR residents gained significant knowledge in an unknown area after participating in this theory-based educational intervention for swallowing disorders. Since dysphagia is best managed by an interdisciplinary team, it is essential that PMR residents receive training in dysphagia, as it represents a significant health problem and is often seen in patients with rehabilitation needs.

The impact of routine lower limb deep vein thrombosis screening on acute rehabilitation admissions

Dra. Cynthia C. Hung; Anne Felicia Ambrose, MD, MS

Goals.Brain-injured patients are at increased risk of deep vein thrombosis (DVT) due to immobility, steroids, prolonged surgery time, and cancer. Previous studies report an incidence of 8.5% to 18% for asymptomatic DVT in the neurorehabilitation population. Despite the increase in mechanical and/or chemical DVT prophylaxis in the acute hospitalization phase, we hypothesized that screening for lower extremity DVT on admission to acute rehabilitation will detect asymptomatic DVT, which will affect management and results.

Project:In this retrospective chart review, we included patients with any intracranial pathology on imaging, including demyelination, intracranial hemorrhage, stroke, and cancer requiring rehabilitation. We excluded patients already on anticoagulation and those who had signs of DVT before screening. Patients underwent popliteal femoral venous duplex ultrasound (VDU) at least 7 days after admission (mean 1.94 days).

Results:A total of 67 hospitalized patients from February to March 2015 were included. 6 patients were excluded because they were already anticoagulated. 2 patients were excluded because they had signs of DVT before screening. 10 patients did not receive VDU. 49 patients, mean age 65.22 years, admitted on average 13.14 days after the triggering event, remained in the study. 18 patients had cerebral hemorrhage, 15 patients had ischemic stroke, 6 patients had tumors, 3 patients had demyelinating lesions, 1 patient had a combination (tumor, ischemic stroke, and cerebral hemorrhage), and 6 patients were classified as miscellaneous. 4 patients were not on chemical prophylaxis or anticoagulation. Of the 49 patients examined for VDU, 3 (6.12%) had asymptomatic DVT.

Conclusions:Screening for lower extremity DVT in our brain-damaged population has changed management and may prevent complications such as postthrombotic syndrome and pulmonary embolism. Larger prospective randomized controlled studies are needed to better understand these long-term benefits of detecting asymptomatic DVT.

Outcomes and costs of comprehensive outpatient therapies in patients with malignant brain tumors

Stacy McCarty, MD; Susan Keeshin, MD; Samman Shahpar, MD; Patricio Semik, BA; Alex Wong, doctorate, DPHIL; Dr. Sarah Eickmeyer

Goals.There is a paucity of literature to support the role of comprehensive outpatient rehabilitation in patients with malignant brain tumor (MBT), although much therapy is moving into the outpatient setting. This study aims to evaluate function, quality of life, pain, depression, and cost in adults with MBT in a comprehensive outpatient program.

Project:A prospective longitudinal cohort study of MBT patients cared for in a comprehensive outpatient program. The control group consisted of 50 patients with brain injury and 50 patients with stroke, 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 month and three months after discharge. The cost of the day rehabilitation program, demographics, and treatment characteristics were evaluated.

Results:49 MBT patients were studied for 35 months. There was a significant improvement in total function (t(33) = −7.524, p < 0.01), mobility (t(36) = −8.636, p < 0.01), activities of daily living (t(35) = −5.418 , p < 0.01) and communication (t (34)=−5.224, p < 0.01). Those who received chemotherapy or radiotherapy had worse mobility gains (t(35)=2.208, p=.034). Younger patients had better mobility gains (r=−0.339, p=0.040). Women had higher functional gains (t(31)=−3.203, p=.003). Those with less pain from discharge to one month had better social/family well-being (r=0.494, p=0.027) and significant gains in total function (r=0.556, p=0.039) and mobility (r=0.039). 561, p=0.024). Total QoL from admission to discharge was correlated with total functional gains (r=0.418, p=0.05) and mobility (r=0.487, p=0.013). Physical well-being at admission was correlated with depression at all time points (r = −0.368, −0.480, -0.513, all p.013). Total QoL at admission was correlated with depression at all time points (r = −0.638, −0.478, −0.623, all p 0.006). There was no significance between functional gains and caregiver burden. Total cost (t(141)=−2.971, p=0.003) and cost per day (t(105)=−2646, p=0.009) were significantly lower than the control group.

Conclusions:Comprehensive outpatient therapies improve function in people with malignant brain tumors and are less expensive than similar therapies in people with brain injury or stroke. QoL also improves, with correlations with depression, pain, and function.

The state of disability awareness education in American medical schools

Dra. Erica Seidel; Dr. A.S. Scott Crowe

Goals.The purpose of this research study was to: 1) determine how many US medical schools include disability awareness in their curricula, 2) explore the format of existing disability awareness programs 3) understand Why some colleges don't include disability awareness on their resume.

Project:An online survey was sent to deans of medical education at all US medical schools (n=167). The questionnaire asked if they had an awareness program. Schools with a program were asked to provide additional details about the characteristics of their program. Schools without a program were asked about barriers to having a program and their interest in adopting a curriculum if one were provided.

Results:75 schools completed surveys. 52% (39/75) reported having a disability awareness program. The most common format was people with disabilities or carers speaking in a large group. The programs were more likely to focus on adults with physical disabilities. Among schools without a program, the main barriers were lack of advocacy for inclusion in the curriculum and time constraints. Nearly half of the schools without a program expressed interest in adopting an awareness curriculum if one were provided.

Conclusions:52% of surveyed medical schools have a disability awareness program. The actual rate across all US medical schools could be as low as 23% if we assume there was selection bias with schools without programs less likely to respond. Efforts should be made to increase this number through further promotion or the provision of additional resources for schools without a curriculum. It is encouraging that almost half of the schools would be willing to adopt a curriculum if it were provided. Programs described by other respondents can be used as a starting point for curriculum development.

The use of a submaximal exercise program in the rehabilitation of normal pressure hydrocephalus complicated with myotonic dystrophy type 2

Franz Jones, do; Dr Noel Rao

Diagnosis of the case:A 62-year-old woman with a previous diagnosis of Type 2 Myotonic Dystrophy who presented normal pressure hydrocephalus 9 months after mechanical fall

Case description:A 62-year-old woman with a prior diagnosis of myotonic dystrophy type 2 who presented to her primary care physician in August 2013 with complaints of confusion, progressive memory loss, urinary incontinence, and increased gait problems in the past 9 months from a fall. in December 2012 The etiology of the fall was considered mechanical, as the patient had been suffering from weakness, muscle fatigue, and pain that had slowly and progressively worsened since the diagnosis of myotonic dystrophy type 2 in 2005. Brain imaging revealed the diagnosis end of normal pressure hydrocephalus. In September 2013, a ventriculoperitoneal shunt was placed by Neurosurgery and the patient was discharged to an Acute Rehabilitation unit. On admission, the patient complained of moderate to severe muscle pain, stiffness, weakness, and fatigue during the first physiotherapy evaluation and subsequent initial physiotherapy sessions. A submaximal exercise program combined with daily muscle stretching and range of motion exercises was implemented to help the patient relieve pain and work toward discharge goals. The patient reported a significant decrease in daily pain and muscle soreness levels with a subjective increase in physical endurance.

discussions:Myotonic dystrophy type 2 is a rare multisystem progressive neuromuscular disease with limited evidence supporting the use of specific physiotherapy exercises or specific therapeutic modalities in the management of the disease. Although the primary diagnosis here is normotensive 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 myotonic dystrophy type 2.

Conclusions:In patients with myotonic dystrophy type 2, clinicians should consider using a prescribed submaximal exercise program combined with daily muscle stretching and ROM exercises to decrease pain, decrease stiffness, and obtain better results. Further studies and evidence are needed to assess the effectiveness of such exercise prescription for use in both acute inpatient rehabilitation and in the outpatient setting.

Usefulness of ultrasound in the diagnosis of CAM-type femoracetabular impingement

Dr. Raisa Bakshiyev

Diagnosis of the case:Femoracetabular impingement - CAM type

Case description:A 34-year-old man with a significant medical history of painless, self-resolving infantile claudication was told that his left lower extremity was longer than his right during a routine PCP visit. She was prescribed to wear an insole in her right shoe only. Simultaneously, he began a running regimen of 2 to 3 miles a day. One month after the change in exercise routine, he began complaining of pain in his right groin, worsened by right hip rotation, which woke him from sleep. The patient also noted that he lost 30 to 40 degrees of hip external rotation during yoga class. He was evaluated by the physiatry service with the help of a musculoskeletal ultrasound. On physical examination, it was noted that he actually had a 1 cm shorter actual left leg length, the right foot was rotated outward relative to the left, and hip impingement maneuvers were positive. On ultrasound (images available), a bony tip was noted protruding from the femoral head-neck junction and an anterior superior labral tear was visualized. A diagnostic lidocaine injection resolved the patient's pain from 3/10 to 0/10, and the patient was given the option of seeing a surgeon specializing in hip arthroscopy and FAI. After consultation, the patient decided to postpone surgery because the lip lesion, confirmed by MRI, was small and the symptoms resolved with modification of physical activity and self-directed physiotherapy. The patient will be followed up annually for his control.

discussions:This case illustrates several important issues. It is not known whether correction of the leg length discrepancy with shoe inserts contributed to the symptoms; however, instead of correcting for asymmetry, the reason for the asymmetry should be considered. Etiologies may include mild hip dysplasia or early hip osteoarthritis, coxa vara, or the result of childhood disease such as SCFE. Because it is possible to visualize the bony contour of the anterior superior femoral head-neck junction, ultrasound is useful in the evaluation of CAM-type FAI. Furthermore, it is a widely available tool and does not provide radiation exposure to the patient. Once the diagnosis of FAI was made, arthroscopic surgical correction was considered by the patient, his family and the surgeon. Ultimately, there is a paucity of long-term evidence for or against arthroscopic intervention, with the final decision depending on patient expectations, the extent of intra-articular pathology, and the degree of pain.

Conclusions:As demonstrated by previous studies, ultrasonography has been shown to be useful in detecting CAM-type FAI, but is not routinely used for this purpose. This patient had a clear abnormality of the femoral head and neck junction seen on ultrasound, which, if used in the office, can save time in obtaining an accurate diagnosis, ordering the correct sets of films, and is a first aid. important step to prevent secondary injuries. disorders that may occur may complicate future treatment.

The Virtual Hallway Consult as an effective means of continuous professional development in physiatry

Karen Ethans, BSC, MD; dr Tim Deutscher

Goals.Continuing Professional Development (CPD) is a term that reflects the learning needs of the various roles of physicians, including the specialist physician. Many patients go to the physiatrist with complex cases that a simple literature search cannot help to resolve. Physicians often rely on other colleagues who consult formally, or even informally, down the hall at their institution. However, in physiatry, there may be only one physiatrist with a particular interest, such as spinal cord injury (SCI) in the city or even province/state, so there are no colleagues to personally consult for help. Thus, Virtual Rehabilitation Corridors germinated, providing a simple tool to extend our corridors to virtual “corridors” across Canada. Various physiatry corridors have been developed, but SCI Corridor is the most active and is reported here.

Project:To join the SCI restricted corridor, SCI Physiatrists must be invited by the moderator. This service was in the Yahoo Groups at no cost to users. Members posted a specific question related to individual patient care or ICS issues in general. Once posted, each registered member received the question and any member could respond. The answers were based on professional experience and knowledge, links to other information or literature on the subject were posted. No patient identifying information was allowed and all content was supervised by the moderator.

Results:There have been 1,950 messages in the corridors of the SCI since 2001, in 384 conversations. In addition to questions from medical experts, there were conversations related to other medical roles; defender, scholar, manager, collaborator and professional, such as calls for scholarships or jobs and assistance in structuring interdisciplinary teams.

Conclusions:The SCI broker website has been active with physiatrists seeking CPD advice on the management of SCI. This intermedical consultation that traditionally took place in the corridors of the institution can now be carried out throughout the country and potentially throughout the world.

Fracture of the tibial plateau disguised as cellulite

Michael J. Suer, MD; Dr. Kimberly Arndt

Diagnosis of the case:Tibial Plateau Fracture

Case description:A 48-year-old woman with cerebral palsy (GMFCS IV) was seen in the emergency department on two occasions three months apart for redness and swelling in her left foot and ankle. At each exam, she was minimally cooperative and had swelling and redness from her foot to her mid-calf. Foot and ankle radiographs were obtained on both occasions and revealed no pertinent pathology. In the second evaluation, lower limb Doppler was also negative for DVT. Each time, she was diagnosed with suspected cellulitis, discharged after a 10-day course of Bactrim and Keflex, and the swelling and redness resolved after treatment. Three weeks after her second visit to the emergency room, she was seen for the same complaints, although she refused to bear weight on the affected limb. X-rays of her knee revealed a medial tibial plateau fracture of indeterminate age. She was fitted with an extension locked knee brace and she was weight free for six weeks. She has continued to work with her therapists and is now able to weight bear and transfer.

discussions:In this case, it is difficult to determine the lesion mechanism, especially since the medial plateau tends to have greater force than the lateral one. He has a history of osteoporosis and a habit of putting his feet on the wheelchair with great force. This has been the speculated etiology, although it cannot be confirmed.

Conclusions:In many people with developmental delay, communication difficulties can prevent an accurate diagnosis. The patient was unable to truly express the pain she was feeling, leading healthcare professionals to treat her based on physical examination, i.e., swelling and erythema of the foot and ankle, rather than history and examination. combined. This case illustrates the holistic approach that we must take in this special population when it comes to looking for harmful pathology.

Tibial posterior tenosynovitis: a unique musculoskeletal manifestation of gout

Peter J. Shupper, MD; Todd Stitik, MD, RMSK; Sanjay Kumbar, MD; dr. Charles Koon

Diagnosis of the case:Posterior tibial tenosynovitis secondary to gout

Case description:An 82-year-old man with a history of gout on treatment with Febuxostat 40 mg daily, polymyalgia rheumatica, and possible temporal arteritis (negative biopsy) on treatment with prednisone (4 mg daily), reported acute-onset pain in the left ankle that started at 5 days before the presentation. He denied recent trauma, diet/lifestyle changes, fever, chills, nausea, or vomiting. His last gout attack was 6-7 years ago. The symptoms were characterized as acute and painful, worsening with walking (VAS 9.5/10) and improving without load (VAS 3.5/10), interfering with sleep and ADLs.

Physical examination of the left ankle revealed a slightly erythematous medial ankle region with moderate dorsal medial edema and mild dorsolateral edema, severe tenderness in the medial retromalleolar region. Active range of motion of the left ankle was pain limited in all planes, with a 10 degree range from maximal plantarflexion to maximal dorsiflexion and a 25% reduction in maximal eversion and inversion. Strength was 4+/5, pain was limited throughout the left ankle, and sensation was intact in all peripheral nerve distributions.

Ultrasonography revealed sheath effusion of the left posterior tibial tendon and edema of the overlying soft tissues in the longitudinal and transverse axes. There was no sonographic evidence of tendon rupture or other overt signs of tendinopathy. Left tibiotalar joint without effusion.

Subsequently, the patient underwent an ultrasound-guided tibial nerve block with 2% lidocaine, followed by aspiration/injection of the tendon sheath with a mixture of 1% lidocaine and 4mg dexamethasone. A 0.5 mL cloudy yellow aspirate was removed prior to steroid injection. He was also prescribed Percocet 5/325 mg, 0.5-1 TID PRN tab, and ankle cast. He left the exam room with virtually no pain. Subsequent analysis of the aspirate revealed sodium urate crystals and a white blood cell count of 6400. Febuxostat was then increased to 60 mg daily and a serum uric acid level was requested and returned to normal ranges.

The patient returned for follow-up 2 weeks after initial presentation and reported "99% improvement" with barely perceptible medial ankle pain presenting with weight bearing. Repeat ultrasonography showed no evidence of posterior tibial tendon sheath effusion.

discussions:Although gouty tendinopathy and enthesopathy have been frequently reported in the literature, these conditions most commonly occur in the Achilles tendon or in the flexor tendons of the wrist and hand. Less commonly, it has been seen at the patellar tendon, triceps, quadriceps, tibialis anterior, and plantar fascia insertions. To the best of our knowledge, there are no documented cases of gouty tenosynovitis occurring in the posterior tibial tendon in the literature. Treatment of gouty tenosynovitis is important because uncontrolled aggregate deposits of monosodium urate crystals can lead to necrosis, fibrous proliferation, and tendon rupture.

Ultrasonography may be essential in the diagnosis and treatment of gouty tenosynovitis. Ultrasound findings in gouty tendons typically include ovoid-shaped microdeposits of hyperechoic densities, intratendinous tophi, and small hypoechoic halos indicating an inflammatory response. With ultrasound guidance, fluid can be effectively aspirated for analysis, while corticosteroids can be precisely placed under ultrasound guidance to treat inflammation and decrease pain. A tibial nerve block may be used as an adjunctive procedure to help minimize procedure-related pain and achieve rapid overall pain relief.

Conclusions:Posterior tibial tenosynovitis secondary to gout is an extremely rare extra-articular manifestation of gout. Ultrasonography may play a role in the diagnosis and treatment of this perhaps under-recognized condition.

Transient osteoporosis of the hip in a middle-aged man.

Liza Hernandez-Gonzalez, MD; Brenda Enid Castillo, MD

Diagnosis of the case:Transient osteoporosis of the hip (TOH)

Case description:Male patient, 44 years old, with a 3-month history of pain in the left hip. The pain started insidiously and localized to the groin and radiated to the thigh. The pain was sharp and severe with associated weakness and impaired ambulation. Pain worsened with weight bearing and improved with rest and NSAIDs. The patient denied trauma and the systems review was not contributive. Physical examination revealed pain in the anterior capsule of the hip. Passive ROM of the hip was painful with flexion, adduction, and internal rotation. The special test for intra-articular pathology of the hip was positive. Laboratory examinations and hip radiographs were normal, with evident bone marrow edema on MRI. He was treated conservatively without weight bearing and physical therapy (PT). At the 8-week follow-up, he had improved pain, ROM, and no gait impairment.

discussions:OHT is an atypical cause of joint pain that can start spontaneously or after minor trauma. It is characterized by severe pain in and around the hip joint during weight bearing. Its pathophysiology is unclear, but the most accepted theory is microvascular bone damage, leading to tissue ischemia and subsequent bone marrow edema. Advanced imaging is essential for an early diagnosis of OHT, with MRI being the examination of choice, with a characteristic finding of bone marrow edema. OHT is a self-limited disease that improves with conservative treatment that includes oral analgesics, PT, and protected loading.

Conclusions:OHT is a possible cause of acute and severe hip pain in middle-aged men that should be considered in the differential diagnosis of hip pain. Protected weight bearing and PT are the pillars of treatment. Failure to identify this entity early in the disease process can lead to stress fractures of the femur and surgery, leading to early disability.

Treatment of headaches with nerve blocks in the ophthalmic division (V1) of the trigeminal nerve

Mickey Y. River, DO, MPH; Sandeep Kola, D.O.; Kester J. Nedd, DO

Diagnosis of the case:Headache secondary to ophthalmic division (V1) Trigeminal neuralgia

Case description:A 33-year-old right-handed woman has had chronic left supraorbital frontal headache since age 5 years. Her medical history was significant for superficial left supraorbital and facial infantile hemangiomas treated with corticosteroid injection and pulsed dye laser surgical treatment at the age of 5 years. her and on an ongoing basis, she reported left-sided supraorbital throbbing headaches that often progressed to throbbing headaches. With the throbbing headaches, she experienced nausea and associated vomiting. Her headaches were previously treated with varying degrees of success using caffeine-based products, antiemetics, benzodiazepines, and NSAIDs. Topiramate was not effective in controlling headache. The patient sought medical attention at the neurorehabilitation clinic for worsening left-sided headache that was affecting her work performance and her social life. She had a history of multiple ER visits for severe headaches with no positive results. Pertinent physical examination findings showed increased headaches when pressure is applied to the left supraorbital region in the distribution of the ophthalmic division (V1) of the trigeminal nerve. The patient was noted to have hyperesthesia, decreased sensation, and visible changes in skin color in the V1 dermatome regions on the left side of the head after applying pressure to the V1 division of the trigeminal nerve.

As a result of the findings of the history and physical examination, a diagnosis of trigeminal neuralgia involving the V1 division of the trigeminal nerve was made. Diagnostic and therapeutic nerve block with a mixture of 9 mL of 0.5% Bupivacaine and 1 mL of 40 mg/mL Methylprednisolone Sodium Succinate. A total of 3 ml of this mixture was injected into the left supraorbital foramen, where the V1 division of the trigeminal nerve is located. The patient's visual analogue scale (VAS) pain level went from 10/10 before injection to complete resolution of her pain (0/10) after injection. Following injection, anesthesia was observed in the distribution of the V1 division of the trigeminal nerve. The patient was contacted by phone 1 month after the nerve block and continued to experience complete pain relief from her.

discussions:Trigeminal neuralgia can be a cause of a persistent headache. In this case, the symptoms of trigeminal neuralgia were caused by the infantile hemangioma and the resulting treatment. Based on the clinical history, it was evidenced that the onset of symptoms coincided with the administration of treatment with corticosteroid injection and pulsed dye laser.

Superficial localized nerve blocks involving the V1 distribution of the trigeminal nerve have been shown to be effective in the treatment of headaches with relatively good results and a safe side effect profile. Given the favorable response of patients to localized nerve block in the ophthalmic division of the trigeminal nerve after more than 28 years of chronic headache symptoms; Nerve blocks in the V1 division of the trigeminal nerve may be an effective treatment modality in the management of these patients.

Conclusions:Trigeminal neuralgia should be considered as a major cause of headaches potentially diagnosed and treated with nerve blocks. Palpation of the supraorbital region, which reproduces symptoms of headache and hyperesthesia and decreased sensation in the distribution of the nerve, provides a high index of suspicion for trigeminal neuralgia affecting the ophthalmic division. A diagnostic and therapeutic nerve block in the ophthalmic division of the trigeminal nerve should be considered due to its efficacy and favorable side effect profile.

Ulnar neuropathy of the elbow (UNE): Contribution of ultrasound when electrodiagnostic studies are limited by the presence of polyneuropathy

Namrata Raut, MD; Dr. Oscar Ortiz

Diagnosis of the case:Left UI secondary to an osteophyte in the cubital tunnel.

Case description:A 78-year-old right-handed man was referred to our outpatient clinic for an electrodiagnostic evaluation (EDX) of UNE. He reported a progressive 6-month history of left hand weakness, numbness, and intense burning pain in the fourth and fifth fingers. He also reported similar but milder symptoms on his right hand. His medical, surgical, and family history was unremarkable, except for a release of the third left trigger finger and traumatic osteoarthritis of the left wrist. Physical examination of the left hand revealed: atrophy of the intrinsic muscles of the hand with motor strength 4/5 and decreased sensation on the palmar surface of the 5th and 4th middle fingers. Tinel's sign was obtained at the elbow.

EDX were more consistent with generalized axonal polyneuropathy, but inconclusive for the diagnosis of UNE. Ultrasound examination of the ulnar nerve revealed a focal enlargement at the entrance to the cubital tunnel (20 mm cross-sectional area², swelling ratio 2.5) and periosteal bone changes of the medial epicondyle causing flattening of the ulnar nerve.

discussions:UNE is the second most common entrapment neuropathy of the upper limb. Decreased sensation or dysesthesias in the fourth or fifth fingers are the main complaint, often associated with pain on the medial side of the elbow. Although this entrapment can be suspected clinically, EDX is required to confirm the diagnosis.

EDX may be of limited value or may not confirm the diagnosis due to the presence of additional neuropathies or polyneuropathy, as was the case in this case. In these circumstances, ultrasonography can satisfactorily confirm the diagnosis and reveal the causes of nerve compression when there are structural abnormalities or space-occupying lesions.

Ultrasonography increased the diagnostic sensitivity of the EDX test for UNE from 78% to 98% according to the study by Beekman et al.

Conclusions:Ultrasonography is a readily available diagnostic tool that physiatrists can use to complement EDX testing.

Ulnar neuropathy secondary to fracture diagnosed with EMG and ultrasound

Joshua Brown, MD; John Norbury, MD; Dra. Deanna Boyette

Diagnosis of the case:Ulnar neuropathy secondary to ulnar fracture

Case description:A 68-year-old right-handed man presents to an electrodiagnostic laboratory with pain and numbness in the right hand and wrist secondary to a traumatic ulnar nerve injury 1.5 years ago. Electrodiagnostically, the patient was found to have right ulnar mononeuropathy demonstrated by a decreased amplitude of the right ulnar motor nerve conduction study with an amplitude of 4.6 mV with 50.8% on the contralateral side consistent with an axon loss lesion. The needle EMG was normal. On neuromuscular ultrasound, the lesion was located in the right ulnar styloid and manifested as tenderness on sonopalpation and a slight increase in caliber and increased hypoechogenicity of the nerve as soon as it passed through the ulnar styloid.

discussions:This case demonstrates how ultrasound can help in cases where electrodiagnostic data cannot accurately locate the lesion. Both diagnostic modalities show evidence of axonal continuity. Ultrasound findings were fairly mild with hypoechogenicity and side-to-side difference in an area of ​​less than 1 mm2. In this case, ultrasonography was able to provide information that would otherwise be obtained by an intensification study.

Conclusions:Nerve conduction studies/Needle EMG and ultrasound can provide more precise characterization and localization of peripheral nerve pathology than either modality alone.

Ultrasound finding of ischiofemoral impingement syndrome and new treatment with botulinum toxin: case report

Keyonna M. Jenkins, MD; Yin-Ting Chen, MD

Diagnosis of the case:Ischiofemoral impingement syndrome (IFIS) is the entrapment of the quadratus femoris (QF) between the lesser trochanter of the femur and the ischium. It is a little-known condition with an uncertain etiology.

Case description:A 34-year-old woman presented with pain in the left posterior buttock 11 months ago while training for a triathlon. Initially presenting as a dull ache in the buttocks and hamstrings, exacerbated after 30 minutes of running or cycling, rated 5/10, but increased to 7/10 with activity. Previous treatments included physiotherapy, chiropractic, iliolumbar prolotherapy, and dry needling of the gluteal region, as well as injection of the ischial bursa, sacroiliac joint, intra-articular hip, and piriformis, all without improvement. On physical examination it was difficult to reproduce the complaints. Ultrasound examination reproduced pain on passive external rotation of the hip with significant impingement and QF displacement. The ischiofemoral space was 1.19 cm on the affected side and 1.38 on the unaffected side. The diagnostic injection of QF with anesthetics resolved her symptom, establishing the diagnosis of IFIS. The patient had chemodenervation due to QF botulinum toxin. The thickness of the QF pretreatment was 2.27 cm on the affected side and 2.30 cm on the unaffected side; The QF thickness on the affected side was measured at 1.89 cm after the first treatment and 1.73 cm after the second treatment. The patient had complete resolution of symptoms after the second treatment and was able to return to her previous activity level.

discussions:Bedside ultrasound was essential in this case. Accurate diagnostic injection determined the diagnosis, and the direct impact of QF on dynamic ultrasound examination was a novel finding not previously reported. Botulinum chemodenervation led to a measurable decrease in QF size, thus minimizing the impact.

Conclusions:This case highlights the diagnostic value of ultrasound in musculoskeletal medicine, the new IFIS ultrasound finding, and the new treatment for botulinum chemodenervation.

Ultrasound and electrodiagnostic examination of complex ulnar nerve trauma

Michael-Flynn L. Cullen, MD; Mateo E. Miller, MD; Yin-Ting Chen, MD

Diagnosis of the case:We present a case describing the use of ultrasonography in conjunction with electrodiagnosis to confirm a Martin-Gruber anastomosis (MGA) in the setting of trauma and ulnar nerve transposition.

Case description:A 27-year-old man is described who sustained an ulnar nerve injury 21 days prior to examination following an open fracture of the distal left humerus while rock climbing. He underwent surgical fixation, repair of a partially severed ulnar nerve, and subcutaneous transposition of the ulnar nerve hours after the injury. On physical examination, his strength was 5/5 wrist extension, 2/5 finger abduction, and 1/5 finger flexion DIP 2-5 and thumb PIP. He had a positive signal from Froment and OK.

A nerve conduction study showed severe left ulnar axonal neuropathy with axonal continuity to the ulnar FDP, but no evidence of axons originating from the ulnar nerve in continuity with the ADM/FDI. There is evidence of a Martin-Gruber anastomosis to the left, which explains the response obtained to ADM/FDI.

discussions:Timely surgical intervention for traumatic peripheral nerve injuries offers the best chance for functional recovery. However, the electrodiagnostic examination of trauma patients is complex, often complicated by massive soft tissue trauma with the resulting altered anatomy. After traumatic injury and ulnar nerve transposition, where electrodiagnostic examination may be inconclusive, ultrasonography is a useful adjunct, especially in the setting of abnormal innervation such as AGM. The use of ultrasound in combination with electrodiagnosis can lead to earlier diagnosis, intervention, and better outcomes.

Conclusions:Ultrasound and electrodiagnostic studies should be used by trained clinicians to supplement studies in patients with suspected traumatic nerve injury, as it helps define altered anatomy such as nerve transpositions, improves injury location, minimizes exploration surgical and can lead to more timely and precise surgeries. intervention.

Ultrasonographic and functional evaluation in patient Charcot Marie Tooth: case report

Rafael E. Arias-Berrios, M.D.; Burgos Anaya R. Luis, MD; Gory Ballester-Ortiz, MD; Eduardo Ramos, M.D.

Diagnosis of the case:Charcot Marie Tooth disease (CMT) is the most common hereditary peripheral neuropathy. Limited information is available on ultrasound in neuromuscular conditions, and even less in Hispanic patients. For this reason, we decided to evaluate the physiological and non-physiological factors that affect gait in this patient with CMT.

Case description:A 13-year-old male patient with a diagnosis of CMT (CMT4F) was evaluated to assess the factors that affect ambulation at the neuromuscular clinic in San Juan, Puerto Rico. To assess physiological factors, three ultrasound (US) measurements of the cross-sectional area (CSA) of the common peroneal nerve (CPN) and the depth of the tibial anterior muscle (TMJ) in the axial plane were performed. A 10-meter walk and 12 stair climbing tests (SCT) with ankle braces and feet (W-AFO) and without ankle braces and feet (WO-AFO) were performed to assess how the use of assistive devices affected ambulation. A wild-type control subject (sibling) with similar gender, age, height, and BMI was used for comparison.

discussions:Ultrasound evaluation showed a significant increase in CPN CSA (4.03 times greater) and a decrease in TMJ depth in the axial plane measurement (70.9%) with disorganized heterogeneous fibers and fatty infiltration compatible with muscle atrophy in comparison with the control individual. Walking was faster with AFO use in Automatically Selected Pace (SSP) but slower in Fast Pace (FP) compared to WO-AFO walking. Less time was required to complete 12 STC W-AFO tests compared to WO-AFO.

Conclusions:To our knowledge, no previous study has described ANC and TAM with US, which are important components for ambulation in CMT. Ultrasonographic evaluation of neuromuscular disease is a promising tool in patient care. A similar large-scale survey is underway at our institution to better characterize the factors affecting ambulation in patients with CMT. The correlation of US findings and functional tests is a potential area of ​​research for future projects.

Ultrasound-guided intra-articular injections with precision confirmed by cadaveric dissection

Armen Derian, MD; Richard Vasquez-Duarte, MD

Goals.Ultrasound has become a promising modality for administering injections. The purpose of this study was to evaluate the accuracy of ultrasound-guided intra-articular hip injections using an oblique long-axis approach, confirming visual assessment in an embalmed cadaver model. Ultrasound-guided hip injections can be taught to untrained medical residents with precision comparable to blind injection techniques. Although there are palpation-based methods for intra-articular hip injections, the accuracy ranges from 52-80%. Ultrasound-guided hip injections have the advantage of avoiding ionizing radiation and visualizing the neurovascular bundle in real time during injection. Disadvantages of ultrasound-guided hip injections include the inability to provide an image as clear as fluoroscopy and the potentially long learning curve for the clinician to correctly recognize the anatomy. There are no studies reporting a visual assessment on a cadaver to determine if the injection entered the joint space completely or leaked out of the joint. We attempted to demonstrate that ultrasound-guided hip injections can be a reasonable and accurate method of delivering intra-articular injections with injection accuracy confirmed by cadaveric dissection.

Project:A prospective pilot study was conducted in nineteen formaldehyde-preserved cadaveric hips to assess the ability to teach ultrasound-guided intra-articular hip injections to a resident physiatrist by an experienced physiatrist, with accuracy verified by cadaveric dissection. The total training time was forty minutes, in which the residents practiced on ghosts while being trained. The study was performed in the anatomy laboratory of an academic medical center. Ultrasound examination with a 5 to 2 MHz C11x curved probe was performed to include only joints without signs of trauma, deformities, surgeries, or intra-articular abnormalities. After proper identification of the femoral head-neck junction in longitudinal section, the hip joints were injected with a blue latex solution mixed 1:1 with water. The solution was injected into the anterior synovial recess between the femoral head and the femoral neck. The cadavers were then dissected and latex distribution graded for accuracy by three independent observers. Three separate categories were used to define the precision of the injected latex: Accurate (76-100% of the latex within the joint), Partially Accurate (26-75%), and Inaccurate (0-25%). The consensus between two of the three raters was considered the final score.

Results:The percentage of "precise" injections was 79%, "partially precise" 10.5% and "imprecise" 10.5%. If the categories of "Accurate" and "Partially Accurate" were combined to describe clinical cases where the entire injected content is not required for a therapeutic effect such as a corticosteroid injection, then the overall accuracy would be 89.5%. The inaccurate sites were found to be located in the iliopsoas bursa and along the iliopsoas muscle anterior to the joint capsule. The error rate can be explained by several factors: Anatomical variant in which there is communication between the iliopsoas bursa and the ligaments of the hip joint in 15% of cadavers, the embalming process through which formaldehyde crosses the Collagen proteoglycan monomers in soft tissue causing joint space narrowing, rigor mortis, rater bias, and small sample size. Finally, a previous study demonstrated that injection through the femoral neck resulted in greater contrast leakage on magnetic resonance arthrography compared with the femoral head approach. A change in the injection target at the femoral head may lead to better accuracy rates.

Conclusions:Given the technical difficulties of using an embalmed cadaver for this experiment, ultrasound-guided intra-articular hip injections can be taught to residents with minimal training with accuracy comparable to blind injection techniques. Ultrasound-guided injections are safer for both the patient and the doctor compared to fluoroscopy due to the lack of exposure to ionizing radiation. The procedure can be considered a reasonable modality to provide corticosteroids or viscosupplementation for degenerative disease of the hip joint.

Unpredictable rehabilitation performance in hospitalized patients with newly diagnosed glioblastoma multiforme: decision to rehabilitate or palliate

Mateo Dawson, MD; Rebecca S. Hayworth, MD; Anita Kou, MD; Brian D. McMichael, MD; Márcia Bockbrader, MD, PhD

Diagnosis of the case:Glioblastoma multiforme (GBM) with mobility and ADL (activities of daily living) problems

Case description:Two previously healthy men, 35 and 27 years of age, respectively, naïve to chemotherapy and radiotherapy, presented for inpatient rehabilitation (IPR) after near-total GBM resections. Patient 1 presented with a right parietal mass (4.3X3.1cm-AP/transverse by MRI), postoperative seizures controlled with antiepileptic drugs, and received rehabilitation for left hemiparesis and neurobehavioral deficits. Patient 2 presented a left temporal mass (4X3.7cm-AP/transversal by MRI), postoperative nausea and vomiting, and received rehabilitation for visual impairment and right hemiparesis. FIM full admission^MONTEs were similar (69 and 73, respectively), both patients received antiepileptics and decadron taper during their rehabilitation stay, and both patients received neurorehabilitation from the same therapy team. However, patient 1 had a FIM of 14 points^MONTEgain and was discharged home with outpatient therapy after 12 days, while patient 2 had a FIM of 51 points^MONTEDropped after 8 days due to neurological deterioration from disease progression, discharged home with hospice, later died.

discussions:As illustrated above, the functional outcomes of IPRs are often unpredictable for cancer patients, in part because rehabilitation efforts are often thwarted by disease progression and complications of cancer treatment. While admission to the IPR carries a reasonable expectation of functional gains, loss of FIM and changing goals of care may require a change in plan of care for the safe transition of patients home. Instead of rehabilitation goals, the IPR focus shifts to energy conservation techniques, family education, hospice care, and/or home discharge with hospice care.

Conclusions:The above two cases demonstrate that projected functional gains, discharge location, and survival may be uncertain for cancer patients with similar disease pathology and functional level of performance. Therefore, best practices for the rehabilitation of hospitalized patients with acute cancer include a rehabilitation pathway with a palliative arm to maximize safe discharges home.

Unusual case of cervical myelopathy in an adolescent

Victor N. Gran, MD; Aaron J. Yang, MD

Diagnosis of the case:Cervical myelopathy secondary to spinal arteriovenous malformation.

Case description:The patient is a 19-year-old man with sickle cell trait who presented to the electrodiagnostic clinic with progressive weakness in his arm over the past 4 to 5 months. He had previously been seen by his primary care physician for his weakness and had a negative infectious test, as well as a normal thyroid panel and liver enzymes. He was referred to rheumatology for further evaluation, but in the meantime also saw neurology, who referred him for electrodiagnostic testing. He complained of upper extremity weakness and noted that playing basketball was becoming more difficult along with losing about 30 pounds of weight. He denied lumbar or cervical pain, as well as pain radiating to the arms or legs. Examination revealed 3/5 strength in the proximal upper extremities and 4/5 in the proximal lower extremities. Sensation and reflexes were intact bilaterally. Electrodiagnostic testing revealed diffuse denervation in the upper extremities with normal nerve conduction studies. The patient was referred back to his neurologist, who ordered an MRI of the cervical spine and brain. Cerebral (cerebral) MRI was normal, while cervical spine MRI demonstrated multiple dilated arteries and veins in the upper left neck, suggesting an AV malformation. There was a moderate amount of mass effect in the cord, shifting it to the right, and edema was seen throughout the spinal cord. The patient was admitted to the hospital after his MRI and underwent embolization of the left vertebral AV fistula. He had immediate improvement in strength and was discharged with outpatient therapies. The patient has given his consent to use his case for review. The literature on this case was reviewed.

discussions:This was a 19-year-old man who had upper extremity weakness and weight loss. The differential diagnosis for this type of clinical presentation is as follows: 1. Spinal AV Malformation: Intradural Arteriovenous Malformation Type 2 - Men > Women - Symptoms usually appear within 20 years; nearly 20 percent of people diagnosed are under the age of 16. - patients with spinal lesions may have a mass effect caused by growth in the spinal cord. -Intradural spinal vascular malformations (types 2-4) can present difficulties in the upper or lower extremities, unlike dural AVMs, which generally involve only the lower extremities 2. Myathenia Gravis Peak incidence in women 20-30 and men 50 -70 Skeletal muscle weakness with preserved sensation and reflexes. Weakness exacerbated by continued use. Cranial muscles affected: MOST COMMON INITIAL SYMPTOMS: ptosis, diplopia, blurred vision Limb muscles: proximal and asymmetrical 3. Polymyositis Symmetrical proximal muscle weakness develops over weeks to months Muscle groups affected early and more severely ( neck flexors, shoulder girdle and pelvis girdle) Myalgia: in 33% Dysphagia: up to 30% (striated muscles of the esophagus) 4. Fibromyalgia: Adult women 80-90% of cases Chronic, NOT progressive with ups and downs in severity. Key to diagnosis: Multiple trigger points Disrupted sleep patterns + anxiety + depression.

Conclusions:This was an unusual case of cervical myelopathy in a 19-year-old man due to spinal arteriovenous malformation. The diagnosis was delayed due to the rarity of the case. Patients with intradural AVMs may have difficulties in the upper and/or lower extremities, unlike patients with dural AVMs, which typically only affect the lower extremities. Specific complications may include: • Progressive loss of ambulation, as the patient loses the ability to ambulate, which is unlikely to return even with surgery • Pain, tingling, and numbness (sensory deficit) • Spinal deformity • Vessels bulging blood vessels (aneurysm) • High pressure in the veins (venous hypertension), which can lead to fluid buildup (edema) and tissue death due to lack of oxygen (spinal cord infarction) • Bleeding, which can accelerate spinal cord damage Future considerations should be made for spinal AVMs in young patients, especially men in their 20s who have progressive weakness in the upper and lower extremities.

Unusual case of left hemiparesis and neglect after cerebral retraction after callosotomy of the body

Natasha C. Mehta, MD; Shailesh Parikh, MD, MS

Diagnosis of the case:Unusual case of left hemiparesis and neglect after cerebral retraction after corpus callosotomy.

Case description:A 41-year-old woman after right craniotomy and subsequent full-body callosotomy for refractory multifocal epilepsy since she was 11 years old with a history of failed vagus nerve stimulation implantation and partial resection of the right frontal lobe. The patient presented frequent falls attacks with convulsions refractory to conservative measures. The operation was complicated by left-sided hemiplegia, hemineglect, and hemianopsia due to retraction of the right middle parietal lobe.

discussions:Corporal callosotomy is a palliative procedure that aims to prevent the spread of seizure activity and typically affects visual, speech, and tactile abilities. In this case, due to cerebral retraction, the patient developed left hemiplegia and neglect. The history of callosotomy of the body dates back to the 1940s, and the postoperative characteristics of patients were studied much later, in the 1980s. A partial procedure separates the anterior two-thirds of the callosum, whereas a complete callosotomy it also includes somatosensory information from the parietal lobe and the visual cortex of the occipital lobe traversing the posterior callus. Personality, intelligence, and emotion are normally not affected.

Conclusions:The patient's left-sided hemiplegia and neglect improved over time. He continued to have difficulties following commands with his non-dominant left hand, along with tactile anomia of the left hand and anomia of the left visual field. The therapy focused on working within his deficits.

Unusual cause of pain in the buttocks and pudendal neuralgia

Amy M. West, MD, EDM; Kelly C. McInnis, DO

Diagnosis of the case:Large lipoma causing gluteal myofascial pain and pudendal neuralgia

Case description:A 53-year-old woman presented to the clinic with a three-year history of pain in the left gluteal region. She also reported numbness and tingling in her left groin and labial area. The patient reported difficulty sitting up, walking uphill, and standing on one leg, particularly during yoga class. Physical examination revealed tender left gluteal muscles and numbness in the left perineum. Treatment included physiotherapy and piriformis trigger point injections with immediate improvement but no long-term improvement. Lumbar spine MRI was within normal limits. A pelvic MRI was requested to evaluate the region of discomfort in the buttocks and rule out a compression injury. muscles. The lesion measured 13cm TV x 15cm SI x 8cm AP in its greatest dimensions. and compressed the left sciatic and pudendal nerves. She was referred to orthopedic oncology for consultation and finally open surgical removal of the mass. After surgery, the patient's pain and paresthesias disappeared.

discussions:The patient's clinical assessment of chronic buttock pain and piriformis tenderness was most consistent with piriformis-myofascial pain. Associated paresthesias in the groin and genitalia suggested pudendal versus obturator neuralgia. Conservative treatment did not provide long-term relief. The large mass observed in the magnetic resonance infiltrated the gluteal musculature and compressed the sciatic and pudendal nerves that exited from the greater sciatic notch. While there are some reported cases of lipoma causing sciatic neuralgia, there have been no reported cases of lipoma causing concomitant gluteal pain and pudendal neuralgia.

Conclusions:In patients with refractory gluteal pain and groin paresthesias, a compression injury should be considered as a possible source of sciatic and pudendal neuralgia and myofascial pain.

Use of D-dimer levels to detect deep vein thrombosis in patients with traumatic brain injury

David Glazer, MD; Robert Bruner, MD; Elizabeth Richardson, PhD, MSPH; Sharon Gui. Renfroe, CRNP; Thomas Novack, PhD, ABPP

Goals.This study investigated whether it is reasonable to use D-dimer as a surveillance tool when deciding to order diagnostic lower limb ultrasound for detection of deep vein thrombosis in the TBI patient population of an acute rehabilitation hospital in the absence of other signs. clinical. and symptoms. .

Project:A retrospective chart review was performed to obtain consecutive D-dimer values ​​and ultrasound reports from 113 patients enrolled in the TBI model system database from a rehabilitation hospital between 2012 and 2014. To patients who were not receiving anticoagulant medication An ultrasound of the lower limbs was performed before admission to the acute rehabilitation hospital. D-dimer values ​​were collected on admission and weekly throughout the stay in the acute rehabilitation setting. Ultrasound was obtained if D-dimer values ​​increased by any specified percentage.

Results:D-dimer values ​​remained the same or decreased in 109 patients. Increased values ​​in 4 patients. Of these 4 patients, 75% had a negative ultrasound report for deep vein thrombosis. Twenty-five percent tested positive for deep vein thrombosis and had the largest increase in D-dimer value. Sixty-nine patients had ultrasonographic reports negative for deep vein thrombosis before admission to the acute rehabilitation setting. Twelve had positive ultrasound reports for DVT prior to admission to the acute rehabilitation hospital with treatment initiated. Thirty-two patients did not undergo ultrasound prior to admission to the acute rehabilitation hospital.

Conclusions:The results suggest that obtaining consecutive D-dimer values ​​is of minimal value in determining when to obtain lower extremity ultrasound in the absence of clinical signs and symptoms to detect DVT during acute rehabilitation. However, there were no deaths from DVT/PE. These data are also limited to patients in the TBI model system. Future studies could examine the relationship between functional status, anticoagulation status, the presence of DVT, and patients with brain tumor resection.

Using podcasts to improve rehabilitation education and awareness

Doug Elwood, MD, MBA; Geoffrey W. Hall, FACHE, MBA, RSU, LCSW; Michelle Conley, MPH

Goals.In recent years, a deluge of new technologies has engulfed physicians and other healthcare professionals (HCPs) and created both a challenge and an opportunity. The challenge is an overabundance of information and the inability of most health professionals to keep up with learning on the vast amount of topics and materials available. The opportunity arises from facilitating the acquisition of information in short content formats that provide health professionals with a high-quality educational experience. The aim of this study was to see if podcasting would be a good approach to achieve this goal.

Project:To complete this study, several steps were taken: First, a series of interviews were arranged with a wide variety of people from a Physical Medicine and Rehabilitation (PM&R) department representing physiotherapy, occupational therapy, physiatry, speech therapy and many others. . These conferences were then grouped by specialty, such as spinal cord injury, stroke, pediatrics, pain management, and all the areas that define PM&R, but also expanded to cover relevant topics in healthcare reform, outcomes and the education. Second, these interviews were conducted using standard equipment, including a microphone and computer software, and posted on a number of different online forums, including iTunes(c) and Stitcher(c). Third, staff were invited to listen to these interviews to learn more about specific topics related to research, clinical care, and more. Finally, objective measures were used to gather information on the extent to which the podcast reached its target audience, in this case, a PM&R department. More than 45 interviews were completed and published weekly, each detailing not only information about the role of the healthcare professional in the PM&R environment, but also research and clinical experience. Topics included emerging trends in PM&R, patient care, education, multidisciplinary approaches, and more.

Results:In just under three months, the podcast has been downloaded more than 5,000 times and has received high praise from across the department, garnering nearly 80 positive reviews on iTunes(c) and dozens of testimonials about the podcast's effectiveness in delivering great content from different parts. .parties interested in relevant issues. It was also listed in the top three new and notable podcasts in various health-related categories on iTunes(c), reaching #1 multiple times and thereby helping to reach an external audience and helping to educate the public about the benefits of MP&R.

Conclusions:The reception of podcasts supports the idea that short content delivered in a format that accommodates busy daily schedules is a viable mechanism for educational delivery. Future plans include using the forum to provide more updates on PM&R and making the educational opportunity inherent in this communication more accurate for general information, board preparation, clinical care, health care reform, and other topics. critics in the field. Future studies will include more quantitative measures of the success of podcasts in driving educational success and awareness.

Weakness and gait abnormality in the initial presentation of neuromyelitis optica

Totka R. Koutzeva, MD; María Apiafi, MD; Gary Inwald, D.O.

Diagnosis of the case:optic neuromyelite

Case description:A 67-year-old woman with a significant medical history of post-traumatic lumbar disc herniation resulting in laminectomy at the L4/5 level 23 years ago and osteoporosis presents with progressive weakness and numbness in the lower extremities, associated with bilateral dull pain causing a decrease in wandering. Subsequently, the patient developed urinary retention and perineal numbness. At presentation, the patient was ambulating with a straight cane but reported feeling very unstable. On physical examination, bilateral patellar tendon hyperreflexia was noted; Muscle strength was notable for bilateral lower extremity weakness and intact bilateral upper extremity strength. Sensation of light touch, pinprick, decreased vibration in the bilateral lower extremity and intact in the bilateral upper extremity.

Complementary examinations and interventions: - Brain magnetic resonance showed altered periventricular signal, accompanied by abnormal enhancement, suggestive of encephalomyelitis of uncertain etiology, as well as irregular foci without enhancement of white matter consistent with chronic microangiopathic changes. Magnetic resonance imaging of the spine revealed extensive spinal cord edema and abnormal enhancement suggestive of neuromyelitis optica (NMO). Lumbar puncture was performed and treatment with intravenous corticosteroids was started. The cerebrospinal fluid showed inflammatory changes with leukocytosis, predominantly lymphocytic and elevated proteins. Viral culture, encephalitis panel, Lyme Ab, VDRL, and rheumatology laboratory studies were negative. Oligoclonal bands and positive NMO IgG antibody. The patient showed improvement in muscle strength with the steroid regimen, but no improvement in sensory deficit was noted, so the decision was made to start plasmapheresis. The patient underwent seven cycles of treatment and also began to show improvement in the sensory deficit. His gait also showed a gradual improvement. The patient's bladder did not improve during her rehabilitation stay and she was discharged with delayed urination.

discussions:NMO is a rare recurrent autoimmune disorder that causes inflammation of the optic nerve and spinal cord. It affects women more than men, it occurs in different age groups, beginning around 40 years of age. It is characterized by longitudinal transverse myelitis affecting at least three vertebral segments. Detection of NMO-IgG antibodies is highly specific > 99% and 48–72% sensitive. In NMO, early diagnosis is essential because acute episodes are often severe and, if left untreated, can have devastating and irreversible effects, including loss of function.

Conclusions:The role of the physiatrist is essential to recognize the warning signs when a patient presents with back pain. In an inpatient rehabilitation setting, the physiatrist plays an important role in bowel and bladder management, a comprehensive rehabilitation program to maximize the patient's functional outcome and community reintegration after discharge, and a quality of care. optimal life.

Wegener's granulomatosis and rehabilitation challenges in the context of steroid-induced myopathy: a case report

John Leuthner, MD; Padma Srigiriraju, MD

Diagnosis of the case:Wegener's granulomatosis complicated by steroid-induced myopathy

Case description:The patient is a 57-year-old woman with a significant medical history of autoimmune vasculitis with Wegener's granulomatosis from chronic steroid use, hypothyroidism, diabetes, and steroid-induced Cushing's disease who presented to the hospital with significant lower extremity weakness. Subsequent evaluation revealed that the patient's weakness was probably related to steroid-induced myopathy. The patient was evaluated by rheumatology and was not a candidate for plasmapheresis. The hospital course was complicated by PCP pneumonia requiring intubation. After a prolonged period in the hospital, the patient was found to require maximum assistance in most ADLs. Attempts were made during the patient's acute rehabilitation hospitalization to withdraw steroids, however, the patient could not tolerate oral doses of prednisone less than 60 mg per day without worsening the vasculitis-related skin lesions. This dose of steroids made it difficult to control her diabetes and her blood pressure. The patient had frequent attacks of hypotension due to adrenal suppression, and she had difficulty tolerating therapy in the acute setting.

discussions:Wegener's granulomatosis is an autoimmune disease affecting small vessels with nonspecific symptoms including fatigue, weakness, arthralgia, and neurologic dysfunction. Current treatment regimens include the use of steroids to suppress the disease. Myopathy is a less common side effect and presents as proximal motor weakness. There are three proposed pathophysiological mechanisms for steroid-induced myopathy: steroids may 1) directly catabolize skeletal muscle; 2) inhibit the IGF-1 cascade that leads to myocyte apoptosis; or 3) suppressing an intracellular protein kinase, Akt1, which increases atrogin ubiquitin ligase 1 (MAFbx) promoting muscle breakdown.

Conclusions:Currently, there is no gold standard for the treatment of steroid-induced myopathy. Acute inpatient rehabilitation for 3 to 4 weeks that emphasizes aerobic exercise, resistance training, endurance, ADLs, and avoiding high-intensity exercise helps significantly. Future research is needed on treatment protocols for steroid-induced myopathy. Physiatrists must be aware of the side effects of steroid use and treatment modalities for steroid-induced myopathy.

When conservative treatment of DVT fails: acute propagation of an unstable fibular DVT to seal PE during serial ultrasound in a patient with hemorrhagic stroke on prophylactic doses of anticoagulation

Monal H. Desai, MD; Jayesh Vallabh, MD; Mateo J. Fanous, MD; Marcia Bockbrader, MD, PhD; dr. Kevin J. Donlon

Diagnosis of the case:Deep vein thrombosis (DVT) spreading to saddle pulmonary embolism (PE) during venous duplex ultrasound (VDS)

Case description:53-year-old hemiparetic man, post-ischemic stroke with hemorrhagic conversion and craniectomy (but no Doppler DVT) presented for inpatient rehabilitation (IPR). He received mechanical DVT prophylaxis until day poststroke (PSD) 22, when he started prophylactic heparin. Two days later, he developed acute calf pain on the hemiparetic side and VDS revealed acute right peroneal DVT. He continued anticoagulation with a prophylactic dose until his next serial VDS at PSD 31, which visualized his right fibular DVT and identified a new partially occlusive thrombus in the right proximal femoral vein, which disappeared on examination. He developed tachycardia, tachypnea, and O2 desaturation and he was found to have acute PE in the grande sella that was treated with therapeutic anticoagulation and IVC filter placement.

discussions:1 of 6 calf DVTs spread to become proximal DVTs or PEs. Current recommendations stratify treatment according to patient risk, with the majority of patients with IPD being in the “high risk” category (secondary to recent surgery, immobility, cancer, etc.). Henry (2014) recommends 1 month of therapeutic anticoagulation for “high-risk” patients and serial screening for “low-risk” patients and “high-risk” patients with contraindications to anticoagulation. The assumption is implicit that serial VDS presents minimal risk of clot propagation. However, in the early stages of DVT formation, sessile and unstable clots with tenuous adherence to vessel walls may be amenable to pressure dislodgement, a technical mechanism for assessing venous coaptation during VDS.

Conclusions:This case shows that conservative treatment of DVTs with serial VDS may not be benign in the acute stage of thrombus formation, when clots are likely to be unstable. IVC filter placement may be preferable for high-risk patients to prevent PE.

When Paraplegia becomes Tetraplegia; Case Report of Rehabilitation of a Patient with Marfan Syndrome After the David Procedure, with Strict and Prolonged Sternal Precautions with Pre-existing; T7 (ASIA-A) Paraplegia

Joseph Scholz, PhD; Benjamin Pierson, M.A.

Diagnosis of the case:41-year-old woman with Marfan Syndrome (MS) without David Procedure, with pre-existing sternal precautions; T7 (ASIA A) paraplegia.

Case description:Our patient is a 41-year-old woman with MS and a significant medical history of arachnoiditis resulting in a T7 (ASIA A) spinal cord injury, prior DVT-PE with lifelong anticoagulation, and OSA presenting with an aortic aneurysm. (5.2cm). She underwent valve-sparing aortic root repair with postoperative complications (anemia, hypervolemia, and arrhythmias). Before the surgery she was independent with all the ADLS. After stabilization, due to sternal precautions, she effectively became a quadriplegic, completely eliminating all personal care. Transfer to the acute rehabilitation floor at WRNMMC, a multi-D team implementing ROM-focused strength conservation therapy. Her temporary condition and her large size required nursing with a Link-O-Lift to perform basic care.

discussions:Marfan syndrome is associated with a marked decrease in life expectancy, due to incorrect breakdown of the glycoprotein fibrillin-1, allowing accumulation of TGF-β in the lungs, heart valves, and aorta. This abnormal structure in vascular smooth muscle weakens cardiac connective tissues, leading to aortic dissections. With appropriate screening interventions, the median age of survival has increased by 25 years since 1972, but as life expectancy increases, comorbidities/medical complications increase, so rehabilitative medicine must be prepared. As with many high-functioning patients, there were conflicts with hospital schedules, regimens, and protocols, and the patient's well-established habits. Requires flexibility to change based on schedule and patient preferences.

Conclusions:Our patient's case provides an example of the increasing range of medical complexities that multiple sclerosis patients presenting for long-term aortic repair can encounter, and how rehabilitation facilities must be prepared to handle complex patients at the same time. time that meet their needs, providing a high level of rehabilitation and returning patients a significant quality of life in a reasonable time.

Presentation of posters Friday, February 19, 2016

Case report of suspected MoyaMoya in 28-year-old Japanese women with ischemic infarction of the left PDA

Saylee Dhamdhere, MD; Vanessa Cooper; Mohammad S. Islam, MD

Diagnosis of the case:A 28-year-old Japanese man with possible moyamoya rare chronic progressive cerebrovascular disease.

Case description:Previously healthy woman with h/o headaches presented with weakness and numbness on the right side associated with dizziness, diplopia, and complete visual hemianopsia. Pertinent positive findings on physical examination include mild right ptosis, absent right pupillary reflex, right homonymous hemianopsia, and decreased right-sided facial sensation. Motor strength was 3-/5 on the right side, with increased tone of MAS 1 in RUE. Reduced sensations and impaired sense of position on the right side of the body. Computed tomography and magnetic resonance imaging of the brain consistent with a right subacute distribution stroke involving the left temporal and occipital capsule, as well as internal capsule with mass effect in the left occipital horn. CTA and MRA findings of the neck include right proximal internal carotid artery possibly secondary to chronic dissection, without definite fibromuscular dysplasia. ANA, ANCA and complement vasculitis tests negative, TEE - normal, lupus anticoagulant negative, investigation negative for hypercoagulability and collagen disorders. The patient was transferred to an acute rehabilitation clinic and motor strength improved significantly. At discharge, she was able to ambulate and climb stairs with a cane and contact guard.

discussions:Moyamoya disease is a chronic progressive cerebrovascular disease caused by blocked blood vessels in the Circle of Willis. This disease was first described in Japan in 1950 and occurs predominantly in the Japanese or Asian population. Clinical manifestations include recurrent intractable headaches, TIAs, stroke, and epilepsy. Suzuki staging is used to classify the angiographic progression of moyamoya disease. Initial stages with narrowing of the carotid bifurcation, progression with dilation of all the major cerebral arteries, reduced flow in the middle and anterior arteries, minimization of vessels and finally disappearance of moyamoya vessels. Diagnosis is possible with angiographic studies of the Circle of Willis or transcranial Doppler. Brain CT and MRI are important for detecting clinically suspected cerebral infarcts and hemorrhages. Dilated collateral vessels in the basal ganglia and thalamus is a diagnostic finding of moyamoya, along with concentric enhancement of the distal ICA. Cerebral angiography is the gold standard for diagnosis and shows occlusion/stenosis in the distal ICA, ACA, and MCA. Note the presence of a collateral meshwork of small enlarged and dilated arteries, also known as “moyamoya” vessels, which branch from the circle of Willis.

Conclusions:This case demonstrated the possibility of moyamoya disease based on initial presentation, patient demographics, young age, family history, and possible irregularity in internal carotid artery anatomy. Rehabilitation in this study included strengthening exercises, functional activity training, and neurodevelopmental treatment using the Bobath concept of promoting motor learning for efficient motor control in various settings, thereby improving participation and function.

There is no curative treatment for moyamoya disease. Prophylaxis for stroke prevention, control of hypertension, and bypass interventions and surgery to reduce the risk of ischemic stroke by improving circulation have all been shown to be superior to conservative treatment and are part of current treatment guidelines. the ACCP and the AHA. Patients with motor weakness after stroke improve with long-term physiotherapy after neurosurgical revascularization. Improvements in motor skills, muscle tone, and ambulation were observed in a retrospective study in children with moyamoya disease.

A nontraumatic C5-C6 epidural abscess complicating postoperative medical factors

Alex Lu, Bachelor of Science; Jay M. Meythaler, MD, JD; Steven R. Hinderer, MD, MS, PT

Diagnosis of the case:Cervical cord myelopathy secondary to severe stenosis of the central canal due to an epidural abscess at C5-C6

Case description:A 55-year-old male patient was admitted to the hospital with severe neck pain, headache, and progressive weakness in all extremities. Magnetic resonance imaging showed cervical myelopathy secondary to severe stenosis of the central canal due to an epidural abscess at C5-C6. An anterior cervical discectomy was performed with decompression of the cervical epidural abscess and vertebral arthrodesis. In the postoperative period, the patient developed a bilateral pulmonary embolism and was anticoagulated. Urine culture was positive for MRSA and Pseudomonas aeruginosa bacteremia. Acute nephropathy and rash developed after intravenous antibiotic administration. Renal biopsy revealed acute interstitial nephritis. The patient started dialysis. The patient progressed from C6 AIS B to C6 AIS D, he was discharged from inpatient rehabilitation and transferred to subacute rehabilitation for further treatment.

discussions:Epidural abscess is usually caused by bacteria, with Staphylococcus aureus being the most common underlying bacteremia. Most epidural abscesses are caused by hematogenous spread and are treated with antibiotics. However, the antibiotics used in this patient caused a maculopapular rash and acute interstitial nephritis. Antibiotics are not recommended in patients with renal insufficiency, however, they were essential to eliminate the infection from the patient. He also developed a bilateral pulmonary embolism (PE) during his stay. The patient had DVT and was therefore at increased risk of PE.

Conclusions:Physicians and residents must have knowledge of the treatments and medications necessary to clinically manage complex patients with problems in multiple body systems.

A new approach for the treatment of cortical visual impairment after anoxic brain injury in adults using visual stimulation therapy: a case report

Edward Wieseltier, DO; Lauren Kremm, DO; Rachel Dratnol, MOT, OTR/L, CLT; Marissa H. Cohler, MD

Diagnosis of the case:cortical visual impairment

Case description:A 26-year-old man with chronic hydronephrosis underwent left ureteral stent replacement complicated by asystolic cardiac arrest. The patient suffered anoxic brain injury with associated cortical visual impairment (CVI) and cognitive deficits. CVI is a condition of bilateral visual loss due to damage to the visual areas of the brain without involvement of the eye or the anterior visual pathway. CVI is associated with a normal pupillary response and no additional abnormalities on ophthalmologic examination. The most common cause of CVI is due to hypoxic ischemic injury with resultant periventricular leukomalacia. MRI showed multiple non-enhancing lesions in a watershed area and occipital cornices suggestive of encephalomalacia. Initially, it was maximum assistance/dependent for all activities of daily living (ADLs) and mobility and improved to minimal assistance/supervision.

discussions:In the setting of hypoxic brain injury, CVI occurs due to infarction of the visual cortex, specifically the visual cortex, resulting in damage to the visual pathways associated with the macula.

VST is a program established for the pediatric population that includes: Programs for Light Reflex, Outline Perception, and Outline Bits and Slides. The VST program was used to promote visual pathway connections within the brain to enable visual recovery.

Our patient demonstrated improvement in visual acuity after 6 weeks of VST as part of acute rehabilitation.

Conclusions:This case presents an adult after anoxic brain injury who demonstrated visual recovery after participating in VST in CVI rehabilitation.

A peculiar case of rib fractures with subsequent placement of a chest tube, leading to an infection that seeded the spine and caused complete tetraplegia.

Andres Abdou, DO; Lisanne C. Cruz, MD, MSc; Michael Escalon, MD, MPH

Diagnosis of the case:A peculiar case of rib fractures with subsequent chest tube placement leading to infection spreading to the spine causing complete quadriplegia.

Case description:This case describes a 73-year-old man who fell from his bicycle with comminuted fractures of 4-6 right ribs, a moderate right pneumothorax, and a small right hemothorax. He placed a right perilateral chest tube. The next day, he developed a fever and blood cultures were positive for MRSA. He received intravenous antibiotic treatment. Eight days later, he underwent video-assisted thoracoscopic surgery, in which two more pockets of fluid were found and two more chest tubes were placed. On hospital day 23, the patient presented a sudden loss of sensation and motor strength in the arms and legs bilaterally. An MRI of his cervical spine revealed an epidural abscess. The patient underwent a C3-C6 laminectomy with evacuation and fusion of the abscess. Upon entering acute rehab, he was found to have complete C4 tetraplegia.

discussions:A spinal epidural abscess (SEA) is a collection of pus in the epidural space that can mechanically compress the spinal cord. The classic diagnostic triad consists of fever, back pain, and neurologic deficits. Magnetic resonance imaging is essential for early diagnosis. Its most common cause is contiguous infected tissue or direct inoculation into the spinal canal, making this case exceptionally rare and difficult to diagnose. Treatment includes reduction of the size of the inflammatory mass and eradication of the causative organism. Physiatrists must be accessible and visible in intensive care settings to be consulted to evaluate patients with acute neurological impairment. In this case, early knowledge of the SEA and cord involvement may have prevented lesions or reduced their severity.

Conclusions:Knowledge of the unusual causes of spinal cord injury is important when considering all possible differential diagnoses in a person with acute weakness.

A Pilot Safety Study of Minocycline for the Treatment of Neuropathic Pain in Traumatic Spinal Cord Injury (SCI)

Vanessa Bernal, B.S., CCRP; Matthew E. Davis, MD; Joel E. Frontera, MD; Gerard E. Francisco, M.D.

Goals.Chronic neuropathic pain (CNP) is a major problem in people with SCI. Animal studies have shown minocycline to be effective in reducing pain behaviors. To the best of our knowledge, minocycline as a treatment for CNP due to IBS has not been studied in humans.

Project:This double-blind, placebo-controlled, crossover pilot study aimed to assess the safety of minocycline (main outcome: serious adverse event profile). Subjects were assessed before and after an 8-week intervention period, along with week 2 and week 4 interim assessments. Leeds Neuropathic Pain Score [LANSS]) in subjects with neuropathic pain due to IBS. Subjects were randomized to receive oral minocycline (200 mg/day) or placebo for 8 weeks. All individuals have severe CNP, defined by poor pain control by other medications or modalities.

Results:Of 176 potential subjects evaluated over a 15-month period, only 13 (10 men; 36-68 years of age; 9 complete SCI; 7 cervical, 4 thoracic, and 2 cervicothoracic per ASIA baseline assessment) have enrolled thus far (7 of those eligible did not participate due to various reasons). One subject withdrew due to an abnormal baseline liver profile even before drug administration. Subjects were already treated with other drugs and modalities at the time of enrollment and were asked not to change their existing treatment regimen. There were no significant changes in laboratory test results or worsening of BNP according to LANSS pain scores.

Conclusions:For the primary outcome measure (safety), there were no adverse events attributable to minocycline at the dose used in the study. Regarding the secondary endpoint (efficacy), minocycline did not appear to provide additional control of CNP in subjects already treated with other drugs. Possible reasons for not demonstrating efficacy include small sample size; PNC severity; inadequate dose of minocycline; and differences in responses to treatment between species.

A pilot study evaluating the effectiveness of a biofield energy therapy in patients with chronic pain

Ahilraj Sivapathasuntharam, MD; Eric Leskowitz, MD; Vinjamuri R. Chari, MD; Maureen Foye, BSN, MSN; Dr. Michael Maliszewski

Goals.Complementary and alternative therapy is a common approach to treating chronic pain. Biofield therapies are energy-based healing techniques that are gaining popularity, but research on their effectiveness has produced mixed results. The purpose of this study was to explore the effectiveness of a form of biofield energy (ET) treatment in the treatment of patients with chronic pain.

Project:This study was conducted in an inpatient pain management unit. The experimental group (n=8) received standard interventions from the pain program plus additional TE sessions. The control group (n=8) received standard treatment, but without ET. The ET session lasted 60 minutes and took place once a week for four weeks. The efficacy of TE was measured using two pain self-rating scales: the Visual Analogue Scale (VAS) and the Brief Pain Inventory (BPI), which were administered to subjects before and after completing the pain program. The data were submitted to an Analysis of Covariance (ANCOVA).

Results:The mean results of the final VAS and BPI scores in the experimental group were lower than in the control group, but did not reach statistical significance. The change in VAS and BPI scores before and after the intervention was greater in the experimental group than in the control group, but did not reach statistical significance.

Conclusions:This preliminary study failed to demonstrate a statistically significant additive benefit of TE in patients with chronic pain. Additional research is needed to more fully evaluate the effectiveness of TE.

A rare complication of a common problem: prostate abscess in a patient with cervical spinal cord injury

Dr. Zach Bailowitz; LaTanya Lofton, MD

Diagnosis of the case:Prostatic abscess in a patient with a complete spinal cord injury (SCI) on the C4 scale of the American Spinal Injury Association (ASIA).

Case description:D.G. is a 22-year-old man who presented for rehabilitation at the hospital after a diving accident and was diagnosed with a C4 ASIA A complete spinal cord injury. He was progressing as expected with the ability to propel an electric wheelchair and direct the activities of daily living. During his rehabilitation stay, he developed a fever and was diagnosed with a Pseudomonas aeruginosa urinary tract infection. Despite antibiotic therapy, the fever persisted and he later developed a high leukocytosis with vague abdominal pain. Initial studies of plain radiography of the abdomen were negative for acute pathology. An abdominal CT scan was obtained which revealed a prostatic abscess. Blood cultures confirmed Pseudomonas aeruginosa bacteremia. He was treated with a high dose of intravenous cefepime and repeated imaging confirmed the decrease in the size of the abscess. He finally had a complete resolution of symptoms after 2 weeks of intravenous antibiotics.

discussions:Prostatic abscess is a rare urological condition that is often diagnosed late due to vague and non-specific symptoms. It is a complication of acute bacterial prostatitis, which in turn often results from lower urinary tract infections. It is observed more frequently in patients with HIV or diabetes, its incidence is very low among all individuals and unknown in patients with SCI. In patients with high-level SCI, many abdominal and pelvic pathologies have vague and similar symptoms. Although urinary tract infections are very common among patients with IBS, there are no reports of prostatic abscesses in this patient population in the literature.

Conclusions:Prostatic abscess is a rare but possible pathology in high-level SCI patients with vague abdominal symptoms. Physiatrists must be knowledgeable about recognition and treatment in this patient population.

A rare metastatic leiomyosarcoma lesion presenting as an incomplete spinal cord lesion

Andrew L. Parker, MD, BA, BS; Terrence M. Pugh, MD, BS

Diagnosis of the case:Metastatic leiomyosarcoma (LMS) presenting as an intramedullary lesion of the lower thoracic spinal cord in the absence of bony involvement.

Case description:M.H. is a 70-year-old woman who was discovered to have SML after pelvic exploration surgery and resection of suspected uterine fibroid sixteen years prior to presentation. She remained asymptomatic for fifteen years after receiving radiation therapy. In the year prior to filing, it was discovered that she had metastatic disease to her brain, lungs, and lymphatics.

One year after these metastatic lesions were found, M.H. He presented to his oncologist with progressive weakness in his legs and neuropathic pain. An MRI of the spine revealed a metastatic lesion within the lower thoracic spinal cord, slightly superior to the tip of the conus medullaris. Her symptoms progressed to paraplegia and loss of bowel and bladder control. She underwent radiation treatment at the hospital for her spine and glucocorticoid treatment, which were unsuccessful. She later entered acute inpatient rehabilitation for her non-traumatic spinal cord injury.

discussions:Soft tissue sarcomas comprise one percent or less of all malignancies, and LMS constitutes approximately five to ten percent of these diagnoses. Common primary sites include the uterus, gastrointestinal tract, and retroperitoneum. LMS is known to be aggressive and commonly metastasizes. Bone metastases are rare, but it is not uncommon for the vertebrae to be involved. These bony vertebral metastases have been documented to cause lytic lesions, compression fractures, and even invasion of the epidural space, all of which can lead to non-traumatic spinal cord injuries. However, intramedullary metastases without bone involvement, as in this case, are extremely rare in the literature.

Conclusions:Intramedullary spinal cord lesions in the absence of skeletal involvement are an unlikely but potentially devastating sequel to metastatic LMS that may be refractory to common treatments for metastatic disease.

A retrospective review of autologous platelet-rich plasma for symptomatic acetabular labral tears refractory to conservative treatment.

Ali Valimahomed, MD; Dr. Jaspal Singh

Goals.The aim of this study was to describe the clinical outcome of patients who underwent image-guided PRP injections for the treatment of acetabular labral tears.

Project:Retrospective case series. Nine patients aged between 49 and 85 years with chronic hip pain, one or more positive physical examination maneuvers, diagnosis of lesion of the acetabular labrum on MRI, and no satisfactory improvement with conservative treatment (physiotherapy, oral and/or intra-articular injections). ) underwent image-guided injection of platelet-rich plasma (PRP) (guided by ultrasound or fluoroscopy) into the acetabular labrum. Outcomes were measured at baseline, 2 weeks, and 12 weeks using the Visual Analogue Scale (VAS) for pain intensity and Hip Osteoarthritis and Disability Outcome Score (HOOS).

Results:At 2 weeks, there was a statistically significant (p < 0.05) improvement in function on three HOOS subscales: activities of daily living (ADL), sports/recreation, and quality of life (QOL). There was a statistically significant improvement in HOOS pain (73.3 ± 13.6, p < 0.01), HOOS symptoms (73.9 ± 12.8, p < 0.01), HOOS ADL (75.8 ± 6.3, p < 0.01), sport/recreation HOOS ( 65.3 ± 11.9, p < 0.01) and HOOS QOL (80.3 ± 11.1, p < 0.01) 12 weeks after PRP injection for acetabular labral tear from the beginning. A statistically significant improvement in VAS was also observed at 12 weeks (baseline VAS 7 ± 0.7 → 12-week VAS 2.4 ± 1.0, p ± 0.05) after PRP injection for labral tears acetabular.

Conclusions:The results of this study suggest that in patients with symptomatic acetabular labral tears refractory to conservative treatment, PRP injection is a safe and minimally invasive technique that appears to reduce pain and improve functional outcomes at 12 weeks.

AbobotulinumtoxinA (Dysport®): Doses Used to Treat Upper Extremity Muscles in Adults with Spasticity Enrolling in a Randomized, Double-Blind, Placebo-Controlled Phase III Study

Fatma Gul, MD, MMM; Peter McAllister, MD; Heather Walker, MD; Dra. Christina Marciniak; Steven Edgley, MD; Bruce Rubin, MD; David Simpson, MD; Philippe Picaut, PhD/PhD

Goals.An international, randomized, double-blind, placebo-controlled Phase III study was conducted with two doses of abobotulinumtoxinA (Dysport®) 500 and 1000 units (U) for the treatment of hemiparetic adults after stroke or traumatic brain injury ( TBI)

Project:243 patients received abobotulinumtoxinA 500 or 1000 U or placebo by intramuscular injection into their primary target muscle group (PTMG, selected from extrinsic finger flexors, wrist flexors, and elbow flexors) and at least two other upper extremity muscles , including the shoulder muscles. Doses delivered to muscles of the upper extremities are reported here.

Results:For the 500 U group, the mean (SD) (U) doses to the flexors of the fingers were: 93.5 (17.0) for the flexor digitorum profundus (FDP), 95.4 (14.3) for the flexor digitorum superficialis digitorum (FDS) and 76.9 ( 26.8) for the other flexors of the fingers (flexor pollicis longus, adductor pollicis); in the wrist flexors: 92.2 (18.1) for the flexor carpi radialis (FCR) and 89.9 (25.7) for the flexor carpi ulnaris (FCU); in the elbow flexors: 88.3 (28.5) for the brachioradialis, 148.5 (60.2) for the brachialis, and 108.6 (49.5) for the other muscles of the elbow (biceps brachii, pronator teres ) and 122.2 (44.1) for the shoulder muscles (triceps brachii, pectoralis major, subscapularis, latissimus dorsi). For the 1000 U group, the doses were 195.5 (25.9) for FDP, 196.8 (28.4) for FDS, 157.0 (53.3) for other finger flexors, 178.1 (45.5) for FCR, 171.2 (45.2) for FCU, 172.1 (44.8) for brachioradialis, 321.4 (103.2) for brachialis, 216.5 (92.2) for other elbow muscles and 300.0 (129.1) for shoulder muscles.

Conclusions:In these hemiparetic patients, the mean doses administered were 76.9 to 196.8 U for finger flexors, 89.9 to 178.1 U for wrist flexors, 88.3 to 321 U. .4 U for the elbow flexor muscles and from 122.2 to 300.0 U for the shoulder muscles. The total dose administered (in the PTMG and at least 2 upper extremity muscles) was 500 or 1000 U, which has previously been shown to improve muscle tone in this patient population, with a favorable safety profile.

Abulia, a medical reason for lack of interest in rehabilitation: a case report

Chirag D. Shah, MD, JD; Yogen Patel, DO; Merrie Viscarra, DO

Diagnosis of the case:A 60-year-old woman with a significant history of bipolar I disorder who consulted due to drowsiness after a fall that was later diagnosed as avolition.

Case description:The patient was transferred to an outpatient hospital for mental deterioration following a fall with an emergency brain CT scan showing larger than right bilateral left frontal hemorrhagic contusions with surrounding vasogenic edema requiring external ventricular drain placement. Despite medical stabilization and motivational therapy, the patient correctly followed less than 40% of the orders, showed no interest in therapy, and did not actively communicate with medical personnel. In lieu of the patient's frontal brain lesion, history of psychiatric illness, inability to follow most commands, and passivity, a diagnosis of Abulia was made. To increase participation, motivation and focus; Treatment was started with escitalopram, amantadine, carbidopa/levodopa, and divalproax sodium. After the aforementioned medication took effect, the patient was able to follow more than 60% of the commands, had a longer attention span, and was able to participate in dynamic conversations and therapy.

discussions:Abulia is a medical condition that is often misdiagnosed. Symptoms include decreased initiation of voluntary movements, reduced spontaneous speech, emotional responsiveness, cognition, and general interest. Frontal brain injuries are commonly involved in Avolia cases. It has also been linked to psychiatric illness, dementia, TBI, and stroke. Early and accurate clinical diagnosis is essential in the treatment of Abulia, since it can profoundly affect the course of rehabilitation, the prognosis, and the speed of recovery of the patient. If Abulia is misdiagnosed as apathy, recovery will be limited despite strong motivational therapy. Treatment includes medical optimization to maximize physical tolerance leading to increased functional capacity. Any underlying condition related to decreased motivation, such as depression, should be treated. Since the mesolimbic and mesocortical systems are related to motivation, it is believed that avolition can be treated with dopaminergic agents. Because this drug combination can take several weeks to work, starting it right away is key to faster recovery. This, along with physical rehabilitation, is believed to increase recovery time, prognosis, and mood.

Conclusions:Abulia is often misdiagnosed as apathy. Patients should start taking antidepressants and dopaminergic agents immediately to improve overall recovery. Without drug therapy along with motivational and supportive therapy, recovery will be limited and family and professional frustration will increase.

Acquired C3-T1 Spinal Canal Stenosis Complicated by Distal Type 1 Congenital Multiple Arthrogryposis: Case Report

Rodion Erenburg, MD; Oryan Baruch, DO; Sanjeev Agarwal, MD

Diagnosis of the case:Acquired C3-T1 spinal canal stenosis complicated by congenital distal arthrogryposis multiplex type I.

Case description:A 48-year-old woman with a history of distal arthrogryposis multiplex type I after multiple remote corrective surgeries, hyperthyroidism, hypertension, seizure disorder, and cervical carcinoma presented with complaints of progressive worsening bilateral lower extremity weakness and bilateral lower extremity numbness. the upper extremities. Extremities Prior to her presentation, the patient was a modified independent ambulatory using a rolling walker and requiring minimal assistance with activities of daily living. At the time of her evaluation, she could no longer ambulate with an assistive device and required maximum assistance with her daily activities. MRI of the cervical spine revealed canal stenosis with multiple herniated discs and evidence of myelomalacia. She underwent a C3-C4 anterior cervical discectomy and fusion, C3-C7 laminectomy and C3-T1 instrumented fusion and was subsequently presented to our tertiary hospital for acute inpatient rehabilitation. The patient participated in acute inpatient therapy, including physical and occupational therapy, and she was able to improve her functional status with FIM score increases of at least 2 notches in transfers, mobility, and activities of daily living. A significant decrease in neck pain and an increase in cervical spine ROM were also observed.

discussions:There are few reported cases of newly acquired cervical stenosis requiring surgical intervention in patients with arthrogryposis of the distal type. Rehabilitation of such patients requires a multidisciplinary approach and can be complicated by severely compromised range of motion and, as in this case, significant postoperative pain requiring delicate titration of analgesics.

Conclusions:Patients with AMC who require cervical canal decompression have the potential to regain a significant amount of functional independence with the correct approach to acute inpatient rehabilitation.

Acalculous acute cholecystitis in a patient with chronic spinal cord injury: case report

Yuemeng Dai, MD, PhD; Jeremias West, MD; Benjamin Carlock, MD

Diagnosis of the case:Acalculous acute cholecystitis in a patient with chronic spinal cord injury

Case description:A 28-year-old man with a 6-year history of C7 ASIA Quadriplegic Spinal Cord Injury (SCI) underwent surgery to place a flap over a sciatic pressure ulcer without incident until sixteen days later, when he had a sudden onset of unexplained spasm. located. such as abdominal discomfort, right chest and right shoulder pain, leukocytosis, fever, and restlessness. The physical examination was significant for tachycardia, abdominal distension and discomfort on palpation without localized tenderness. Blood culture, urinalysis and urine culture negative. Broad-spectrum antibiotics were started, but the patient's condition continued to deteriorate. The diagnosis and imaging study were complicated by flap surgery. The risk of flap failure was weighed against the diagnostic significance. On the third day, an emergency abdominal CT scan was performed and acute cholecystitis was found. Emergency laparoscopic cholecystectomy was performed, which confirmed the diagnosis of acute acalculous cholecystitis (CAA). Finally, full recovery was achieved.

discussions:Gallbladder function has been reported to be affected in patients with SCI. Acute calculous cholecystitis (ACC) is not uncommon, especially in patients with acute SCI. However, CAA is much less common in patients with IBS, and to date, there are no reports of CAA in patients with chronic IBS. The diagnosis of acute cholecystitis in patients with IBS is often delayed or missed due to the absence of typical symptoms. In this case, the diagnostic process was further complicated by flap surgery. The treatment of CAA in patients with SCI is comparable to those without SCI. Cholecystectomy is the preferred treatment option with favorable results.

Conclusions:To the best of our knowledge, this is the first case report of CAA in a patient with chronic SCI. Indistinguishable signs and symptoms can easily cause diagnostic delay or misdiagnosis and lead to delayed treatment. The threshold should be low to perform an abdominal imaging study to find CAA as soon as possible.

Acute bilateral paramedian thalamic infarcts as a result of occlusion of the perforating arterial variant of the thalamus

Laurent Delavaux, MD; Craig Van Dien, MD; Christine Greiss, DO; Dr. Sara Cucurullo

Diagnosis of the case:Acute bilateral paramedian thalamic infarcts

Case description:A 48-year-old man with a history of hypertension was admitted to acute hospital rehabilitation for functional deficits resulting from bilateral thalamic infarcts. The patient presented to an outpatient hospital for progressive visual disturbances, followed by decreased arousal and confusion. The patient was unresponsive, with subsequent progression to fluctuating levels of arousal. Head CT was negative for ischemia or hemorrhage. The patient, however, was unable to receive IV thrombolytic therapy. Magnetic resonance imaging of the brain revealed bilateral thalamic infarcts and one midbrain infarct. He was transferred to our medical center for further evaluation. Repeat head CT was confirmatory. The Percheron artery is a rare variant of the posterior cerebral circulation characterized by a solitary trunk that supplies blood to the paramedian thalamus and rostral midbrain bilaterally. A diagnostic cerebral angiogram did not show an apparent Percheron artery. Given the patient's bilateral infarcts with a discrete symmetrical vascular distribution, a clinical diagnosis of occlusion of the probable Percheron artery was made. After medical optimization, the patient was transferred to acute inpatient rehabilitation for ADL dysfunction and visual impairments. Examination revealed horizontal gaze palsy, decreased inferior tracking, bilateral inferior visual field slices, and blood pressure-dependent arousal levels. The patient progressed toward his functional goals with improved visual tracking and increased arousal, resulting in better ambulation, ADL, and transfers at discharge from inpatient rehabilitation.

discussions:Bilateral thalamic infarcts are rare. These vascular territories are usually supplied by perforating branches of the thalamus from the posterior cerebral arteries. Rarely, a vascular variant is found, in which a single Artery of Percheron arises from a unilateral P1 segment, to bifurcate and supply both paramedian thalami.

Conclusions:This is a rare case of occlusion of the Artery of Percheron leading to bilateral paramedian thalamic infarcts. This unique presentation is accompanied by a constellation of functional deficits of which the physiatrist and treatment team must be aware.

Acute functional impairment in a patient with posthemorrhagic hydrocephalus secondary to ventricular cleft syndrome

Alexander J. Feng, MD; Peter Riedel, DO; Daniel Luna, MD, MS

Diagnosis of the case:Intracranial hypotension and slit ventricle syndrome due to ventriculoperitoneal (VP) hypershunt

Case description:A 65-year-old man with right temporal-parietal intracranial hemorrhage and hydrocephalus after right hemicraniectomy and VP shunt placement presents with functional impairment in gait and posture during his course of acute rehabilitation. Before the decline, he could stand up and walk 50 to 60 feet with minimal assistance. However, over several days, he regressed and required maximum assistance to hold still and complete assistance to ambulate due to worsening left trunk lateral tilt. Computed tomography (CT) of the head revealed a significant reduction in ventricular size compared with previous imaging studies, especially on the right side. Infectious and electrolytic abnormalities were ruled out. The patient did not experience position-dependent headaches, nausea, or vomiting during this period. After neurosurgical adjustment of the shunt, he recovered his function and a repeat CT scan showed an increase in the size of the ventricle.

discussions:Split ventricle syndrome occurs in a minority of patients with VP shunts. It refers to findings of reduced size of the ventricle on imaging with associated symptoms of position-dependent headaches, lethargy, and/or nausea and vomiting probably due to intracranial hypotension. These symptoms often present years after shunt placement. Abnormal gait is generally associated with increased cerebrospinal fluid (CSF) volume, ventriculomegaly, and/or increased intracranial pressure. We present a unique case of worsening gait and postural deterioration in the context of decreased CSF volume. Review of the scientific literature reveals that decreased cerebrospinal fluid volume and intracranial hypotension due to excessive shunting may manifest in some rare cases with seizures, hearing loss, or myelopathy. To our knowledge, no cases of acute decrease in gait and posture associated with over-maneuvering have been reported in the literature, suggesting that this phenomenon may often go unnoticed. Identification and intervention may result in the reversal of the patient's functional decline and allow for further recovery.

Conclusions:Reduced CSF volume and intracranial hypotension due to excessive shunting may be an iatrogenic cause of functional impairment in patients with posthemorrhagic hydrocephalus. We highlight the importance of early diagnosis and intervention in split ventricle syndrome, especially during the neurological recovery period.

Acute paraplegia secondary to spinal epidural lipomatosis in an obese child: a case report

Lauren A. Kremm, DO; Ashley Zapf, MD; Edward Wieseltier, DO; Dra. Lisa Thornton

Diagnosis of the case:Nine-year-old boy with spinal epidural lipomatosis (SEL) secondary to obesity.

Case description:A 9-year-old boy with a history of obesity (BMI: 40) presented with a 6-month history of progressive bilateral lower extremity weakness. The examination was significant for: weakness of the lower extremities, hyperreflexia, presence of Babinski signs and bilateral clonus of the lower extremities. MRI of the spine demonstrated SEL at all spinal levels and spinal cord enlargement in the thoracic spine. The patient underwent T3-T8 laminotomies with epidural fat resection. The postoperative course was significant for the loss of motor strength and sensation of the lower extremities (T4 ASIA A). Nuclear magnetic resonance showed edema of the spinal cord from C5 to the cone. The patient completed acute inpatient rehabilitation and progressed from dependent with transfers and ADL to modified independent at the wheelchair level before discharge.

discussions:This is a rare case of SEL causing paraplegia in an obese child. SEL is the excessive growth of fatty tissue in the spinal canal. SEL is associated with the use of exogenous steroids, excessive levels of endogenous steroids, and obesity. Most reported cases occur among adults (mean age 42 years) and have rarely been documented in children. Clinical manifestations include back pain, weakness, acute myelopathy, and/or radicular symptoms. SEL can cause spinal cord edema with resultant SCI. The treatment protocol for SEL in the adult population depends on the severity of neurological symptoms; however, there are no clear protocols for non-surgical versus surgical management, especially in children.

Conclusions:This case is a rare example of paraplegia resulting from obesity-related SEL in a child. Highlights the childhood obesity crisis in the United States. It also raises several important questions about protocols for appropriate treatment and prevention of recurrence in the pediatric population. These questions do not have definitive answers. More research is needed to establish a protocol for the management of children with SEL.

Acute rehabilitation in a patient with multiple system atrophy: case report

Christian Youssef, DO; Laura Davids, MD; Jun Zhang, MD

Diagnosis of the case:multiple system atrophy

Case description:A 67-year-old woman with a 4-year history of progressive ascending weakness secondary to suspected chronic inflammatory demyelinating polyneuropathy (CIDP) was admitted with vocal cord paralysis, ventilatory failure requiring tracheostomy, and urinary retention. Upper extremity strength was 4/5 and lower extremity strength was 2/5 with increased tone and rapid reflexes. She showed tremor in her hands at rest and a shuffling gait without sensory deficits. Her symptoms remained unchanged despite IVIG treatment and rehabilitation interventions. The patient was evaluated by a movement disorders specialist and diagnosed with multiple system atrophy (MSA). The patient was started on carbidopa/levodopa and transferred to an acute rehabilitation center. She was started on an aggressive course of physical, occupational and speech therapy. Physiotherapy emphasized postural awareness and external cues for ambulation. Occupational therapy helped facilitate proper alignment of the body when sitting and transferring without support. The speech therapist trained the patient in oral motor exercises and eventually advanced the patient's diet to include light fluids. The FIM score improved 24 points in two weeks.

discussions:Although this patient received therapy shortly after the onset of her initial symptoms, her CIDP misdiagnosis and subsequent IVIG treatment did not improve her symptoms. Once her symptoms progressed and she was diagnosed with AMS, she was successfully treated with Carbidoba/Levodopa. Concomitant use of appropriate medication and rehabilitation led to improvement in symptoms and function.

Conclusions:MSA is a progressive degenerative neurological disease that can only be definitively diagnosed at autopsy. Pathology specimens obtained postmortem show abundant glial cytoplasmic inclusions in the central nervous system. Although studies have shown that very few patients benefit from levodopa, this patient responded well. Therapy is essential to prevent contractures, preserve mobility, and maintain swallowing function. Despite the poor prognosis, multidisciplinary rehabilitation can significantly improve quality of life.

Acute rehabilitation of spinal epidural abscess after triple laminectomy: case report

Brian A. Dahlben, MS; Dr. David Fleischmann

Diagnosis of the case:Spinal epidural abscess C1-S5 s/p C7-T1, T7-8, L4-5 laminectomies.

Case description:A 36-year-old man presented with a large epidural collection, shown on MRI to extend from C1-S5, causing narrowing of the spinal canal. The patient was admitted for acute rehabilitation after neurosurgical treatment and stabilization s/p C7-T1, T7-8, L4-5 laminectomies. He had problems with mobility and activities of daily living and reported moderate pain in his back and lower extremities, but without a specific distribution, during PT/OT therapies.

Throughout his 7-day stay, the patient was closely monitored for methicillin susceptibility.S aureusbacteremia and received IV oxacillin and oral rifampicin. Active medical problems included bright red blood from the rectum with a probable diagnosis of hemorrhoids, DVT prophylaxis, newly diagnosed type 2 DM, and urinary retention. The patient was switched from direct to intermittent catheterization, but the inability to urinate was complicated by a urinary tract infection (UTI). Urination improved after treatment of the UTI with the antibiotic macrobid.

discussions:Infection of the epidural space, known as a spinal epidural abscess (SEA), is an extremely rare condition that can be difficult to diagnose. Although patients classically complain of fever and back pain, the low incidence of EAS, estimated at 2-25 per 10,000 hospital admissions, actually makes it an unlikely cause of such common medical symptoms. Two-thirds of SEAs arise from complications ofS aureusinfection, and identification of the lesion is helpful using magnetic resonance imaging. If left untreated, SEA compression of the spinal canal leads to severe back pain, sensorimotor changes, bowel and bladder dysfunction, and ultimately paralysis and death. The management of EAS is twofold: (1) reduce the size of the abscess, through drainage or surgical intervention, and (2) eliminate the causative infection with empirical antibiotic therapy. In this patient with an abscess extending throughout the spinal cord, an aggressive triple laminectomy was required, followed by antimicrobial therapy and close monitoring.

Conclusions:Spinal epidural abscess (SEA) is an infection of the central nervous system that leads to compression of the spinal cord and can cause permanent disability or death. Timely diagnosis and early treatment, particularly antimicrobial therapy, are absolutely essential to prevent adverse outcomes.

Acute Epidural Abscess: Description of Two Cases in the Rehabilitation Service

Ayesha Khan, MD; Sikha Guha, MD; Maria Jouvin-Castro, MD; Yuri O. Ivanov, DO

Diagnosis of the case:Acute spinal epidural abscess

Case description:The first case is a 41-year-old woman with a history of hypertension, diabetes, stroke, and pituitary adenoma, who developed an L4-5 epidural abscess with paraspinal phlegmon extending to the psoas muscles after a transabdominal oocyte retrieval procedure under epidural anesthesia. . The causative organism was found to be Escherichia coli. The patient received a prolonged course of intravenous antibiotics. The rehabilitation course was complicated by poor pain control, and the patient was finally discharged home after an improvement in her medical and functional status. The second case is a 48-year-old woman with multiple comorbidities, who developed a spontaneous T5-6 thoracic epidural and paraspinal abscess and thoracic discitis/osteomyelitis. The patient underwent laminectomy T5-6, spinal instrumentation T3-5 and T7-9. MSSA grew in the abscess culture and the patient was given a prolonged course of intravenous antibiotics. After the stabilization of her medical condition, the patient was finally discharged to a subacute rehabilitation unit.

discussions:Although spinal epidural abscess is a rare condition, occurring in only 2 to 25 patients per 100,000 hospitalized, there is evidence that the incidence may have increased in the past 30 years. the field of pain control and an increase in the number of patients undergoing invasive spine procedures for pain control. The risk of epidural abscess has been reported to be substantially lower for short-term epidural catheters used for obstetric anesthesia.

Conclusions:Spinal epidural abscess is becoming an increasingly common diagnosis in the rehabilitation department. Rehabilitation after traumatic or non-traumatic spinal cord injury should begin as soon as possible, ideally while the patient is still in the intensive care unit. Spinal cord injury requires a multidisciplinary approach to rehabilitation with the ultimate goal of achieving medical, physical, social, emotional, and functional recovery.

Aggressive Multidisciplinary Management of Severe Spasticity in a Young Woman with Traumatic Brain Injury

Gurpreet Palak, MB, BCH, BAO; Seyed Hossein. Hosseini, MD; Denise Johnson, BHSCPT

Diagnosis of the case:This is a young woman who sustained a grade three diffuse axonal brain injury as well as multiple trauma in 2013. Upon admission in 2015, she developed severe tone and contractures affecting her trunk and all four extremities.

Case description:He had severe tone affecting the trunk, neck, and all four extremities. Tone was grade three-four using the modified Ashworth scale. He also presented significant contractures that affected all the joints of the upper limbs, knees, and ankles. Given the extent of the contact, we increased the oral antispasmodic medication. We expedite the bilateral surgical lengthening of the tendons of the lower limbs through orthopedics. This was followed by the insertion and dose escalation of an intrathecal baclofen pump by our colleagues in neurosurgery and anesthesia. Physiotherapy remained involved before and after surgery. He had two additional operations to lengthen the tendon in his upper extremities. Our dialogue with anesthesia facilitated the increase in intrathecal baclofen. Focal chemoderivation was used in both the neck and trunk. By improving your musculoskeletal problems with gains in other aspects of rehabilitation

discussions:In patients with severe spasticity and contracture formation, we feel that early identification and aggressive management in a multidisciplinary team produced significant gains and improved quality of life; with surgical intervention, with the support of braces, braces, and allied health therapists, combined with control of spasticity through the use of antispasmodic medications and focal chemodenervation. By defining your goals at the beginning of your hire and establishing an action plan and sharing it with our colleagues, we were able to efficiently and aggressively gradually progress towards a successful outcome.

Conclusions:Early identification and a multidisciplinary team approach to the management of severe spasticity led to significant improvements. This extended beyond his musculoskeletal issues and affected almost every facet of his rehabilitation.

Alien hand syndrome after acute ischemic stroke with hemorrhagic transformation

Virginia A. Leona, BA; Dr. A.S. Percival Pangilinan

Diagnosis of the case:Acute ischemic stroke with hemorrhagic transformation in the left temporal-parietal region, resulting in severe right hemisensory neglect.

Case description:A 72-year-old woman with a history of hypertension, diabetes, hyperlipidemia, and a prior stroke presented with right-sided weakness, clumsiness, and new-onset aphasia. An initial CT showed no signs of intracranial hemorrhage and her NIH Stoke score was 13. The patient was treated with tPA and a follow-up CT showed hemorrhagic transformation. Upon admission to the acute rehabilitation unit, her physical examination was notable for right hemiparesis and right-sided hemisensory neglect severe enough that she did not recognize her right hand. She also had significant fluent aphasia. After two weeks of inpatient treatment, the patient was discharged for outpatient rehabilitation to other services.

discussions:Potential hemorrhagic transformation is one of the main complicating factors of tPA thrombolytic therapy. This patient had hypertension and diabetes, both known risk factors for hypertension. After the bleeding event, he was diagnosed with Alien Hand Syndrome, a neurological disorder that made her believe that his right hand was not hers and that he could not control his actions. This condition made it difficult for him to participate in therapy, although mirror therapy and tasks to keep the alien hand busy did show some positive effect. At discharge, the patient could recognize her right hand as part of her body, but she still displayed significant right-sided hemisensory neglect and required a maximum of verbal cues to complete most tasks.

Conclusions:This case of a patient with alien hand syndrome demonstrates a potentially serious consequence of hemorrhagic transformation following administration of tPA to treat possible stroke. The extent of her deficits highlights the need to develop new screening measures to better predict AHT risk after tPA administration.

Treatment with Amantadine and Cyroablation for Apraxia of Gait and Hand Tremor Secondary to Paraneoplastic Syndrome of Renal Oncocytoma: Case Report

Dr Alex Behar; Christopher Hicks, BS, MD; Sheree Occenad, Bachelor of Science; Dr Ravi Kasi; Dr. Chirag D. Shah, Juris Doctor

Diagnosis of the case:Renal oncocytoma causing paraneoplastic syndrome leading to functional impairment, apraxia of gait, bilateral hand tremor, and fatigue.

Case description:A 40-year-old woman with a medical history of congenital intellectual disability who presented with a 6-month history of worsening mental status, functional decline, apraxia of gait, bilateral hand tremor, and increased fatigue. The patient was originally misdiagnosed with Parkinson's disease and was unsuccessfully treated with Sinemet. Due to worsening symptoms, the patient was readmitted and the following tests were performed: paraneoplastic panel (ANA ∼ 1.65, TSI antibodies ∼ 1554, TPO antibodies ∼ 1232), CT C/A/P ∼ thyroid nodule and right renal mass ( subsequent compatible biopsy). with renal oncocytoma). The patient was diagnosed with paraneoplastic syndrome and treated with methylprednisolone and IVIG with slight improvement in symptoms. However, she soon began to worsen her symptoms and she was readmitted for definitive treatment and cryoablation of the renal oncocytoma was performed, in addition to 5 rounds of plasmapheresis. Movement disorders he was consulted due to her apraxia of gait who started amantadine 100mg TID. The patient was then admitted for acute rehabilitation, where she showed significant improvement in all functional domains, in addition to tremor resolution, apraxia of gait, and mental status changes.

discussions:Paraneoplastic syndrome is a condition that affects the central nervous system or secondary to an immune response to a tumor. It usually presents secondary to breast, ovarian or lung cancer, and there is little literature on this entity secondary to renal oncocytoma. Treatment of neurological symptoms usually involves treating the underlying cancer. Renal oncocytoma is a non-urothelial epithelial neoplasm found in the kidney that is usually benign with an incidence of 1.3% to 14%. The prognosis is excellent, given its slow-growing nature and low metastasis rate.

Conclusions:Paraneoplastic syndrome can be caused by any type of cancer, including renal oncocytoma. Subsequent neurological symptoms can be treated with medications such as amantadine (for apraxia of gait, in this case) and treatment of the underlying condition (cyroablation, in this case).

Anabolic steroid abuse as a cause of ischemic stroke: case report

Just N. Walker, MD; Dr. A.S. Kirk Lercher

Diagnosis of the case:Ischemic cerebrovascular accident secondary to anabolic steroid abuse

Case description:A 48-year-old man with no significant medical history had a left ICA/left MCA ischemic stroke and received IV tPA and underwent left ICA tombectomy. He is a bodybuilder with a one-year history of testosterone-containing anabolic steroid abuse, administered by daily intramuscular injections for two months, with thirty days between each two-month interval; blood work confirmed history of anabolic steroid use with low testosterone and LH levels. No relevant family history; he does not smoke or use other drugs. Negative TEE for thromboembolic source. Monitoring by telemetry and implantable loop recorder did not reveal arrhythmias or atrial fibrillation. Anticoagulation investigation was negative, except for increased protein C and PCR activity. The lipid panel was borderline cholesterol 220 and LDL 117 but otherwise normal. As the stroke scan was negative for other etiologies, his stroke was attributed to anabolic steroid abuse.

discussions:Anabolic steroids are widely used by athletes and bodybuilders for muscle building as they produce anabolic effects. Although some adverse effects of anabolic steroid use are well known, such as cardiomyopathies and psychiatric disorders, their relationship to stroke has not been firmly established. In high doses, these agents are believed to cause a hypercoagulable state and have been suggested in some case reports to be the cause of ischemic stroke. As in this case, these patients are usually young athletes with no other known risk factors for ischemic stroke and have a negative evaluation for stroke.

Conclusions:This case suggests a relationship between anabolic steroid abuse and ischemic stroke. Additionally, he emphasizes the importance of obtaining a complete history, including anabolic steroid use. As physiatrists, we encounter a large proportion of athletes and stroke patients and therefore need to be aware of this possible association between anabolic steroid abuse and stroke.

Analysis of unexpected readmissions at 30 days due to stroke in an Intensive Care Academic Hospital

David S. Kushner, MD; Estin Kelly, MS, Master of Business Administration; Rachael Leigh L. Morrison, B.S.; Katherine E. Camfield, Bachelor of Science

Goals.To analyze the etiologies, rates, and original sources of discharge preparation for unexpected 30-day hospital readmissions in stroke patients at an intensive care teaching hospital.

Project:Retrospective study involving 84/824 (10.2%) stroke patients unexpectedly readmitted within 30 days out of a total of 824 stroke discharges during fiscal years 2012, 2013, and 2014 at an academic acute care hospital . The main outcome measure involved comparison of readmission etiologies and readmission rates for all original dispositions.

Results:Number (percent) of stroke patients unexpectedly readmitted within 30 days out of a total of 824 discharges in FY 2012-2014, categorized by original discharge disposition: Against medical advice 2 of 20 (10%), home without home health care (HHC) 27/448 (6%), home with HHC 11/105 (10.5%), Skilled Nursing Unit (SNF) 35/161 (21.7%), Inpatient Rehabilitation (IR) 4/25 (16%), Long-Term Care 4/17 (23.5%).

Reasons for readmissions

Cerebrovascular 22/84(26.2%), Cardiovascular 13/84(15.5%), Respiratory 10/84(11.9%), Gastrointestinal 7/84(8.3%), Genitourinary 6/84(7 .1%), Infections 6/ 84 (7.1%). 22 (26.2%) patients were readmitted for a similar diagnosis; 62 (73.8%) were readmitted due to a new diagnosis.

Geriatricians (>75 years) accounted for 48/84 (57.1%) of readmissions for stroke.

Conclusions:IR had a lower rate of unexpected readmissions for stroke than SNFs and long-term care. The main readmission diagnoses included cerebrovascular, cardiovascular, and respiratory; 73.8% readmitted due to a new diagnosis. 57.1% of readmissions were geriatric patients.

Analysis of patients with craniotomy with complication of seizures in a hospital rehabilitation unit

Kyle Aman, MD; Mohammad Aalai, BS, MD; Adrian Cristian, MD

Goals.To assess the incidence of seizures in patients with craniotomy and the need for ongoing seizure prophylaxis.

Project:retrospective review

Results:Two patients of 51 (4%) reported postoperative seizures and both were receiving prophylactic seizure medication. Of this patient population, 13 patients of 51 (25%) did not receive seizure prophylaxis and reported no seizures during the acute rehabilitation service. The average stay in the IRF was 19 days, with a range of 4 to 48 days. Men represented 32 of these patients (63%) and women 19 (37%). Thirty patients (58%) received craniotomy for bleeding and evacuation, 17 patients (33%) craniotomy for mass resection, and 4 patients (8%) craniotomy for other causes. Levetiracetam was used for seizure prophylaxis in 33 of 37 patients (89%) receiving seizure prophylaxis, while 2 patients received depakene, 1 patient received dilantin, and 1 patient received a combination of dilantin and levetiracetam.

Conclusions:Patients who have undergone craniotomy for a variety of etiologies, including hemorrhage and tumor resection, receive seizure prophylaxis. The use of long-term seizure prophylaxis should be considered, as the incidence of seizures is low in this population and may impede cognitive recovery during the acute rehabilitation service.

Anterior Spinal Artery Syndrome After Untrained Spinal Manipulation: Case Report

Carolyn Campbell, MD; Alexandra Flis, MD; Jacob Christiansen, Bachelor of Science; Benjamin T. Jensen, M.D.

Diagnosis of the case:This case report describes the acute presentation and diagnosis of anterior spinal artery syndrome (ASAS) after untrained spinal manipulation.

Case description:A 24-year-old woman with no prior medical history complaining of lower extremity weakness after receiving spinal manipulation was evaluated. A family member of hers stood behind her and wrapped her arms around her chest and lifted her off the ground in an attempt to "break her back." She developed acute weakness in her lower extremities and collapsed to the ground. She immediately had bilateral upper and lower extremity weakness, numbness and tingling, and difficulty standing. She was taken to the emergency room and hospitalized for further testing. Examination revealed bilateral upper and lower extremity weakness, bilateral loss of pain and temperature, and intact proprioception and sense of vibration. MRI revealed a C3-T3 spinal cord lesion centered on the anterior cord within the anterior gray matter. The anterior spinal artery could not be visualized on spinal angiography, according to ASAS.

discussions:ASAS is the most common type of spinal cord infarction and usually presents later in life as a complication of atherosclerosis, aortic surgery/dissection, hypotension, or vascular malformations. This case describes a rare cause of anterior spinal artery occlusion as a result of trauma from untrained spinal manipulation leading to localized ischemia in the anterior cord. Spinal manipulation is a common practice in chiropractic and osteopathic manipulation for the treatment of back problems and can be performed safely with proper training. Complications from spinal manipulation have been previously reported, even when performed by a professional.

Conclusions:Spinal manipulation carries a risk of spinal injury when performed incorrectly. Although spinal manipulation can be used therapeutically, it should only be performed by a trained professional and without contraindications.

Arachnoiditis and hydrocephalus resulting in paraparesis after lumbar epidural steroid injection: a case report

Erika Trovato, DO, MS; Umar Mahmood, DO; Ashish Kumar, D.O.

Diagnosis of the case:Arachnoiditis, spinal cord injury, hydrocephalus

Case description:The patient is a 68-year-old female with a history of L4-5 spondylolisthesis, right chronic low back pain (LBP) who underwent a right L4-5 epidural steroid injection. Shortly thereafter, she developed acute worsening of low back pain, numbness in her right foot, saddle-back paresthesia, and urinary incontinence. MRI revealed severe L4-5 stenosis, at which time she underwent L4-5 lumbar spinal fusion and laminectomy. After the operation, she reported an improvement in pain, but she continued to have difficulty walking. She entered acute care rehabilitation (AIR) and was later discharged to her home walking with a tripod cane. She was admitted to the hospital three weeks later with worsening paresis and confusion. Nuclear magnetic resonance revealed arachnoiditis and hydrocephalus. She underwent VP shunt placement and was admitted to AIR, where she initially required maximum assistance with activities of daily living (ADLs) as well as transfers. She made significant functional gains during her rehabilitation course, which required supervision for ADLs, minimal assistance for transfers, and was able to ambulate using a walker with minimal assistance.

discussions:Epidural steroid injections are a commonly used non-surgical approach to treat chronic low back pain with radicular symptoms. The most common complication is a transient headache with other reported side effects including insomnia, increased back and leg pain, facial flushing, and vasovagal reactions. Arachnoiditis is a rare complication caused by the invasion of bacteria, blood, or injections of irritant substances into the dural sac, resulting in pathological changes in the arachnoid membrane. Symptoms include numbness, tingling, and intense, intractable burning pain in the lower back. Severe cases result in paralysis of the lower extremities leading to permanent disability. Treatment focuses on relieving pain and improving function and ADLs with physical and occupational therapy.

Conclusions:This case illustrates the risk of infection after spinal epidural steroid injections. The diagnosis of arachnoiditis should be considered in patients with severe pain after the procedure.

Rehabilitation outcomes after anoxic brain injury are different from those after traumatic brain injury: a combined case-control study.

Emre Adiguzel; Universo vive; Yasin Demir; Ismail Safaz; Ridvan Alaca; Arif Kenan Tan

Goals.To compare the rehabilitation results of patients with anoxic brain injury (AnBI) with control patients with traumatic brain injury (TBI).

Project:Patients with AnBI and TBI admitted to the clinic between 2011 and 2014 were included in the study. We retrospectively investigated patient records and recorded demographic data, Functional Independence Measure (FIM), Functional Gait Scale (FAS) before and after treatment. AnBI patients were matched with TBI patients admitted within the same age period, coma interval, and FIM score before treatment.

Results:Forty patients with AnBI and 20 patients with TBI were included. The mean age in the AnBI group was 37.7 years and 29.4 years in the TBI group. The coma interval in the AnBI group was 47.4 ± 34.0 days and 43.4 ± 39.0 days in the TBI group. There were no significant differences between the groups with respect to age, sex, coma interval, FIM score, and FAS before treatment (p>0.05). The etiology in the AnBI group was cardiac arrest in 72.5% of the patients, whereas 80.0% of the patients in the TBI group were due to motor vehicle accidents. The FIM score in the AnBI group was 41.7 ± 28.5 before treatment and increased to 57.1 ± 31.4 after treatment. The FIM score in the TBI group was 33.9 ± 25.5 before treatment and increased to 37.6 ± 60.7 after treatment. There were no statistically significant differences in FIM scores after treatment between groups (p>0.05). The frequencies of swallowing dysfunction, speech disorders, and fecal-urinary incontinence in the AnBI group were 42.5%, 75.0%, and 90.0%, respectively. In the TBI group, the frequencies of swallowing dysfunction, speech disorder, and urinary-fecal incontinence were 40.0%, 90.0%, and 30.0%, respectively. There were no differences between the groups with respect to swallowing dysfunction and speech disorders, but the frequency of fecal-urinary incontinence in the AnBI group was significantly higher than in the TBI group (p = 0.018, chi-square test). ).

Conclusions:In this study we found no significant differences in the rehabilitation outcomes of ANBI patients compared to TBI patients. Considering the paucity of information in the AnBI rehabilitation literature, this study may be important to guide rehabilitation teams.

Aspercream as treatment of pain and pruritus in a patient with polycythemia vera: case report

Julie Ann Zitterkopf Larson, MD, MPH; Wilson Chang, MD, MPH; Dr. Reza Taher; Dr. S. Kamal Fetouh

Diagnosis of the case:Patient with Polycythemia Vera (PV) and a 6-year history of pain with almost complete resolution of symptoms after the application of aspercreme, zyrtec and 81mg of ASA.

Case description:The patient is a 68-year-old woman with significant HMP for polycythemia vera (PV), Jak2 positive with associated splenomegaly. The patient presented to the cancer rehab clinic with a 6-year history of burning/stinging/itching sensations in all extremities. She rates the average daily pain as 7-8/10, which interferes with her sleep and quality of life.

discussions:Polycythemia vera (PV) is a panhyperplastic malignant neoplastic disorder of bone marrow stem cells. Patients with PV have increased blood hyperviscosity secondary to a marked increase in cellular blood elements. The pruritus, which occurs in 40% of patients with PV, is caused by elevated levels of histamine released by increased numbers of basophils and mast cells. The itching is often exacerbated by a hot bath or shower. Aspercreme (10% trolamine salicylate) is a topical salicylate pain reliever. It works by reducing swelling and inflammation in the muscles and joints.

Conclusions:As the field of cancer rehabilitation and pain management grows, more studies are needed on additional treatments for patients suffering from pain and dysfunction secondary to malignancy. To our knowledge, this is the first case report of Aspercreme (Trolamine Salicylate 10%) completely eliminating pain and itching caused by PV in a patient who had previously failed all invasive and drug treatments. and that he had suffered for six years. New studies should be done to investigate this phenomenon.

Association between sleep, activity and function in patients with TBI undergoing acute hospital rehabilitation

L. Tyson Sloan, DO; Romero Dubiel, DO; Monica Bennett, PhD; Cynthia Dunklin, Bachelor of Science; Simon Driver, PhD

Goals.To examine the relationship between sleep activity and therapy and functional outcomes in patients with TBI in the acute rehabilitation setting.

Project:Observational study enrolling patients over a 12-month period who were undergoing inpatient rehabilitation. Inclusion criteria were age between 18 and 70 years and moderate to severe TBI occurring 30 days or less prior to admission. Subjects wore an Actiwatch accelerometer 24 hours a day for 2 to 8 days to measure activity counts during sleep (10:00 PM to 6:00 AM) and therapy (7:30 AM to 3:30 PM). , and the percentage of sleep was calculated. In addition, admission and discharge FIM scores, demographic and injury-related data were collected.

Results:The sample included 26 patients with a mean age of 44.5±16 years, predominantly Caucasian (n=22) and male (n=17). Significant and positive Spearman correlations were found between the percentage of sleep and the cognitive (r=0.55; p=0.0036), motor (r=0.46; p=0.0171) and total (r=0.0171) FIM scores. =0.0171 =0.53; p=0.0049) on admission. In addition, significant negative correlations were found between mean sleep activity and cognitive (r=-0.45; p=0.0214), motor (r=-0.42; p=0.0314) and total FIM scores. (r=-0.48; p= 0.0125). at admission None of the remaining associations were significant.

Conclusions:These initial results suggest that admission FIM scores are associated with sleep quality, as people with lower FIM scores had higher nocturnal activity and a lower percentage of sleep. On the other hand, individuals with higher FIM scores had less nocturnal activity and a higher percentage of sleep. Clinically, this shows that functionally worse TBI patients are more likely to sleep less and have more active nights.

Association of Post-Stroke Pain Scores with Functional Outcomes in an Inpatient Rehabilitation Setting

Dr. Prateek Grover, Doctor en Medicina; Michael Ahuja, MD; David Carr, MD; angela valleck

Goals.Studies have shown a wide variation in the prevalence of pain after stroke, from 19% to 74%. According to the National Stroke Foundation, post-stroke pain is often multifactorial and can include headache, hemiplegic shoulder pain, central post-stroke pain, neuropathy, and musculoskeletal pain, alone or in various combinations.

Given the multifactorial nature of post-stroke pain and the often impaired communication/cognitive status in many stroke patients, assessing and treating all factors involved in post-stroke pain can be challenging. In the context of acute inpatient rehabilitation, we have observed that inadequate pain control often leads to loss of therapy units. However, this relationship of pain, lost therapy units (MTUs), and impaired functional outcomes has not been well established in the literature.

The aim of our quality improvement (QI) project was to assess whether pain-affected therapy units were lost during the rehabilitation of acute patients. In addition, this IQ study evaluated whether pain or MTUs affected functional gains during inpatient rehabilitation.

Project:This QI project was designed as a retrospective study over the period January 2014 to July 2014. 94 stroke patients entered acute rehabilitation at the St. Louis Rehabilitation Institute. Louis were included in this record review.

Data collected by retrospective chart review included maximum daily pain scores, total therapy units lost (tMTU), and FIM (Functional Independence Measure) scores at admission and discharge. Peak daily pain scores were subgrouped throughout hospitalization, averaging 19 days, as days 1-5, 6-10, 11-15, and 15+. The total pain score was calculated as the mean of the four subgroups. The tMTUs have been subgrouped into low MTUs (1-12) and high MTUs (13-25). FIM gains were calculated as the difference between the FIM scores at discharge and admission. Correlation coefficients were used to assess the relationship between pain and MTUs, as well as their individual effect on FIM gains.

Results:The mean age was 63.1 years and the male/female ratio was 0.92:1. The etiology of ischemic stroke was approximately 3 times more frequent than hemorrhagic. The Middle Cerebral Artery was the most commonly affected arterial territory. Effusions on the left and right sides were almost equal in incidence.

The mean total pain score was 4.7/10. The highest average pain score was obtained on days 6-10 (5/10). The mean low MTU (range 1-12) and high MTU (range 13-25) were 4.7 and 17.6, respectively. The mean FIM data at admission and discharge were 44.9 and 77.0, respectively. Total pain score and tMTU showed a positive correlation (coefficient = 0.58), with the strongest positive correlation of tMTU with pain scores at +15 days (coefficient = 0.62).

Conclusions:This IQ study quantitatively establishes a relationship between pain during acute stroke rehabilitation and therapy units lost. The study also suggests a similar impact on FIM gains, with the derived trends in line with the expectation that improving pain control will decrease tMTU and improve FIM gains. Future studies that include larger samples may help to better understand these relationships. Ultimately, an intervention/tool ​​implemented to improve early recognition and management of pain could help reduce the number of therapy units lost and potentially affect stroke recovery outcomes.

Baclofen pump failure due to stenosis in a 2-part catheter: a case report

Joshua Brown, MD; Dra. Carrie McShane; Eric Rush, médico

Diagnosis of the case:Increased spasticity secondary to baclofen pump failure

Case description:42 years old M C4 ASIA C with a history of non-dominant and dominant spastic hemiplegia secondary to a bicycle accident in August 2012, treated with a bicomponent baclofen intrathecal pump placed in February 2014.

The patient presented to the clinic with increased spasticity, gait deviation with toe drag D>L, increased frequency of falls, difficulty handling Lofstrand crutches.

The deposit was aspirated, the actual volume corresponded to the expected volume. However, when attempting to access the catheter access port, fluid could not return from the catheter, ruling out the possibility of performing a catheter dye study. A plain radiograph was requested to assess the location of the catheter, it was difficult to assess the trajectory of the catheter, since the catheter only has a radiopaque marker at the tip. The patient was referred to neurosurgery, who on examination found significant torsion in the catheter pump near the connector. Once the connector was removed, good CSF return was found in the intrathecal catheter, a new pump catheter and connector were replaced. Over the course of titration, your patient's spasticity and gait on baclofen improved significantly.

discussions:This is the first report of which we are aware of a kink causing decreased efficacy in a 2-piece catheter for an intrathecal baclofen pump.

The fact that the torsion has occurred in the place designed to be resistant to torsion is cause for concern. The lack of radiopaque markers along the length of the catheter also made it difficult to assess the catheter track.

Conclusions:There are two worrisome factors in this case. The first is that although 2-piece catheters are designed to resist kinking, they are susceptible to kinking at the hub. The second is that the lack of radiopacity along the entire length of the catheter precludes evaluation under plain film without dye.

Baclofen: a rare cause of reversible thrombocytopenia

Emma Nally, MD; Fady G. Boutros; Rachna Malhotra, DO

Diagnosis of the case:Baclofen-induced thrombocytopenia in a patient with acute ischemic stroke.

Case description:A 32-year-old male with recent ischemic stroke of the right middle cerebral artery, operated on 07/08/2015 for right hemicraniectomy complicated by hemorrhagic extension after a fall. During his stay in intensive care, he was found to have protein C deficiency with bilateral pulmonary emboli. Therapeutic anticoagulation was contraindicated and an inferior vena cava (IVC) filter was placed and, due to the hypercoagulable state, the patient was maintained on heparin for deep vein thrombosis prophylaxis. He entered acute inpatient rehabilitation for weakness in his left upper extremity and lower extremity. During his rehabilitation stay, he presented increased tone in the left upper extremity with a Modified Ashworth Scale of 2. Treatment with baclofen was started for spasticity. Weekly laboratory tests revealed that after starting baclofen, the patient's platelets decreased from 313,000 to 113,000 (normal 150,000-450,000) over three weeks. Baclofen and heparin were discontinued and the antibody test for heparin-induced thrombocytopenia (HIT) was negative. After baclofen was discontinued, the number of platelets increased steadily. He was started on tizanidine for muscle spasticity and continued to show improvement with physical therapy.

discussions:Baclofen is a skeletal muscle relaxant with common side effects of lethargy and hypotension. Thrombocytopenia as an adverse reaction is rare and most of the reported cases affect men over 40 years of age. This rare side effect should always be considered because of its catastrophic side effects and that it is easily reversible with discontinuation of baclofen.

Conclusions:This case presents a rare incidence of baclofen-induced thrombocytopenia. Physiatrists prescribing this medication should be aware of this rare side effect, and a complete blood count should be checked before starting Baclofen therapy and also periodically during Baclofen therapy.

Behavioral and histological evaluation of a mouse model of closed traumatic brain injury

Nathan K. Evanson, MD, PhD; Michael D. Goodman, MD; Dr. James P. Herman

Goals.To establish and characterize a closed head model of traumatic brain injury (TBI) that can be used to assess environmental effects on recovery from experimental traumatic brain injury.

Project:C57BL/6J mice were used in these experiments. TBI was induced with a loading device after isoflurane anesthesia. Animals were then subjected to behavioral testing using a conditioned fear paradigm at days 1, 3, 7, and 14 post-TBI. In separate groups of mice, brains were harvested for histological examination at 7 and 14 days post-injury. Sham TBI animals, subjected to anesthesia only, were used as controls for all of these investigations.

Results:Behavioral analysis using a conditioned fear paradigm revealed changes in behavioral acquisition and extinction. In particular, there was greater acquisition and more rapid extinction of conditioned fear behavior just after the experimental TBI. Furthermore, there appeared to be a slower extinction of conditioned fear at 1-2 weeks after experimental TBI. Histological examination using fluorojade B revealed damage more particularly in long fiber tracts such as the optic tract compared to mock animals.

Conclusions:Closed-head experimental TBI caused damage to white matter tracts in a closed-head TBI mouse model. There were also changes in conditioned fear behavior after experimental TBI, suggesting altered frontal lobe function. Together, these results suggest that this closed-head TBI model is relevant to human TBI and will be useful in further evaluating interventions to improve outcomes after TBI.

Bilateral corpus callosum stroke: review of a case on the use of neurostimulants for the treatment of this patient population

ShaEssa L. Wright, DO, MBS; Brian Greenwald, MD; Dra. Sara Cuccurrullo

Diagnosis of the case:This case deals with a 58-year-old man s/p CABG who clinically deteriorated on the third postoperative day with clinical findings of hemiparesis L, aphasia, dysphagia, and mental deterioration secondary to multiple embolic infarcts in his bilateral corpus callosum.

Case description:A 58-year-old right-handed male with a medical history of recently diagnosed type II diabetes mellitus, arterial hypertension, paroxysmal atrial fibrillation, and coronary artery disease, who underwent 3-vessel CABG surgery complicated by ventilator-dependent respiratory failure. On the third postoperative day, the patient was found to have a decrease in verbal production and a decrease in following commands. MRI of his brain demonstrated multifocal cerebral ischemia predominantly in the corpus callosum secondary to an embolic infarction attributed to his paroxysmal atrial fibrillation. The patient had significant left hemiparesis, aphasia, dysphagia, decreased arousal, and poor initiation secondary to bilateral embolic infarction of the corpus callosum, and he presented for acute inpatient neurorehabilitation.

On admission to acute rehabilitation, the patient's physical examination was consistent with poor control and follow-up, atrial fibrillation, incontinence, L-hemiparesis, aphasia, and apraxia. His functional level at the time of admission was maximum assistance for transfers and ADL.

discussions:Research indicates that bilateral corpus callosum effusions are rare due to the rich arterial system that the structure provides. The main function of the corpus callosum is to integrate motor, sensory and cognitive performance in the cerebral cortices. To address this patient's poor functional status, this patient was treated with neurostimulants to address problems of decreased initiation, impaired arousal, and inability to initiate speech. After four weeks of neurostimulant use and acute inpatient neurorehabilitation, the patient significantly improved reasoning, processing speed, and communication with significant improvement in his ADLs and physical function.

Conclusions:Additional research is needed to support the use of neurostimulants and acute neurorehabilitation in patients with bilateral corpus callosum infarcts. This case study identifies the benefits of neurostimulant use in addition to comprehensive neurorehabilitation for patients with bilateral corpus callosum stroke, demonstrated by improved functional outcomes.

Bilateral frontal infarcts due to anomalous cranial vasculature: a case study

Anup Patel, DO; Trishla R. Kanthala, DO; Nidhi Parikh, NA; Lyn Weiss, Doctor of Philosophy

Diagnosis of the case:Bilateral frontal lobe infarcts caused by hypoplasia of the A1 segment of the anterior cerebral artery

Case description:This is the case of a 71-year-old woman, previously independent, with a history of hypertension, dyslipidemia, hypothyroidism, and chronic obstructive pulmonary disease, who came to the hospital due to incontinence, lower limb weakness, aphasia, fever, and mental disturbance. condition. She had no history of stroke or transient ischemic attack. On initial CT scan, she was found to have bilateral areas of hypoattenuation in the frontal lobe, likely representing anterior cerebral artery (ACA) infractions. Meningoencephalitis due to fever, incontinence, and altered mental status has also been considered. A lumbar puncture was performed, but the results were inconclusive. When the lumbar puncture was repeated, the results were negative for meningitis. Vascular etiology was also considered and she was referred for magnetic resonance angiography (MRA). MRA showed a hypoplastic right A1 segment of ACA with both ACAs fed by the left A1 segment.

discussions:Meningoencephalitis can often mimic symptoms similar to those of a stroke. In this case, meningoencephalitis was initially suspected as an etiology due to the low probability of bilateral ACA infarcts. Bilateral ACA hemorrhagic infarcts occur due to ruptured aneurysms of the anterior communicating arteries or the distal ACA. Bilateral ACA ischemic infarcts may be due to anatomic variations of the anterior circulation of the circle of Willis. In this case, the patient had bilateral ACA infarcts due to a hypoplastic A1 segment. A study by Gunnal et al. dissected 112 brains and found an 8% prevalence of hypoplastic A1 segments. To the best of our knowledge, the incidence of bilateral ACA infarcts is unknown. More research is needed to assess the true prevalence of bilateral ACA infarcts.

Conclusions:Bilateral cerebral arterial infarcts are rare but may be due to abnormalities of the cerebral vasculature, such as ACA segment A1 hypoplasia. It is important that physiatrists are aware of these abnormalities and the challenges that accompany the sequelae of these infarcts when managing these patients in an inpatient rehabilitation unit.

Bobble Head doll syndrome in an adolescent patient with non-traumatic head injury: case report

María E. McClanahan, MD; Dr. Tobias J. Tsai

Diagnosis of the case:Bobble Head Syndrome in an adolescent patient with non-traumatic brain injury

Case description:A 17-year-old male who was admitted to the pediatric rehabilitation unit for treatment of functional impairment secondary to non-traumatic head injury after resection of a pilocytic astrocytoma occupying the posterior fossa. He had a poor postoperative recovery, with posterior fossa syndrome mimicking locked-in syndrome, as well as hydrocephalus, which required placement of a ventriculoperitoneal shunt. On hospital day 26, the patient developed head shaking, as if he were nodding. He was withdrawn from neurocognitive stimulant medication without improvement, and trials with levodopa and clonazepam failed. He eventually required to see a movement disorder specialist, who diagnosed him with Bobble Head Syndrome. He underwent review of the shunt settings, with resolution of the head titration.

discussions:Bobble Head Doll syndrome is a movement disorder characterized by rhythmic movements of the head and is associated with lesions involving the third ventricle. Despite being a rare entity, with fewer than 50 cases reported in the literature, inpatient pediatric rehabilitation presents a scenario where this disorder is likely to be found, since most pediatric brain tumors are located in the posterior fossa. Head movements associated with the condition can significantly limit an individual's functional performance, as head movement is a common way for people recovering from brain injury to indicate yes or no preferences. The condition generally responds poorly to medication, but neurosurgical intervention is often curative. For this patient, recognition of the syndrome led to a neurosurgical intervention that decreased her symptoms, allowing her to continue to progress functionally.

Conclusions:Bobble Head Doll syndrome is a rare and functionally limiting movement disorder that can be seen in patients with posterior fossa lesions. Physiatrists should be aware of this rare condition, as it can often improve or even be cured after neurosurgical intervention.

Breaking the Performance Code Inpatient Rehabilitation Facility Equipment and Processes Governed by Private-Academic Associations

Rosemarie Filart, MD, MPH, MBA; Brian McGillen, MD; Sherri Luchs, MHA, BSN, RN; Kristen Young, MSN, RN; Nasrollah Ghahramani, MD, MS, FACP

Academic medical centers seek to partner with private organizations to expand patient access to care in established markets, reduce costs, and diversify opportunities in clinical education and workforce development to support educational and research missions. Aligning clinical services requires streamlined coordination, accelerating decision making, evolving leadership team roles, and emphasizing transparent communication between departments. As these new partnerships take hold, collaborations face new dual-systems governance management challenges to balance systems with different cultural norms with economic alignment in value-driven healthcare. These new challenges can feel like cryptograms that, when unlocked, catalyze innovative approaches for quality, patient-focused outcomes. A cryptogram is seen in the transfer process, where cracking the code would optimize efficient and effective two-way patient flow between academic medical centers and inpatient rehabilitation facilities governed by academic and private associations. This performance process is critical. In a dual governance, this handover process requires diverse members of the leadership team who represent key decision points along the continuum of rehabilitation care, engage in transparent communications, and meet regularly to develop processes within a framework of innovative structural management. Productivity leadership teams should capture representatives at both ends of this rehabilitation continuum, for example, medical center medical-surgical teams, care coordinators/social worker, quality care leadership, Dir. Rehabilitation and Rehabilitation Medicine Consultation, e.g., Inpatient Rehabilitation Facility CEO/Marketing Director, Quality Care Leadership, Medical Director, Chief Nursing Officer, and Chief Rehabilitation Therapist, Rehabilitation Team(s) assistant and case managers/social workers. The core members consist of rehabilitation specialists and a complete interdepartmental team. Meeting regularly, the teams examine communication gaps and patient/carer needs as patients bi-directionally move along the rehabilitation continuum, care outcomes and readmissions, reduce bottlenecks, and recruit the participation of the global team. This poster presentation details the modeling of productivity leadership teams and processes in such partnerships to optimize patient-centered quality outcomes and functional recovery.

Blisters after the use of Lyrica (pregabalin) for the treatment of neuropathic pain in a patient with spinal cord injury

Syed Rashad Ahmed, MD, MS; Dr. Camilo Castillo

Diagnosis of the case:Blisters after the use of Lyrica (Pregabalin) for the treatment of neuropathic pain in a patient with spinal cord injury

Case description:A 50-year-old man, a complete quadriplegic C4 AIS-A after post-C3-C5 laminectomy and fusion with no known drug allergies, suddenly developed multiple abdominal blisters of no known cause while admitted to an acute rehabilitation hospital. Concern about a possible allergic process prompted a complete review of the patient's medication list for dermatologic side effects. Notable medications included Lyrica, of which he took 50 milligrams three times a day for neuropathic pain control. In addition, all potential irritants were removed, including an abdominal bandage, skin tape, and switched to a latex-free suprapubic catheter. Despite the protective measures, multiple blisters continued to appear on various parts of the body, including the upper extremities. Dermatology was consulted and biopsies were obtained that revealed an inflammatory process at the lesion site.

discussions:Bullae/vesicles larger than 5mm in diameter and filled with fluid are known as bullae and are commonly caused by a variety of medical and environmental factors. To the best of our knowledge, this is one of the few reported cases of blistering after the use of Lyrica, an antiepileptic commonly used for neuropathic pain.

Conclusions:Blisters can be caused by the use of Lyrica (pregabalin), although cases are extremely rare. Scholarly documentation of this phenomenon is critical; particularly in the SCI population, where sensitivity can be severely impaired. It is imperative to increase clinical awareness for early intervention.

Can clinic-based measures of walking predict community walking activity in children with cerebral palsy?

Sarah A. witty, do; Kristie Bjornson, PT, PhD, PCS

Goals.Motor ability (the ability to perform tasks in a controlled environment) and motor performance (what a child actually does in the community) are distinct but related constructs that characterize the ambulatory activity of children with cerebral palsy (CP). Our aim is to examine the relationship between clinical measures of walking ability and community walking activity in ambulatory children with cerebral palsy.

Project:We performed a secondary analysis of a cross-sectional cohort of 128 ambulatory children with cerebral palsy (Gross Motor Function Classification System (GMFCS) levels I-III, ages 2-9). Walking ability was measured using the 1-minute walk test (1MWT), the 6-minute walk test (6MWT), the Gross Motor Function Measurement Walk/Run/Jump Score (GMAE-E), and the Activity Performance Questionnaire. ASK -p). Community walking activity was quantified using StepWatch (SW) accelerometry, including average steps per day, percentage of walking time, number of steps > 30 steps per minute, highest step rate per one, and sixty minutes and maximum activity rate. Pearson correlations and inverse linear regressions were used to examine relationships of interest.

Results:The 1MWT and 6MWT were moderately correlated with all SW outputs (r = 0.42-0.59, p < 0.01). The GMAE-E score was moderately correlated with all SW exits and strongly correlated with the number of strides greater than 30 per minute (r = 0.69, p < 0.01). ASK-p was moderately correlated with all SW outputs (r = 0.49-0.59, p < 0.01). GMAE-E and 6MWT significantly predict SW outcomes (p = 0.05 to < 0.001) by regression analysis (variance 0.25 to 0.42).

Conclusions:All clinical measures were significantly related to community walking activity. GMAE-E and 6MWT have the strongest relationship with SW outcomes of walking activity level and intensity in daily life. Since these measures only explain up to 42% of the variability in gait performance, they should be used to complement other clinical features and measures of gait function in ambulatory children with cerebral palsy.

Clinical case of ischemic stroke secondary to PRES and RCVS in a situation of phenylephrine abuse

Lauren S. Rudolph, MD; Dr. William L. Wagner

Diagnosis of the case:Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) are rare presentations of stroke, especially in an acute rehabilitation unit. These two syndromes have overlapping clinical and imaging features.

Case description:We present a case of ischemic stroke in which the patient had evidence of PRES and RCVS on imaging after known phenylephrine abuse. The patient presented after being found lying down for at least eight hours. Initial noncontrast CT scan of the skull revealed a right postero-parieto-occipital stroke and left cerebellar infarction. Brain MRI showed significant occipital and cerebellar FLAIR hyperintensities. In addition, the ARM was quite abnormal with multiple areas of vascular irregularity and angiographic reversal was seen after treatment with a calcium channel blocker.

discussions:Subsequently, the patient was treated with oral verapamil, which was maintained during her stay in our rehabilitation unit. From a rehabilitation point of view, this case focused on the importance of a combined approach with medical management and functional improvement.

Conclusions:As this case and others like it suggest, future studies should investigate a possible shared pathophysiology of PRES and RCVS.

Case Report: Sodium Channelopathies

Donald L. Hamby, DO, MS; Justica Otchere, MD; Jeffrey Rosenfeld, PhD, MD; Dra. Sarah Humbert

Diagnosis of the case:sodium channelopathy

Case description:The patient is a 28-year-old man who presents to the neuromuscular clinic with episodic cramps and loss of muscle control since childhood. These symptoms worsen when the patient is exposed to cold, after exercise, or goes without food for long periods. Swelling of the hands and face is also seen after exposure to cold. The symptoms of it appear approximately 30-45 minutes after exercise, but can be reduced or completely avoided if you eat afterwards. The patient has no other significant pathological history and denies the use of alcohol, tobacco or illicit drugs. He is concerned that his son is experiencing similar symptoms. His 4 siblings do not have similar symptoms. The paternal history is unknown. The physical examination is positive for palpebral myotonia, to grip and percussion. Calf hypertrophy is also seen. There are no upper or lower motor neuron signs, and motor strength tests are normal with normal muscle mass. The genetic test for the CLC-1 gene was negative and the positive for SCN4A was positive. Electromyography was positive for myotonic discharges, whereas heated nerve conduction studies were normal.

discussions:SCN4A mutations in the sodium ion channel are characteristic of three distinct disorders: myotonia congenita, paramyotonia congenita, and hyperkalemic periodic paralysis (HPP). A combination of patient history, electrophysiology, and response to medication can be used to distinguish these genetically identical conditions. Discriminatory factors will be discussed and sodium channelopathies will be contrasted.

Conclusions:For most inherited disease processes, identification of a gene is the gold standard for diagnosis. However, when it comes to sodium channelopathies, knowing the genetic defect does not identify the disease. For this patient, identification of the specific disorder will determine the optimal treatment plan.

Catatonia and abnormal vital signs in a patient with spinal cord injury

Dorothea H. Ellis, MD; Dr. Paul Thananopavarn

Diagnosis of the case:Development of catatonia and abnormal vital signs in a patient with incomplete spinal cord injury.

Case description:A 64-year-old man presented to UNC with an incomplete spinal cord injury after he was found collapsed. He underwent a C3-C4 laminectomy for neurosurgical decompression and was then transferred to acute rehabilitation for treatment of the resulting quadriplegia, neurogenic bowel, and neurogenic bladder. As he was not independent enough to return home at the end of his rehabilitation stay, he was scheduled to be discharged to a subacute unit. Upon receiving this news, the patient began to show confusion and express paranoid ideation. His mental state worsened over the next week, with increasing confusion, agitation, and paranoia. On examination, the patient was reluctant to open his eyes and had intermittent redness and sweating. An infectious test was negative. Nuclear magnetic resonance revealed diffuse atrophy, but no findings to explain the patient's altered mental status. EEG showed asymmetric deceleration, which may be due to atrophy seen on MRI, but did not reveal any evidence of seizure. Psychiatry was consulted and Risperdal was recommended, but the patient began to refuse oral medications and was advised to use intravenous Haldol. The patient then began to develop hypertension and fever. At this time, the differential included previously scheduled GABAergic withdrawal of baclofen and gabapentin, vs. autonomic dysreflexia vs. malignant catatonia. Haldol was discontinued and intravenous diazepam was started in case of possible withdrawal. Neurology was consulted and it was agreed that GABAergic withdrawal was likely. The patient was noted to have slight improvement after receiving his bowel program, supporting the possibility of autonomic dysreflexia. He also had a brief recovery from his mental state after being persuaded to take two doses of baclofen, which supported the diagnosis of withdrawal. Unfortunately, despite these attempts to take action, the patient's mental state deteriorated again and he became increasingly unresponsive. He was eventually transferred to a medical center for close monitoring while he received a scheduled treatment of high-dose Ativan IV. A nasogastric tube was placed due to his refusal to eat or take oral medications. The patient had a prolonged hospital stay, but ended up showing more significant improvement with ECT for the treatment of catatonia by psychiatry.

discussions:The cause of this patient's symptoms is likely multifactorial, with his vital sign abnormalities due to GABAergic withdrawal and possibly autonomic dysreflexia. The patient also showed classic signs of catatonia and responded well to ECT, but he may not have progressed to malignant catatonia as a definitive explanation for all of his symptoms.

Conclusions:Spinal cord injury can complicate the diagnosis and treatment of psychiatric comorbidities. Treatment of catatonia in patients with IBS is particularly important, as delayed intervention can lead to medication discontinuation and possibly contribute to the development of autonomic dysreflexia.

Inflammatory Mass Formation at the Catheter Tip - Presentation of 4 Cases

Fatma Gul, MD, MSc; Patricia Gordon, MSN, MPH, RN, FNP-BC; Patricia Krohn, MSN, MPH, RN, FNP-BC

Diagnosis of the case:Development of an inflammatory mass at the tip of the catheter.

Case description:Intrathecal pump drug delivery is increasingly recognized as an option for patients with chronic nonmalignant pain refractory to other therapies. Intrathecal drug delivery via a programmable pump is used with baclofen for course-related spasticity in multiple sclerosis, cerebral palsy, after stroke, traumatic brain injury, and other neurological disorders, as well as for the pain control in a variety of conditions. A rare complication of this therapy, the formation of an inflammatory mass at the tip of the catheter (called a granuloma), was once thought to be largely related to high concentration/high dose drug therapy. At our center we managed approximately 500 patients with spasticity and pain pump, four of whom developed granuloma at the catheter tip site. We highlight those cases that developed a granuloma at the tip of the catheter with differences in diagnosis, medication, and pump history.

discussions:Case 1: A 68-year-old woman with spastic hemiparesis after stroke who developed a granuloma approximately 5 years after starting ABI therapy with increasing spasticity and progressive bilateral lower extremity weakness.

Case 2: A 57-year-old man with chronic pain secondary to inoperable spinal hemangioma after IT pump implantation in 1998, treated with drugs such as morphine, dilaudid, baclofen, clonidine, and bupivacaine. Granulomatous mass discovered 4-2015 after increased pain, lack of response to increased dose.

Case 3: 71-year-old woman with a history of chronic pain secondary to failed back surgery syndrome who developed a catheter tip granuloma on 3-2013. The pump and catheter were removed.

Case 4: A 71-year-old male with chronic pain secondary to failed back surgery syndrome, initially underwent IT pain pump implantation in 2009. He was treated with various analgesics such as ziconotide, bupivacaine, clonidine, sufentanil, fentanyl. It turned out that he had developed a granuloma on T-7.

Conclusions:Trying to identify patients at risk of developing this rare complication of intrathecal drug administration is challenging, as there do not appear to be clear patterns with the type of drug used in therapy that led to the development of the mass. Of the four featured patients, one was treated exclusively with commercially available baclofen monotherapy and the rest with opioid/non-opioid and combination therapy. 3 of the 4 were consistently at what are recognized as recommended concentrations, the 4th had been in a prior practice using morphine at higher concentrations. In this population, regular clinical neurologic examinations, good communication with patients about changes in status, and imaging studies may be recommended when indicated by changes in neurologic status or new refractory pain.

Cauda equina syndrome as an unusual presentation of Hodgkin's lymphoma

Joslyn Gober, DO; Armen Derian, MD; Seema Khurana, DO

Diagnosis of the case:Cauda equina syndrome is a life-changing condition that causes paralysis and incontinence as a result of nerve root damage at the level of the conus medullaris. Presentations can range from back pain, sensory and motor deficits in the lower extremities, urinary or bowel incontinence, and saddleback anesthesia. It is often difficult to diagnose as it mimics other conditions such as herniated discs, spinal stenosis, and lumbosacral plexopathies. Rarely, this condition can result from a metastatic cancer such as Hodgkin lymphoma (5%).

Case description:A 14-year-old man presented to the Emergency Department with bilateral lower extremity weakness that began 26 weeks earlier and gradually progressed until he could no longer walk. The patient and his family denied any recent trauma, infection, psychological event, or other triggering factors. All his vaccinations were up to date. On physical examination, muscle strength was 3/5 for both proximal and distal lower limbs bilaterally; Patellar and Achilles reflexes were absent; and the Romberg sign was positive. Cardiovascular, pulmonary, and abdominal examinations were normal. The patient was admitted to the pediatric unit due to cauda equina syndrome (CES) and investigation of possible causes. Of note, although he was not present on admission, he developed bowel and bladder incontinence within the first few days after admission. Cerebrospinal fluid (CSF) cultures were negative but elevated protein with normal glucose, indicating the presence of malignancy, and the sample was sent for cytology and paraneoplastic panel. Magnetic resonance imaging (MRI) of the brain was negative for any pathology, but MRI of the thoracic and lumbar spine illustrated increased signal intensity and abnormal intradural enhancement in the CSF spaces around the spinal cord in the brain. lower part with marked thickening and enhancement of the cauda equina, which were related to diffuse leptomeningeal enhancement. Based on MRI findings, possible etiologies included inflammatory or infectious processes, as well as malignancy. Later, chest CT scan revealed numerous enlarged axillary and retropectoral lymph nodes, leading to positron emission tomography showing multiple hypermetabolic masses in the right neck, right axillary, and right retropectoral regions. Finally, a right axillary lymph node biopsy revealed nodular sclerosis Hodgkin lymphoma.

The patient completed 2 cycles of chemotherapy including doxorubicin, bleomycin, vincristine, etoposide, and cyclophosphamide (A-VHR). Repeat PET scan performed after the first cycle showed a positive response to treatment. The patient entered acute rehabilitation for a total of 16 days, where he received three hours daily of physical and occupational therapy services to improve his gait, mobility, self-care, and general functional abilities that had declined as a result of CES. His Functional Independence Measure (FIM) score, which is a widely accepted scale used to measure the functional abilities of patients undergoing rehabilitation, improved dramatically, nearly doubling from 49 to 90. After diagnosis, he recovered remarkably. After undergoing chemotherapy and intensive rehabilitation, the patient improved significantly.

discussions:Cauda equina syndrome (CES) is a serious neurological condition that occurs due to damage to the lumbar and sacral nerve roots. Malignant CES is rare, with an annual incidence of 3.4%. Finding the cause is imperative because, if left untreated, it can lead to permanent paraplegia and incontinence. Spinal cord compression occurs as the initial manifestation of an underlying malignancy, such as Hodgkin lymphoma (HL), 0.2% of the time. HL accounts for approximately 7% of childhood cancers and 1% of childhood cancer deaths in the United States, and is most commonly seen between the ages of 15 to 19 years. The frequency of HL with spinal cord compression is rare and often only seen in the setting of advanced disease.

HL treatment is generally successful with 5-year survival rates of 65% for stage IV disease. Full recovery of function depends on the extent of damage to the spinal cord. Engaging in acute rehabilitation as soon as possible allows for the greatest level of improvement. The Functional Independence Measure (FIM) score is a widely accepted scale used to measure the functional abilities of patients undergoing rehabilitation. Our patient's FIM scores nearly doubled, initially requiring maximum or full assistance for most of her activities. Upon discharge home, he required minimal to moderate assistance.

Conclusions:However, compression of the cauda equina and spinal cord as the initial presentation in Hodgkin lymphoma may be more common than initially thought. In this case, the development of ESC unmasked an underlying malignancy. With chemotherapy and rehabilitation, patients have a better chance of remission and functional recovery. As unfortunate and painful as it is for this young teenager to be diagnosed with cancer, the development of the cauda equina possibly saved his life.

Management of chronic pain with pamidronate in a patient with type III mucolipidosis

Neal Washburn, DO, MS; Ravi Mirpuri, DO

Diagnosis of the case:type III mucolipidosis

Case description:The patient was a 7-year-old boy with mucolipidosis type III when he first presented to the Pediatric Rehabilitation clinic. The patient suffered from chronic deep bone pain, mainly affecting the neck, back, hips and knees. His pain had previously been treated with Elavil, Tylenol, Motrin, Gabapentin, and Vioxx, in addition to various forms of therapy. Initial DEXA scans revealed a significant decrease in bone mineral density (BMD) in the femoral neck and lumbar spine with values ​​of 0.551 g/cm²e 0,450 g/cm²🇧🇷 Initially, the patient was started on oral alendronate for a short period of time, but without significant pain improvement. This was then changed to monthly infusions of 60 mg pamidronate, accompanied by daily motrin and calcium carbonate, according to a proposed protocol for patients with type III mucolipidosis. Urine deoxypyridinoline crosslinking tests were followed monthly to monitor bone turnover. After starting the infusion treatments, the patient's BMD improved and his overall pain level decreased. Repeat DEXA scans less than 1 year after starting treatments showed a 10.3% increase in BMD. After 3 years of treatment, the patient's DEXA scan showed normal hip and spine BMD, which was maintained on subsequent repeat DEXA scans. The patient is now 18 years old and continues to receive monthly infusions of pamidronate. During the last 10 years of treatment, he admits to increased pain and discomfort if he did not take the scheduled dose of pamidronate. As urinary deoxypyridinoline crosslinking was monitored, higher levels were found to correlate with increased pain when preceded by a few months of lower levels. Although he sometimes needs narcotic medications to help control pain, he admits that pamidronate treatments have provided a good foundation for pain control.

discussions:Mucolipidosis type III (ML III) is a rare genetic lysosomal storage disease that is inherited in an autosomal recessive pattern. ML III, also known as pseudo-Hurler polydystrophy, results from a deficiency in the enzyme N-acetylglucosamine-1-postphotransferase, which inhibits the proper packaging of digestive enzymes in lysosomes and leads to accumulation of mucolipids within the cell. . These patients suffer from a variety of complications including severe skeletal abnormalities, chronic pain, aortic valve disease, mild mental retardation, and eye problems, among others. Common skeletal abnormalities in patients with ML III include progressive joint stiffness, scoliosis, short stature, as well as multiple dysostosis, a collection of skeletal complications commonly found in patients with mucopolysaccharidoses. More recently, it has been shown that patients with ML III also suffer from osteopenia and osteoporosis due to a high rate of bone turnover. Reports of patients with ML III and metabolic bone disease who were treated with pamidronate, a second-generation bisphosphonate, have shown improvement in pain levels, better mobility, decreased bone turnover, and increased bone density after one year of treatment. treatment. At the moment, however, there is still no clear result for pamidronate treatments in patients with ML III.

Conclusions:ML III is a lysosomal disease complicated by a series of severe skeletal abnormalities and chronic pain. Some reports have indicated good results in the management of chronic pain in patients with SCI III using pamidronate, but without a clear outcome for treatment. In this report we present a case of ML III successfully treated with pamidronate for 10 years. In addition, we note that increased bone turnover, as evidenced by higher levels of urinary deoxypyridinoline crosslinking, may correlate with increased pain. More research is needed to better clarify the outcome of pamidronate treatments in patients with ML III, as well as to establish a clearer correlation between bone remodeling and pain in these patients.

Clinical Sequelae and Rehabilitation of Sustained Vertebral Artery Dissection After Cervical Hyperextension During Tactical Training with Pepper Spray: Case Report

Joseph A. Sclafani, MD; James Liadis, MD; Major J. Amin, MD; Rachna Malhotra, DO

Diagnosis of the case:Bilateral cerebellar, occipital, and parietal infarcts with right vertebral flow emptiness secondary to vertebral artery dissection.

Case description:A 28-year-old hospital security guard experienced rapid cervical hyperextension during a pepper spray tactical training session. On initial presentation, he was found to be minimally responsive and exhibit a flexed posture. He regained consciousness 1 hour later and complained of a severe headache and loss of vision. Initial evaluation, including a head CT scan, was normal. Subsequently, MRI of the head and neck revealed extensive bilateral cerebellar, occipital, and parietal infarcts with empty right vertebral flow secondary to vertebral artery dissection. He entered acute rehabilitation with deficits consisting of cortical blindness and mild ataxia. He received extensive therapy for gait retraining and visual deficits. The ophthalmologist was consulted and dynamic depth-of-field therapy was performed, which significantly improved the perception of light in the visual field. She was discharged from acute rehabilitation on day 27 post-injury, completing all ADLs and walking independently. She was able to return to work as a hospital security officer two months after her injury.

discussions:Vertebral artery dissection should be considered with cervical hyperextension injuries, especially when cerebellar signs or visual field deficits are present. Vascular imaging should be considered with these lesions to allow for early intervention.

Conclusions:Patients with vertebral artery dissection can make excellent progress with focused rehabilitation and achieve a high functional outcome. Dynamic Deep Field Therapy is especially useful in visual rehabilitation.

Complete recovery from diagnosis of ASIA A: case report

David M. Impastato, MD; Dr. Gary Glynn

Diagnosis of the case:Ms. DJ is a 57-year-old African American woman who initially presented with paraplegia and a T5 ASIA A diagnosis of T5, T7, and T8 spinal cord compressions secondary to epidural hematoma or lipomatosis, who after two years was readmitted for a femur fracture and diagnosed as ASIA E on the ASIA impairment scale.

Case description:A 57-year-old woman with a significant medical history, including bladder carcinoma, small cell lung cancer, deep vein thrombosis, steroid-dependent asthma, osteoporosis, diabetes mellitus, and bilateral hip replacements, has developed weakness in the right lower extremity. and increased gait instability one week before initial presentation. Three days prior to admission, she developed new back pain, reported inability to move her legs, inability to urinate, and bilateral numbness from the waist down. In the following days, the patient began to present pain in the upper thoracic region, which took him to the hospital. On initial admission, the patient immediately received a treatment dose of lovenox for a concomitant diagnosis of pulmonary embolism. Physical examination showed lower extremity paraplegia with increased tone, lower extremity deep tendon reflexes of 3-4+, and a T5 sensory level. MRI showed multiple compression fractures, particularly at T5 (75% compression fracture), T7 (30% compression fracture), and T8 (50% compression fracture). In the sagittal section, a collection of epidural fluid was observed that extended from T3 to T9, which suggested a sign of fat (epidural lipomatosis vs. epidural hematoma). Two neurosurgical consultants noted that the patient's myelopathy was complete. The patient then underwent T5, T7, and T8 vertebroplasties and received a TLSO brace. After this procedure, reassessment showed no palpable muscle contraction in the lower extremities, no pricking/stinging sensation below the level of the T5 dermatome, no perianal sensation, and no sphincter contraction. A diagnosis of T5 ASIA A was given and the patient received two months of inpatient rehabilitation without neurological recovery. She was then discharged home with her on an outpatient therapy regimen; but she got lost in the follow up. Two years later, the patient was admitted to the same rehabilitation center after corrective surgery for a periprosthetic refracture of the left femur. Function observed before surgery was independent for activities of daily living and ambulation with a straight cane. After surgery on the femur, the patient was able to walk 35 feet with a rolling walker. Muscle testing of her hand showed 5/5 strength in her right lower extremity and 3+ deep tendon reflexes in her right lower extremity (examination of left lower extremity was delayed due to surgery). Continence was also observed in both intestine and bladder. At discharge, ADLs were independent and the patient was able to walk 75 feet without assistance. The patient's diagnosis was changed from T5 ASIA A to ASIA E.

discussions:Improvement in ASIA grade usually occurs within 1 to 6 months after injury, with minimal recovery after two years. If diagnosed as complete spinal cord injury after 72 hours, patients are most likely to remain complete by 1 year. We did not find any cases of improvement for ASIA E from ASIA A in our review of the literature. There is limited literature studying delayed recovery from spinal cord injuries. Kirshblum et al performed a review of the MSCIS database that included 571 patients classified as ASIA A with paraplegia or quadriplegia. Five years later, 94.4% of patients diagnosed with ASIA A remained on ASIA A, while 4.6% improved to ASIA B-D and 0% improved to ASIA E. Kirshblum hypothesized that half of patients who improved to ASIA D within 5 years were incorrectly coded. In the case of spinal epidural hematoma/lipomatosis, there are a few theories. One theory is that the hematoma/lipomatosis may leak from the epidural space through the intervertebral foramen and cause decompression of the spinal cord. An alternative theory is that if anticoagulants are administered, the hematoma may spread throughout the epidural space, relieving compression on the spinal cord.

Conclusions:We believe that no literature has described recovery from ASIA A to ASIA E, with only 6% of ASIA A patients improving to grades B-D. In this case, physicians from two relevant specialties examined this patient and initially classified her as ASIA A. Vertebroplasties were performed and there was no neurological recovery during the two months of inpatient rehabilitation, reinforcing beliefs of ASIA A status. However, this patient was admitted two years later with a diagnosis of ASIA E. The mechanisms that explain this unprecedented improvement are unknown, although some have theorized that the use of anticoagulants or expansion of the fluid collection may contribute to the recovery of these patients. This case is unique in that it demonstrates the possibility of complete recovery from the ASIA A diagnosis. More research is needed to understand the mechanisms of spinal cord recovery and regeneration after decompressions, as well as the benefits/risks of the use of anticoagulants in epidural hematomas. .

Complications of non-surgical treatment of a distal femur fracture in a patient with spinal cord injury

Beverly Hon, MD; Drag. Amanda Farag

Diagnosis of the case:Distal femur fracture in a patient with complete spinal cord injury

Case description:A 70-year-old male with a significant medical history of T2 ASI spinal cord injury (SCI) with age-indeterminate fracture of the distal femur. Orthopedics recommended conservative treatment with a knee immobilizer. Over a 5-month period, the patient obtained multiple radiographs showing progressive callus formation, heterotrophic ossification, diffuse osteopenia, and nonunion. The patient developed a medial malleolus injury secondary to the use of the immobilizer. He was admitted to the hospital for treatment of aggressive injuries. Despite receiving antibiotics, the patient developed sepsis from the wound. Bone scintigraphy showed findings compatible with osteomyelitis. Surgical debridement and bone biopsy of the region were performed. Orthopedics were consulted again, which continued to recommend immobilization despite the complications arising from the placement of the orthosis. Unfortunately, the patient's wound worsened and subsequently required a below-the-knee amputation.

discussions:Conservative treatment of the distal femur fracture resulted in serious complications due to the development of osteomyelitis. In the general population, the goal of treatment for distal femoral fracture is to maintain range of motion and return to a weight-bearing state with the hope of returning to ambulation. With a complete thoracic SCI, the patient will not be able to walk, regardless of the healing of their fracture. Due to skin integrity concerns, judicious use of an orthosis for prolonged immobilization should be considered in the setting of a full thoracic SCI.

Conclusions:Fracture of the distal femur is one of the most common fracture sites in the SCI population. Currently, there are no standardized guidelines for the treatment of femoral fractures in patients with SCI. We present an unfortunate case of a conservatively treated femur fracture that resulted in eventual below-knee amputation. Clinical guidelines for femur fractures in patients with SCI should be based on decreasing secondary morbidity, preserving mobility, and improving quality of life.

Conservative management of complete rupture of femoral challenge: case report

Diana M. Molinares, MD; Armen Derian, MD; Dr. Kevin Dalal

Diagnosis of the case:This case involved a complete rupture of the proximal insertion of the rectus femoris tendon in a middle-aged man while playing soccer. The patient had no significant comorbidities that might have contributed to the injury. MRI showed evidence of proximal rectus femoris tendon rupture after an unusual mechanism of injury. Conservative treatment without surgical intervention provided complete resolution of the patient's symptoms.

Case description:A 47-year-old male veteran with a medical history of post-traumatic stress disorder, chronic pain in the right knee and shoulder, presented with acute pain in the left hip. The patient reported having suffered a traumatic hip injury during a soccer match a month earlier. He described a quarterback who landed on his left hip during a tackle. His left hip was hyperextended and internally rotated as a result of the impact. After the injury, the patient presents moderate to severe pain in the left hip, which limits his daily activities, mainly running or jogging. The pain eased with rest, but he limped after walking a few blocks. Physical examination showed normal strength, sensation, reflexes, and range of motion in the lumbar spine, hips, and knees bilaterally. No tenderness was detected in any hip joint. Resisted activation of the hip flexor with knee extension caused pain. Left hip radiograph revealed an old avulsion fracture fragment of the lesser trochanter. Anteroposterior and frog views of both hips were negative for any fracture or dislocation. MRI of the hip showed evidence of a full-thickness tear at the proximal insertion of the rectus femoris muscle, with mild inflammatory changes around it and fluid along the fascia.

The patient received a prescription for ibuprofen 800mg q6h prn, analgesic balm and physiotherapy. He attended two outpatient physiotherapy sessions where he received cryotherapy and performed therapeutic exercises to strengthen his quadriceps. One month later, at his follow-up visit, the patient reported complete resolution of symptoms.

discussions:The main function of the quadriceps muscle group is knee extension; however, it also plays an important role in stabilizing the hip and knee when walking. The rectus femoris is the only biarticular muscle in the quadriceps muscle group. Its function is to extend the knee while flexing and stabilizing the hip. Its double action makes it susceptible to injury. Injuries to the knee extensor apparatus are frequently seen in professional athletes. They are prevalent in sports that involve kicking, jumping, and running. The most frequently described mechanism of injury is associated with kicking a ball. Eccentric forces from the proximal muscles of the lower extremity are transferred to the distal leg before making contact with the ball. The patient in this report had an unusual mechanism of injury. It turned out that he had a complete tear of the rectus femoris muscle at the musculotendinous junction due to an extrinsic force. Forced hyperextension of the hip and internal rotation of the left lower limb caused complete rupture of the rectus femoris muscle, as seen on MRI. Despite the emphasis by some scholars on the surgical treatment of these injuries, there is no current standard of care. This patient made a full recovery with physical therapy and pain control.

Conclusions:The rectus femoris muscle is an intricate part of the quadriceps muscle group, allowing the knee to extend while stabilizing the hip. Its unique biarticular anatomy, which crosses the hip and knee joints, increases the risk of injury. The literature reports a high incidence of ruptures in the distal tendon of the rectus femoris muscle. However, proximal tendon tears are very rare and are typically seen in high level athletes after extrinsic force. Treatment consists of surgical intervention with high success rates. Conservative treatment was sufficient to resolve the patient's symptoms, highlighting the possibility of avoiding surgery. Rehabilitation is imperative, as strengthening the proximal hip flexors and knee extensors may lead to a reduction in rectus femoris injuries. Strengthening the quadriceps can be achieved through weight training and electrostimulation. A thorough evaluation of hip pain in all patients is imperative for successful results.

Controversies about the management of scoliosis in Duchenne muscular dystrophy

Dr. David Berbrayer

Goals.To review current surgical therapy for the treatment of scoliosis in Duchenne muscular dystrophy and determine whether respiratory status and function have improved

Project:A comprehensive review of the literature was conducted: PubMed and Embase, Cochrane, and NIH clinical trials databases to assess the role of anesthesia and scoliosis, the role of types of surgery and risk of complications, the impact surgery on respiratory and cardiovascular function and the risk of surgical complications. impact of osteoporosis and surgery, and the impact of gross motor function and respiratory status after scoliosis surgery.

Results:A consensus statement published by the American College of Respiratory Physicians suggests: need for an intensive care unit, no use of depolarizing muscle relaxants, need for cardiology consultation, and use of intravenous and non-gas agents. The Cochrane Database evaluated whether spinal surgery is effective in increasing survival, improving respiratory function, improving quality of life and general functioning; and whether spinal surgery is associated with serious adverse effects. As no randomized controlled trials were available to assess the effectiveness of scoliosis surgery in people with Duchenne muscular dystrophy, no evidence-based recommendations for clinical practice can be made. People with scoliosis should be informed about the uncertainty of the potential benefits and risks of scoliosis surgery. Complications of scoliosis surgery (overall 35%) include: late paraparesis, pedicle screw displacement or migration, infection, nonunion, and death 7%. With the loss of flexibility after spinal instrumentation, there are challenges in custom seating that compromise function at the wheelchair level.

Conclusions:1. The high incidence of osteoporosis with the use of steroids makes the outcome of surgery in DMD doubtful 2. There are great risks of anesthesia and cardiac risks with surgery. 3. Surgery carries a risk of complications, including death in Duchenne muscular dystrophy. 4. The Cochrane database found no randomized controlled trials available to assess the effectiveness of scoliosis surgery in people with Duchenne muscular dystrophy and no evidence-based recommendations for clinical practice can be made 5. Surgery does not improve posture in Duchenne dystrophy, but may worsen physical functioning even in a level 6 wheelchair. There is no evidence of respiratory improvement after scoliosis surgery in Duchenne dystrophy.

corpus callosum stroke

Quoc (Jonathan) Tran, MD; Dra. Kannan Thanikachalam

Diagnosis of the case:corpus callosum stroke

Case description:The patient is a 60-year-old African American woman with a medical history of diabetes, hypothyroidism, hypertension, chronic kidney disease, and the patient was admitted with primary complaints of dyspnea, confusion, and decreased responsiveness. Vital signs were within normal limits. The patient was in mild distress.

The patient presented bibasal crackles on auscultation. The patient was lethargic, disoriented, and slow to respond.

The patient was slow to respond on the left side. The patient's creatinine level was elevated above his baseline.

The patient was diagnosed with acute renal failure and underwent urgent dialysis. A brain CT scan was performed, revealing low density throughout the corpus callosum. Magnetic resonance imaging of the brain revealed a subacute infarct involving the entire corpus callosum. The patient was treated with optimal medical management.

discussions:The corpus callosum is the largest bundle of fibers connecting the cortical and subcortical regions of the brain. It also connects the two cerebral hemispheres, favoring the integration of sensory and motor functions. Infarcts of the corpus callosum are very rare and are attributed to the abundant collateral circulation and rich blood supply: anterior communicating artery, pericallosal artery, and posterior pericallosal artery. Patients may present with gait disturbances, apraxia, agraphia, tactile anomia, and alien hand syndrome. They can present atypically with signs and symptoms that are not localized and of slow evolution, more suggestive of a tumor. They may exhibit tumor-like enhancement and extend toward the midline. Unnecessary biopsy can be avoided by understanding the various clinical and radiological features of corpus callosum infarction. Callous stroke patients have favorable functional outcomes than large artery atherosclerotic stroke patients.

Conclusions:Strokes involving the corpus callosum are rare. Clinicians should be aware of the clinical manifestations and always look for other reasons for decreased responsiveness when ruling out other potentially reversible etiologies, such as uremia.

Cross-sectional study of the use of point-of-care ultrasound in the evaluation and efficacy of glenohumeral joint injections

Jeremy Roberts, Bachelor of Science; Timothy Tiu, MD; Matthew N. Bartels, BA, MD, MPH; Se Won Lee, MD

Goals.Primary objective: To describe ultrasound (US) at the point of care (POC) in patients with US-guided glenohumeral joint injection (USGHJI) for adhesive capsulitis (AdC). Secondary objective: to determine clinical variables and US POC findings related to better results.

Project:A retrospective review of US electronic medical records and images of patients with USGHJI for AdC was performed from February 2014 to August 2015 and compared with available clinical information and other imaging studies. Successful response to the USGHJI was defined as a 50% reduction in pain for at least 2 months with a subjective increase in range of motion. Wilcoxon signed-rank test and chi-square analysis were performed to determine significant differences in clinical and imaging variables between responders and nonresponders. Ultrasound findings, including abnormal acromioclavicular joint complex, bicipital tenosynovial effusion, and rotator cuff tendon tears, were reviewed.

Results:84 patients underwent POC USGHJI for AdC. The mean age (± standard deviation) was 60.3 (±10.8) years, 61.9% women. The body mass index was 28.9 (±5.7) kg/m²🇧🇷 The mean numerical pain scale was 6.8/10 (±2.2, median: 7) with a mean duration of 11.8 (±12.5) months. 47% of the patients were diabetic and 42.2% obese (body mass index (BMI) > 30). Of the patients followed up (n=64), 76.6% reported a successful response with a single injection, 8.4% required a repeat injection. Other images were present in 72%, mostly before US POC. 6% had additional images after USGHJI. No significant differences were observed in age, BMI, gender, DM, and US POC findings between responders and nonresponders.

Conclusions:This study demonstrated the benefit of USGHJI for AdC with 76.6% of patients experiencing relief from a single injection. The results support the use of US in outpatient musculoskeletal clinics.

Dandy-Walker syndrome: a case of medical treatment

Eric Tam, Bachelor of Science; Mohammad S. Islam, M.D.

Diagnosis of the case:Variante Dandy-Walker vs Mega Cisterna Magna

Case description:A 3-year-8-month-old girl with a wobbly gait, hypotonia, lower extremity clonus, and global developmental delay was referred for PM&R. Physical examination showed generalized mild hypotonia and weakness throughout. Magnetic resonance imaging revealed inferior vermis hypoplasia with prominent communication of the fourth ventricle, leading to a preliminary diagnosis of Dandy-Walker Variant vs. Mega Cisterna Magna. Treatment options for Dandy-Walker syndrome were discussed with the patient's parents, who refused surgery and opted for conservative treatment.

discussions:Dandy-Walker syndrome (DWS) is the most common congenital malformation of the cerebellum, occurring in 1 in 30,000 live births and causing dilatation of the fourth ventricle. Patients present with a waddling gait, hypotonia, and developmental delays. It is speculated that the etiology of the disease is the loss of Zic1/4 genes.

Conclusions:This is a clinically treated case of Dandy-Walker Syndrome. Although surgery is usually the first line of treatment, the patient's family was unwilling to undergo surgery. The patient showed great improvement in motor milestones and is a success of conservative treatment. Dandy-Walker syndrome should be suspected in patients with a waddling gait, hypotonia, and developmental delays. Additional investigations are needed to determine if the breast malformations, amblyopia, and family history of cerebral palsy present in this patient are associated with the diagnosis of Dandy-Walker syndrome.

Late diagnosis of idiopathic spinal cord hernia: case report

James R. Wilson, DO; Alejandro J. Feng, MD; Dr. Wesley Chay

Diagnosis of the case:Idiopathic medullary hernia (ISCH)

Case description:A 33-year-old woman presented with progressive bilateral lower extremity weakness and decreased function. She reports a history of multiple falls in the last 3 years. She had been seen by several doctors with complaints of pain and weakness in her right ankle. Her workup included X-rays and an MRI of her ankle, both of which came back negative. She also underwent a nerve conduction study (NCS)/electromyography (EMG), which demonstrated right tibial and fibular neuropathies consistent with tarsal tunnel syndrome and follow-up with neurology was recommended for unexplained muscle atrophy. She recently presented bilateral paralysis of the lower limbs, hyperreflexia, constipation and urinary retention. An MRI of the spine demonstrated a ventral displacement of the thoracic spinal cord that was initially thought to be an arachnoid cyst. Intraoperatively, a T4-T5 ventral medullary herniation was identified, reduced, and repaired with a duramatrix patch. Postoperative examination of her was consistent with a complete spinal cord injury (SCI) (T4 AIS A). She was admitted to an inpatient acute SCI rehabilitation unit for dedicated SCI care and rehabilitation. Throughout her rehabilitation course, she demonstrated functional gains and neurological improvement (T2 AIS B) at discharge.

discussions:Idiopathic herniation of the spinal cord is a rare cause of progressive myelopathy in which the spinal cord slowly herniates through a defect in the dural sac. As of 2006, there were only 85 reported cases. Definitive diagnosis and treatment often takes much longer from the onset of symptoms. Comorbidities or misdiagnosis, such as peripheral neurological or musculoskeletal disorders, as seen in this case, can easily contribute to delaying treatment and worsening long-term prognosis.

Conclusions:ISCH is a rare and serious cause of myelopathy that should be considered in the presence of poorly explained neurological symptoms.

Late MCA occlusion secondary to firearm fragments - Case report

Steven D. Shapiro, MD; Peter V. Tumminelli, MBS; Saylee Dhamdhere, MD; Mohammad S. Islam, MD

Diagnosis of the case:Cerebral thrombosis with cerebral infarction secondary to an old gunshot wound

Case description:A 41-year-old man with a medical history of a gunshot wound to the cervical region 15 years earlier was brought in by EMS for right-sided hemiparesis and right facial drooping. Based on EMS, the patient was found to have an altered mental status. On admission, the patient did not respond and communicated with a head movement. On physical examination, a well-healed 14-cm old surgical scar was observed along the left sternocleidomastoid. The patient also had global aphasia, right-sided facial weakness, reactive pupils, right-sided decreased sensation, motor strength 0/5 on RUE, 1/5 on RLE, and negative Babinski. Sensory and motor of the left upper and lower extremities were macroscopically normal. Brain CT showed a massive infarction of the left MCA territory, including the basal ganglia, with a hyperdense left MCA consistent with thrombosis. Neck angiotomography showed complete occlusion of the left proximal common carotid artery. Metal fragments were found in the soft tissue along the left mandibular angle, the adjacent carotid space, and the left C3 neural foramina, consistent with a penetrating injury. The patient was not considered a candidate for tPA since he was outside the window period and started aspirin 81 mg daily. Statins were not indicated because the vascular lesion was not atherosclerotic in nature. The patient was admitted to an acute rehabilitation hospital. There are few known case reports of vascular complications occurring decades after the initial injury. Here we present the case of a patient with ischemic stroke in the MCA distribution secondary to complete occlusion of the left common carotid artery by a penetrating gunshot wound 15 years prior to presentation.

discussions:Cervical injuries from firearms are traumatic events with vascular and neurological sequelae. Serious vascular complications include hemorrhage, pseudoaneurysms, fistulas, arterial dissections, luminal obstruction, embolism, and infection. Neurological sequelae include ischemic injury and stroke. Complications usually arise within days or weeks of the initial trauma. The patient's symptoms are compatible with an acute infarction of the left MCA territory secondary to thrombosis. This occlusion was probably due to advanced fibrosis of metallic bullet fragments from a previous gunshot wound. A review of the literature suggests that such cases occur rarely. However, a penetrating injury near the major vessels can cause partial injury to the vasculature without showing any signs. Such injuries have been reported with subsequent complications of pseudoaneurysms, arteriovenous fistulas, and arterial thrombosis or stenosis. In a recent study of 28 foreign military patients with complications from undetected vascular injury, 14% of patients had post-traumatic thrombosis with distal extremity ischemia, primarily the lower extremities. The median time from injury to presentation was 228 weeks, indicating that the majority of these cases presented years after injury. The authors concluded that patients with penetrating injuries require close monitoring, including angiography, even in the absence of overt clinical signs.

Conclusions:This case presents a rare occurrence of ischemic stroke secondary to complete thrombosis of the carotid artery from a non-fatal penetrating traumatic neck injury fifteen years earlier. This demonstrates how an undetected vascular injury causing advanced fibrosis secondary to inflammation of the gunshot wound fragments can lead to arterial thrombosis with late complications years after the initial injury. To avoid such complications, clinicians should have a high index of suspicion after neck injuries and routinely use preoperative angiography when dealing with these cases.

To describe the unusual complication of left gluteal compartment syndrome that occurs in tailed equine patients with diabetes mellitus.

Eduardo Nadal, MD; Luzimar Conaway, MD; Maridolores De Leon, MD

Diagnosis of the case:Left gluteal compartment syndrome mask in a patient with cauda equina and diabetes mellitus

Case description:A 60-year-old woman with a history of type II diabetes mellitus and chronic cauda equina who developed left gluteal compartment syndrome. The diagnostic impression and the reason for hospitalization was low back pain secondary to loosening of fittings vs. infectious process. The initial symptoms on admission were poorly localized low back pain of 2 weeks' duration, classified as intense, which radiated to the posterior aspect of the right leg.

Associated symptoms included numbness, weakness and exacerbation on sitting, pain relief on lying in bed. The patient denied a history of a fall, trauma, dark or bloody urine on admission. The initial images and the laboratory examination were negative for loosening of the hardware and infectious process. Three days after admission, his laboratory results showed evidence of acute renal failure, hyperkalemia, and elevated CPK. Other than back pain, the patient was completely asymptomatic. The patient was started on intravenous fluids and an internal foley was placed. Despite medical treatment, CPK continued with an increasing trend compatible with rhabdomyolysis. The patient also developed hypomagnesemia, which was associated with the polyuric phase of acute tubular necrosis. After two weeks of aggressive treatment with intravenous fluids, CPK levels and kidney function began to normalize. Although the back pain improved, the physical examination at that time revealed a hardened left buttock, the ultrasound was negative for fluid collection, so a pelvic MRI was performed, which revealed findings of intramuscular abscess vs. myonecrosis. She was taken to the operating room for incision in the left buttock, drainage, and muscle biopsy. Final surgical findings were consistent with devitalized muscle consistent with compartment syndrome. The presumed etiology of the compartment syndrome was several intramuscular injections of antiemetic in the left gluteus, started two days before the CPK elevation and renal failure.

After surgery, intravenous antibiotics, fluids, local care and rehabilitation, the patient's labs and function returned to baseline and he was discharged home.

discussions:Compartment syndrome is a dangerous and potentially fatal condition. The development of the left gluteal compartment syndrome was probably the result of intramuscular antiemetic drugs. Intramuscular injection should be used with caution in people with spinal cord injury in areas of low sensitivity. Compartment syndromes have a typical presentation most of the time, but in a patient with cauda equina syndrome, where there is impaired sensation, early diagnosis can be challenging.

Patients with compartment syndrome often present with pain, the intensity of which appears out of proportion to the injury. Common symptoms seen in compartment syndrome include a feeling of tightness and swelling and pain with certain movements, particularly passive ones. Muscle stretching is the first clinical indicator of compartment syndrome. The traditional 5 Ps of acute ischemia (pain, paresthesia, pallor, pulselessness, and poikilothermia) are clinically unreliable and may manifest only in the later stages of compartment syndrome, when extensive and irreversible tissue damage may already have occurred. soft. The most important diagnostic physical finding is a firm, hard sensation on deep palpation. The most consistent early finding is decreased discrimination of 2 points. The clinician must have a high index of suspicion to establish the diagnosis.

Conclusions:Early diagnosis of a compartment syndrome in any patient is crucial, but in patients with spinal cord injury, late recognition is common due to decreased sensation and atypical presentations. Late diagnosis of compartment syndrome can lead to acute renal failure due to myoglobinuria. Knowledge of the condition, early diagnosis, and prompt examination provide the only chance to avoid these devastating consequences.

Description of a delayed reflex arc course arising from spinal shock in an adult with poorly controlled diabetes who sustained an incomplete C6 spinal cord injury, case report

Dr. Maryam Berri; Joe Mendez, MD; Diamond Mark, MD; Dr Riley Smith

Diagnosis of the case:A 67-year-old man presents to a level 1 trauma center after a mechanical slip and fall down a flight of stairs. Patients with GCS were 15 years old on arrival, with no acute head trauma identified on head CT scan and no orthopedic fractures. The patient complained mainly of neck pain and tetraparesis, more pronounced in the bilateral upper extremities. MRI of the cervical spine showed increased signal within the spinal cord at the C6 level consistent with a contusion with compression of the spinal cord identified on the sagittal T-2-weighted image. No fractures or ligament injuries were identified. His hospital evolution included neurosurgical intervention 24 hours after admission. Spinal reflexes were monitored to assess the legitimacy of the American Spine Injury Impairment Scale for prognostic purposes. These reflexes were monitored at hour 13 by the physiatrist at the appointment, day 2, 3, 5, 9, and day 13.

Case description:On the first day of admission with presentation to the hospital, the patient's physical examination findings showed the usual signs of spinal shock. The American Spinal Injury Impairment scale registered a C6 AIS A. There was no evoked bulbocavernosus reflex. Physical examination also showed no upper motor neuron signs with Hoffman negative bilaterally, going down in plantar flexor responses. On the second day, post-neck decompression status, the patient still had no evidence of the bulbocavernosus reflex. On day 3, reflexes increased to 1/4 in the lower extremities. The Hoffman sign was also positive in the right upper limb. On day 5, there were no changes in reflexes or upper motor neuron signals, but the patient had preserved sacral sensation on the AIS scale. But the bulbocavernosus reflex did not return. Lower extremity reflexes were increased in 3/4 bilateral Achilles and patellar tendons and 2/4 bilateral upper extremities. There was persistence of the Hoffmans sign on the right. On day 9, the patient was admitted for inpatient rehabilitation and the AIS score was recorded as C6 AIS B and bulbocavernosus reflex recovered. The patients' rehabilitation course was complicated by a sciatic pressure ulcer, hospital-acquired pneumonia, and episodes of hyperglycemia. The glycosylated hemoglobin level was 18. The patients' measure of functional independence increased by 15 points in a three-week hospital stay.

discussions:Spinal shock is a phenomenon that involves the physiological or anatomical section of the spinal cord, resulting in the loss or temporary depression of all spinal reflex activity. The mechanism of injury is usually traumatic in origin and occurs immediately, but spinal shock with injuries progressing over several hours has been described. At our institution, as at other level 1 trauma centers, spinal shock is believed to terminate with return of the bulbocavernosus reflex. A BC reflex is elicited by squeezing the glans or clitoris and feeling an involuntary contraction of the anus. It usually returns 1 to 3 days after the injury. Progression of other reflex arcs includes an abnormal delayed plantar reflex that this patient did not have, although upper extremity mimicry could be positive for Hoffman's sign. When monitoring the AIS scale in this patient, there has been no change in the scale since the patient's BC reflex returned. At the first positive reflex arc of the corticospinal tract, the Hoffman sign, the patient's AIS scale remained constant.

Conclusions:In many trauma centers across the country, the presence of a positive bulbocavernosus reflex arc is a reliable and reliable physical examination finding that correlates with the onset of spinal shock. In a patient with poorly controlled type II diabetes mellitus, the continued absence of the reflex on day 9 should not necessarily delay the clinician from providing valuable prognostic information to the patient, family, and medical staff. The return of other spinal cord reflexes and the presence of corticospinal tract signs are important in increasing international neurological grading standards for spinal cord injury. Due to this continuum of events after spinal cord injury, the definition of spinal shock itself and the endpoint are variable.

Descriptive analysis of the use of interventional treatment of degenerative lumbar spondylolisthesis from 2000 to 2011

José A. Sclafani, MD; Alexandra Constantin, PhD; Pei-Shu Ho, PhD; Venu Akutota, MD; Leighton Chan, MD

Goals.Degenerative lumbar spondylolisthesis is a frequently identified deformity in symptomatic low back pain. A variety of treatment algorithms, including physical therapy and interventional techniques, can be used to manage clinically significant degenerative spondylolisthesis. This study is an analysis of the use of interventional spinal techniques to manage degenerative spondylolisthesis in Medicare beneficiaries from 2000 to 2011.

Project:This study used an initial cohort comprising 5% of all patients with ICD-9 codes for back pain registered in the Centers for Medicare & Medicaid Services Carrier File, Outpatient File, or Inpatient File. , from 2000 to 2011. A cohort of recipients with a new ICD-9 diagnostic code for degenerative lumbar spondylolisthesis was isolated. Beneficiaries with a concomitant diagnosis of low back trauma, infection, or malignancy were excluded. Current procedural terminology codes for lumbar interventional techniques from 2000 to 2011 were used to identify the number of procedures performed each year by specialty in this cohort, using the CMS Carrier file.

Results:A total of 95,647 subjects with a new diagnosis of degenerative spondylolisthesis were included in the analysis. The mean age at initial diagnosis was 72.8 ± 9.8 years. The diagnosis was more frequent in women (69%) and Caucasians (88%). Interventional lumbar procedures performed in this cohort were as follows: 75,859 primary level transforaminal; 68,372 interlaminar/caudal epidural; 38,756 additional transforaminal level; 18,257 trigger point procedures; 17,430 sacroiliac injections; 10,752 primary level veneer injections; 14,233 additional level facet injections; 7,532 primary level medial branch ablations; 7,133 additional level ablations of the medial branch; 508 discogram studies. More than half of all procedures (124,280/216,088) occurred within 2 years of diagnosis. The proportion of selective procedures (transforaminal and facet) versus non-selective (interlaminar) was 4.25 times higher in Physical Medicine and Rehabilitation than in Anesthesiology.

Conclusions:Interventional techniques are frequently used as a treatment modality for symptomatic degenerative spondylolisthesis. Understanding the use of these techniques is important in determining relative clinical efficiencies and optimizing future healthcare expenses.

Devastating medical complications in a patient with chronic spinal cord injury due to poor adherence: a case report

Nayeema Chowdhury, DO; Vince Si, MD; Umar Mahmud, DO

Diagnosis of the case:Ischemic stroke secondary to severe anemia in the context of pressure ulcers in a chronic quadriplegic patient lost to outpatient follow-up

Case description:This is a 27-year-old man with C7 ASIA C chronic quadriplegia who presented with 2 weeks of right arm weakness, dysarthria, and worsening spasticity. Head images of him revealed a left frontoparietal stroke. Tests revealed a hemoglobin of 2.4, which was thought to be the etiology of his stroke. The origin of the anemia was attributed to gradual bleeding from stage IV sacral and chronic lower extremity ulcers in the setting of severe malnutrition. Imaging exams demonstrated chronic osteomyelitis of the right fibula and posterior calcaneus. Of note, the patient underwent 2 months of acute inpatient rehabilitation (AIR) and 1 year of subacute rehabilitation after his spinal cord injury (SCI) in 2007, but he lost follow-up outpatient treatment for his SCI. Poor adherence, education, social support and access to patient resources were the main factors in the deterioration of his health.

The patient entered an acute rehabilitation center for the second time. Upon entering intensive care rehabilitation, he required full assistance with activities of daily living (ADLs) and mobility. Wound care for pressure ulcers was addressed along with surgery, infectious disease (ID) and wound care nursing. His nutritional status was optimized and he received multiple blood transfusions and nutritional supplements for his anemia. His spasticity improved with the initiation of anti-spasticity medications. After discharge, the patient still required full assistance for most activities of daily living, except supervision for eating and grooming; however, he has been modified to independent mobility with the use of a motorized wheelchair. The patient was discharged home with services under the care and supervision of the family with close outpatient follow-up with DI and rehabilitation

discussions:This is a rare case of stroke secondary to severe anemia in the context of chronic decubitus ulcers in a quadriplegic patient. This particular case demonstrates the importance of social support and patient/caregiver education in coordinating the medical and rehabilitative care of a patient with SCI. The devastating complications this patient faced were directly related to his inability to access proper care and lack of education.

Conclusions:Interdisciplinary discharge planning is crucial when coordinating discharge care for patients with limited access to resources. Providing sufficient patient and caregiver education is also essential to prevent end-stage complications, as demonstrated in this case.

Development of bilateral Blount's disease in a 14-year-old male patient less than two years after undergoing bilateral percutaneous fixation of the hips with a screw for unilateral sliding of the capital of the femoral epiphysis: case report

Marsha Charles-Pierre, MD

Diagnosis of the case:Development of bilateral Blount disease in a 14-year-old male with a history of surgically corrected slipped epiphysis femoris less than 2 years ago

Case description:At the age of 12, the patient presented pain in the left hip for one month. The image was consistent with a slipped capital femoral epiphysis on the left side. Subsequently, he was referred to the operating room for bilateral percutaneous fixation of the hips with screws without postoperative complications. Sixteen months later, he went to the emergency department due to pain in both legs, especially in the medial aspect of the right and tibial knee. The radiograph revealed nonspecific findings of irregularity of the tibial plateau. Six months later, he presented to the emergency room with ongoing pain, this time severe. The family noted the bowing of the legs, which was getting progressively worse. He was diagnosed with bilateral Blount disease and was admitted for orthopedic surgery to repair it. Postoperative complications included foot drop probably due to fibular palsy and readmission to remove infected hardware several months later. The patient evolved as expected. Painful flat feet appeared to be a trend in this patient population at this institution. This particular patient has also been observed to have flat but not yet painful feet, probably due to his sedentary lifestyle.

discussions:Slipped capital femoral epiphysis (SCFE) is a hip disorder most often found in adolescent males, usually between the ages of 8 and 15. It occurs when the proximal femoral epiphysis "slips" posteroinferiorly toward the metaphysis (neck of the femur), which occurs through the epiphyseal plate. Blount's disease is a growth disorder of the tibia. It is also known as tibia vara. This growth dysfunction causes a misalignment of the tibia below the femur; which ultimately causes the appearance of a twisted leg. The patient in this case is a male, obese (6 ft; 280 lbs), and adolescent who conforms to the tendency for slipped capital femoral epiphysis and Blount disease. Although these two diseases share similar risk factors, such as obesity, it is rare for the two to coexist bilaterally. There have been a few reported cases of SCFE presenting after childhood Blount disease; however, to our knowledge, there have been no reported cases in which a patient experienced bilateral Blount disease shortly after SCFE correction.

Conclusions:This case report will summarize the disease and clarify possible ideologies as well as correlations with Blount disease.

Diaphragmatic pacemaker placement in spinal cord patient with respiratory failure

William L. Wagner, MD; Jeff Rosenbluth, MD; Michael Campian, D.O.

Diagnosis of the case:Spinal cord trauma, C5 AIS B, with hypercarbic respiratory failure who underwent a diaphragmatic pacemaker.

Case description:The patient is a 47-year-old man with a C5 AIS B spinal cord injury. At a routine follow-up clinic visit, he was hypoxic, with an ABG showing a carbon dioxide level of 75.9. In addition, he endorsed subtle voice changes, difficulty swallowing, increased weakness, and increased pitch. He was admitted to the intensive care unit for hypercarbic respiratory failure and concern for an ascending level of injury. The etiology of hypoxemia is believed to be multifactorial polypharmacy, nonadherence to CPAP, and diaphragmatic insufficiency secondary to mild ascending injury. The work included the evaluation of the phrenic nerve, which turned out to be functional and intact. He was determined to be a good candidate for a diaphragmatic pacemaker and a diaphragmatic pacemaker was placed. He tolerated higher frequency and duration trails of diaphragmatic pacing, except that it was complicated by worsening neuropathic pain during pacing trails. He still required intermittent use of Bipap, but generally required less oxygen via nasal cannula to maintain adequate oxygen saturation. He continued to have elevated carbon dioxide levels at follow-up, but reported improvement in breathing, tone of speech, and general function.

discussions:Patients with cervical spinal cord injury traditionally rely on mechanical ventilation for respiratory function, especially at high levels of injury. If phrenic nerve function is preserved, a patient with spinal cord injury may benefit from diaphragmatic pacing. There are studies suggesting that diaphragmatic pacing versus mechanical ventilation has the potential benefits of decreasing pulmonary complications, improving speech/breathing/feeding, and improving independence. This is a unique case of diaphragmatic pacing following decreased respiratory function and possibly associated side effects of increased tone and pain.

Conclusions:This case detailed the benefits and challenges associated with the use of a diaphragmatic pacemaker in a patient with spinal cord respiratory failure. Overall, this patient improved respiration, phonation, and function after diaphragmatic pacing.

Diastematomyelia and Hemivertebrae in a 17-year-old male: Case Report

Hana F. Azizi, MD; Dr. Yuxi Chen; Hejab Imteyaz, MD, MPH

Diagnosis of the case:diastematomielia

Case description:A 17-year-old male with no significant medical history was initially evaluated for scoliosis. The patient denied walking difficulties or intestinal and bladder discomfort. The physical examination was significant for short stature, severe scoliosis, normal muscle volume and strength, and intact sensory perception to light touch. The patient also had bilateral quadriceps hyperreflexia, tight hamstrings, with no foot deformities. The MRI findings were: − Severe thoracolumbar scoliosis with segmentation abnormalities at various levels, including fusion of the posterior thoracic elements and lumbar spine. -Hemivertebra L5 and underdevelopment of the right hemisacrum. -A second discrete cord compatible with dystematomyelia, from T2 to the mid-thoracic level, joining at the level of T12; with a syrinx that extends along its entire length. -A cord tied with a cone that extends to the level of the beetle with a filament that ends in a 4.5 cm lipoma. The urodynamic study performed before surgery was normal. The patient underwent release of the tied cord.

discussions:Diathematomyelia is characterized by division of the spinal cord, conus medullaris, or filum terminale to varying degrees. It rarely presents in adulthood. Patients may present with gait disturbances, sphincter disorders, muscle atrophy, reflex changes, congenital scoliosis, and foot deformities. Between 50% and 60% of these patients have associated scoliosis secondary to vertebral abnormalities such as butterfly vertebrae or hemivertebrae.

Conclusions:A combination of diastematomyelia and hemivertebrae is rare. These patients often have scoliosis. Other associated anomalies are the smaller leg, Sprengel's shoulder deformity, and progressive sensory deficit in the lower extremities. Our patient had scoliosis and hyperreflexia with no other symptoms.

Difficulty walking due to one and a half syndrome: case report

Atira H. Kaplan, MD; Gary Inwald, D.O.

Diagnosis of the case:one and a half syndrome

Case description:A 69-year-old man with a medical history of arterial hypertension, osteoarthritis and type 2 diabetes mellitus, previously independent with ADL and ambulation. He went to the emergency room due to difficulty walking for two days, with associated diplopia and vertigo. The examination revealed an ataxic gait, requiring the help of two people to maintain balance. Examination also demonstrated diplopia, right eye fixed abducted, left eye unable to adduct beyond the midline, and rapid phase nystagmus of the right eye when looking to the right. MRI showed two acute dorsal pontine infarcts, one in the left dorsal paramedian pons and the other in the left facial colliculus. Acute rehabilitation focused on improving balance and ambulation. An eye patch, first tried during therapy, was considered the most useful intervention to improve the patient's ambulation, as it resolved the diplopia.

discussions:The examination findings in this patient are consistent with the one and a half syndrome, characterized by gaze palsy in one eye with internuclear ophthalmoparesis (INO) on horizontal gaze in the other eye. This syndrome results from damage to the paramedian pontine reticular formation and/or the oculomotor nucleus and medial longitudinal fasciculus. The divergence of the eyes leads to horizontal diplopia.

Conclusions:Previous reports of one and a half syndrome have not described difficulty walking. This case highlights the functional deficit derived from the syndrome and the relevance of this disease for rehabilitation. It also demonstrates the importance of innovating with available resources, as the patient's eye patch was made up of a piece of gauze and adhesive tape. Although the diplopia returned when the eye patch was removed, since one and a half syndrome is associated with a good prognosis, with symptoms usually resolving in a few to several months, the eye patch is usually only needed temporarily.

Disorders of consciousness: when FIM scores are misleading

Adam Lewno, do; Cara Camiolo Reddy, MD, MMM

Diagnosis of the case:Severe traumatic brain injury, vegetative state

Case description:We present a 21-year-old man who sustained a level one multiple trauma after a VCT accident resulting in traumatic brain injury with cerebral contusions, intracranial hemorrhage, and skull fractures with consequent severe cerebral edema that induced early herniation and required an emergency craniotomy. His injury complex included multiple complex facial and jaw fractures and multiple medical complications. He entered rehab in a vegetative state directly from intensive care 24 days after his injury. Using early goal-directed rehabilitation, serial monitoring with JFK Coma Recovery Scale assessments, and early family training, the patient regained consciousness within fourteen days despite significant medical complications. This allowed the transition to a traditional TBI rehabilitation treatment model. Forty-nine days after admission to intensive care rehabilitation, the patient was released from the hospital and moved into a home therapy program.

discussions:The Functional Independence Measure (FIM) has become the national standard in acute rehabilitation units to measure a patient's functional recovery; however, for patients with impaired consciousness, this scale prevents recognition of significant functional gains, leading to prolonged post-acute care and multiple rehabilitative readmissions due to the patient's fluctuating consciousness. The transition to the JFK Coma Recovery Scale for functional monitoring allows for better arousal detection and direct targeted therapies. When combined with early family training, these interventions improve care delivery for this unique patient population and long-term functional gains while decreasing readmission rates.

Conclusions:Patients with impaired consciousness achieve functional gains that are not captured in FIM and may benefit from acutely targeted therapies to promote functional gains prior to recovery of consciousness.

Effect of abobotulinumtoxinA (Dysport®) injections on spasticity in children with dynamic clubfoot deformity due to cerebral palsy: results of a phase 3 randomized placebo-controlled trial

Maurice R. Thin, MD; Edward Dabrowski, MD; Dennis Matthews, MD; Marek Jozwiak, MD; Anissa Tse, BM BS, FRCSI (OTO), FFPM; Belgin Erhan, MD; Philippe Picaut, Doctor of Pharmacy/PhD; John Charles Velez, MD; Ann H. Tilton, MD; Oscar Benevides Aguilar, PhD; Iwona Maciag-Tymecka, PhD; Ece Unlu, MD

Goals.This international, double-blind, placebo-controlled study evaluated the efficacy and safety of AbobotulinumtoxinA (ABO, Dysport®) versus placebo in children with dynamic clubfoot deformity due to cerebral palsy.

Project:Children (2 to 17 years) with dynamic clubfoot deformity due to CP were randomized (1:1:1) to receive injections of ABO 10 U/kg/leg, ABO 15 U/kg/leg, or placebo at the gastrocnemius. complex soleus (one or both legs injected). Patients had to be ambulatory, Gross Motor Function Classification System (GMFCS) Level I-III, and have a Modified Ashworth Scale (MAS) score ≥2 in the ankle plantar flexors of the most affected leg. The primary endpoint was the change in Modified Ashworth Scale (MAS) from baseline to week 4. Global impression at week 4 was measured by physician's global assessment (PGA) and spasticity was also measured by the Tardieu scale (TS).

Results:241 patients were randomized and 226 completed the study; the ITT population included 235 patients (98%). At week 4, muscle tone (MAS) improved significantly with ABO; mean treatment differences [95% CI] versus placebo were: −0.49 [−0.75, −0.23] (p=0.0002) for 15U/kg/leg and −0.38 [−0, 64, −0.13] (p=0.003) for 10U/kg/leg. Treatment differences with PGA versus placebo of 0.77 [0.45, 1.10] for 15U/kg/leg and 0.82 [0.50, 1.14] for 10U/kg/leg were also significant ( both p < 0.0001). For the 15U/kg/leg dose, week 4 improvements in muscle tone were also accompanied by improvements in spasticity (as assessed by TS): degree (Y), capture angle (XV3); and stop angle (XV1); all p < 0.01. The 10U/kg/leg dose showed a significant reduction in Y (p < 0.0001) and positive trends for XV3 and XV1. The most common treatment-related AE was localized muscle weakness (10U/Kg/leg=2; placebo=1).

Conclusions:This pediatric phase 3 study showed that ABO treatment improves muscle tone and spasticity (as assessed by MAS and TS), resulting in a better overall clinical impression and is well tolerated.

Effect of Aggressive Therapeutic Regimen and Crainoplasty in a Patient with Trepanning Syndrome: Case Report

Corey Reeves, MD; Marissa McCarthy, MD; Dr. Bryan A. Thomas

Diagnosis of the case:burred syndrome

Case description:A 21-year-old man attended rehabilitation 3 weeks after suffering a severe head injury secondary to a fall. The injury resulted in bilateral hemorrhages from the anterior and posterior cerebral arteries. He was diagnosed with panhemispheric subarachnoid hemorrhages and underwent a decompression craniectomy. The patient was noted to have impaired consciousness and significant deficits in his ADLs. The patient derived little benefit from therapy as his participation was limited by balance problems, spasticity, dysphagia, poor speech fluency, nausea, and vomiting. The decision was made to expedite the patient's cranioplasty, as the symptoms correlated with “Sunken Flap Syndrome”.

The patient showed minimal improvement during the first 113 days post-injury (GOAT tested consistently returned pre-surgical values ​​60 to 77 days later. GOAT tested was limited by dense amnesia and non-persistent PTA. Given the improvement in status mental health, patient was able to participate in daily physical, occupational, and speech therapy Right lower extremity MAS was 2-3 and left lower extremity +1 before surgery MAS scores improved to 1 bilaterally 67 days post-op Lower extremities on admission scored 3-4/5 Bilateral post-operative MMT at 67 days post-op improved to 5/5 on all myotomes except right leg dorsiflexion 4/5 a community walker.

discussions:There is still limited literature on rehabilitation approaches and associated outcomes in patients with trephine syndrome. This case highlights improvements in cognitive and physical function as a result of cranioplasty and associated rehabilitative therapy.

Conclusions:Cranioplasty combined with aggressive postoperative comprehensive rehabilitation should be considered in TBI patients with craniectomy and slower-than-expected recovery.

Effect of wheelchair stroke pattern on arm muscle fatigue

Brittany Bickelhaupt, MD; Michelle Trbovich, MD; Sakiko Oyama, PhD; Jon Benfield, do; Dr. A.S. Keith Burau

Goals.There is a high incidence of shoulder injuries among wheelchair users, often related to misuse of the shoulder muscles. This study aims to identify which technique, semicircle or lunge, tires the shoulder muscles more quickly over time, in the hope of preventing shoulder injuries.

Project:A study of two randomized groups was conducted to construct a comprehensive relationship between two wheelchair arm propulsion patterns with shoulder muscle fatigue over time. The study used the Borg CR10 scale of perceived exertion (Borg RPE) and a dynamometer for shoulder and elbow extension strength before and after the test. 18 healthy male participants were randomized into one of two wheelchair arm propulsion pattern conditions, semicircle or pump condition. Over a 10-minute period, the participants propelled the wheelchair continuously while rating fatigue using the Borg RPE scale.

Results:Primary outcome measures were Borg RPE scale scores and dynamometer reports before and after testing for each elbow and shoulder extension. Although not significant, there was a trend observed. The Borg RPE scores for the semicircular condition were consistently higher than the scores for the pump condition. In addition, dynamometer readings before and after the test demonstrated a greater decrease for participants in the semicircle condition than for participants in the pump condition, but were not statistically significant.

Conclusions:From the data collected, it can be inferred that the semicircle technique is more tiring during 10 minutes of continuous activity than the pump technique. It can be correlated that the semicircular technique is more exhausting over long distances. The trend can be attributed to non-disabled participants who were considered amateur wheelchair users. The semicircular technique is known to be most beneficial in experienced wheelchair users. With these data, novice wheelchair users can be taught to push safely using the pump technique, while all users should learn the pump technique for longer distances.

Effective Treatment of Central Pain Syndrome with Acupuncture: Case Report

Samuel I. Matsuo, MD; Hong Wu, MD, MS

Diagnosis of the case:Central Pain Syndrome

Case description:The patient was a 48-year-old woman who had been complaining of a general burning/pain sensation since 2012 after chiropractic treatment for hip pain. She described the symptoms as constant, beginning in the thorax and spreading to the bilateral upper and lower extremities. She noted tenderness to pressure and light touch. She could not tolerate tight shirts and pants and she could not wash her hair or comb her hair. Previously, several vendors saw her do largely negative work. He has failed conventional treatments, including many oral and topical medications (gabapentin, Lyrica, paroxetine, tramadol, Percocet, lidocaine cream, compounded topical ointments), chiropractic care, and physical therapy, including desensitization therapy and a TENS unit test. The initial examination was significant due to exquisite allodynia to repeated light touch in the 4 extremities and the trunk. Given the failure of her previous conventional treatments, she was offered acupuncture as a treatment. Her multiple complaints were cataloged and tracked/evaluated at each acupuncture session. At her fourth acupuncture session, she reported a general decrease in sensation. This was also noted clinically, as she tolerated light touch and needles with less pain and her allodynia decreased significantly. In addition, she reported an improvement in her associated nausea, calming her mood, and increased functionality for her as her transfers became less painful. In her 11th session, her general burning pain and sensitivity were significantly reduced and her symptoms were more manageable. She was able to sleep better, wear normal clothes, wash her hair, and hug other people. She is currently following up as needed.

discussions:Central pain syndrome can be a difficult and challenging task to manage. It can cause a significant decrease in an individual's function and quality of life. When conservative measures fail, this case report shows that acupuncture may be an effective treatment option. Not only can it help with a person's pain, but it can also help with other associated symptoms, such as nausea and mood disturbances, which have a significant influence on pain levels.

Conclusions:Acupuncture is an effective means of treating central pain syndrome and should be seriously considered when conventional treatments fail.

Efficacy of lumbar transforaminal epidural steroid injections with particulate versus non-particulate corticosteroids for lumbar radicular pain due to intervertebral disc herniation: preliminary 5-year follow-up data

Byron J. Schneider, MD; Dr. Zachary McCormick; Lisa Huynh, MD; Dr. David Kennedy

Goals.To determine the long-term outcomes of low back radicular pain due to acute herniation of the nucleus pulposus after epidural corticosteroid injection or spinal surgery.

Project:Long-term telephone follow-up of subjects previously enrolled in a prospective, randomized, double-blind, multicenter study. Independent telephone interviews were conducted to assess: presence of pain in the last 7 days, current use of opioid medications, use of additional epidural steroids after completion of the study, surgical rates, and current unemployment due to pain.

Results:There was no difference between the two steroid groups after the initial 6-month study, with more than 70% of both steroid groups achieving at least 50% pain reduction. Long-term follow-up data: There remained no significant differences between the two steroid groups. Overall, 76%, +/− 15%*) had pain recurrence, but only (20% +/− 14%*) experienced pain in the past week. Even fewer (10% +/− 11%*) were currently using opioids, and similar numbers (17% +/− 13%*) received additional injections. (43% +/−18%*) had surgery and (7% +/− 9%*) were currently unemployed due to pain. Comparisons were also made between those who did and did not need surgery. Of those who required surgery (31% +/− 25%*) reported pain in the past week and (15% +/− 20%*) were currently using opioids compared to (12% +/− 15%*) who reported pain in the last week and (6% +/− 11%*) using opioids in those who did not require surgery.

* represents 95% confidence intervals, all do not overlap.

Conclusions:Despite a high success rate at 6 months, the majority of people with low back radicular pain due to a herniated intervertebral disc experience a recurrence of pain after the initial presentation. However, only a minority of these people required additional injections or control of croinc opioid analgesics. Initially, all subjects were deemed surgically appropriate and several underwent surgery after an initial transforaminal epidural steroid injection. There were no significant differences in outcomes between those who had surgery and those who did not. Lumbar disc herniation is a disease that results in a high recurrence rate, even with surgical fixation.

Effects of Pain Scrambler therapy for the treatment of pain and itching in burn scars

Cheonghoon Seo, MD

Goals.Scrambler therapy is a patient specific electrocutaneous nerve stimulation device. Post-burn itch has been viewed as a form of neuropathic pain, and itch is common, chronic, disabling, and often difficult to treat effectively. Itching is mediated by histamine, which is stored in mast cells and released locally during injury or inflammation. The neural message is carried along small A and C afferent fibers to the spinal cord. In this study, we investigated the effect of Pain Scrambler therapy on burn scar itch.

Project:9 patients from the Department of Rehabilitation Medicine, Hangang Sacred Heart Hospital, Hallym University were recruited to participate in this study. Subjects complained of severe itching with a visual analog scale (VAS) score of at least 5 despite treatments including antihistamines and gabapentin. Each Scrambler Therapy patient received a daily 45-minute treatment for 10 consecutive days, Monday through Friday. The stimulus was increased to the maximum intensity bearable individually by the patient that would not cause any additional pain or discomfort. Numerical Rating Scale (NRS), Nirschl Pain Phase System, 70 Point Scoring System, 5D Itch Scale, Leuven Itch Scale, and Vancouver Scar Scale were assessed prior to Scrambler therapy, after ten sessions.

Results:In all 9 patients, the NRS score, Nirschl pain score, and 70-point functional score decreased significantly after therapy. Itch duration, severity and disability scores on the 5D Itch Scale improved after Scrmabler therapy compared to before treatment. Itch recurrence rate, scratch lesion rate, and Leuven itch scale severity were all improved after Scrambler therapy compared with before treatment.

Conclusions:Scrambler therapy is a non-invasive, non-medicated modality that significantly reduces burn itch. Scrambler therapy should be considered as a treatment option for burn survivors experiencing severe itching.

Effect of conservative therapies in patients with adolescent idiopathic scoliosis: a prospective clinical study in China

Qing Du, MD; Xuan Zhou, MD

Goals.There is not much research on the impact of integrative therapy using supportive therapy plus exercise therapy on HRQL in patients with AIS. To explore the impact of conservative therapy with supportive therapy plus exercise therapy on the HRQL of patients with AIS.

Project:65 patients with AIS were divided into two groups: 20 patients in group A who received simple supportive therapy and 45 patients in group B who received supportive therapy + exercise therapy. The ATR and Cobb angle were measured before and 6 months after treatment, and at the same time, all patients were asked to complete the Chinese version of the Scoliosis Research Society-22 (SRS-22) questionnaire independently.

Results:The ATR in group B became smaller after 6 months of treatment. The Cobb angle in groups A and B became smaller after 6 months of treatment. Self-image and mental health scores after treatment were higher than before treatment in group B. Self-image scores in patients with AIS of the thoracic type were lower than those in patients with AIS of the single thoracolumbar type.

Conclusions:Both supportive therapy and comprehensive therapy can stop the progression of spinal scoliosis in a short period, but the latter has a more positive impact on the HRQoL of AIS patients.

Elucidation of the lesion of the thalamocortical tract of the Papez circuit after a cerebral infarction: diffusion tensor tractography

Dongseok Yang, MD, PhD; Parque Daekwon; Jeong Hee Yang, PhD

Diagnosis of the case:Thalamocortical tract injury after thalamic and hippocampal infarction

Case description:A 20-year-old soldier developed abrupt motor weakness three days before being referred to our department via the neurology department. On admission, physical examination revealed the left limb to be significantly weakened with 4/5 of the upper and lower limbs using hand muscle testing. All sensation and DTR modalities were intact. He was unsteady but could walk with supervision. Within a month of starting, he seemed ready to return to normal life, except for memory loss. We then investigated the cause of memory impairment using diffusion tensor tractography 32 days after baseline and neuropsychological testing 43 days after baseline, respectively. Diffusion-weighted imaging data was analyzed using the Oxford Center for Functional Magnetic Resonance Imaging of the Brain (FMRIB) software library. Fiber tracing was performed by the probabilistic tractography method based on a multifiber model, and tractography routines were implemented in FMRIB Diffusion with 5000 aerodynamic samples, 0.5 mm pitch lengths, curvature thresholds = 0.2 and corresponding at a minimum angle of 80°. We reconstructed neural tracts of the Papez circuit, which are responsible for memory function and are located in the injured areas. We found that all tracts, excluding the right thalamocortical tract, had symmetrical appearances between the two hemispheres in a three-dimensional view. In the right hemisphere, the thalamocortical tract between the anterior thalamic nuclei and the cingulate gyrus was found to be thinner than in the left hemisphere.

The neuropsychological evaluation revealed follow-ups. First, verbal memory was 6.81% ile, 33.72% ile and 72.24% ile for short term, delay and recognition, respectively; visual memory was 24.83% ile, 12.51% ile and 64.43% ile for short term, delay and recognition, respectively. These results imply impaired memory function, particularly short-term verbal memory. Second, Wechsler's adult intelligence score was in the middle range (full intelligence scale, 103). In addition, we found normal ranges of evaluation values ​​in the frontal/executive function, in the visuospatial test and in the attention test.

discussions:The Papez circuit in the brain, which includes the thalamocortical tract, the mammillothalamic tract, the fornix, and the cingulate, has been linked to higher-level cognitive functions. Until now, conventional MRI has shown difficulty in detecting lesions in the Papez circuit. In this study, for the first time, we elucidate damage to the thalamocortical tracts of the Papez circuit in a three-dimensional view using diffusion tensor tractography.

Conclusions:We suggest that for the patient with memory impairment after a cerebral infarction in the Papez circuit, diffusion tensor tractography may be a useful tool to clarify the lesions by the Ministry of Education (nº 2013R1A1A4A01013178)).

Family dynamics and preparation for medical care associated with rare disorders and delays in diagnosis

Rachel E. Asher, Bachelor of Science; Dr William McKinley

Diagnosis of the case:Family dynamics and preparation for medical care associated with rare disorders and delays in diagnosis

Case description:A 35-year-old woman with a primary diagnosis of warfarin-associated calciphylaxis presented with functional mobility and self-management deficits secondary to prolonged pain, chronic necrotic wounds, lack of fitness, and bilateral flexion contractures of the shoulder, hip, and ankle. Comorbidities included chronic systolic heart failure, hypertension, anemia of chronic disease, and iatrogenic opioid dependence. The patient had previously experienced a delay in diagnosis and treatments, including surgical debridement, hyperbaric oxygen therapy, and pharmacologic intervention for calciphylaxis. During his 26-day stay in rehabilitation, family dynamics and the hospital's readiness to treat rare diseases contributed to a suboptimal course of rehabilitation. Despite these challenges, the patient was successfully reduced from oral pain medications, demonstrated improvements in self-care and mobility, and was discharged home to hers.

discussions:Delayed diagnosis, maladaptive family behavior, and loss of trust in the health care system are common experiences of rare disease patients. In this case, a specialized bed was not immediately available and the patient's wounds worsened before initial evaluation by the wound care team. During this time, parent-caregivers taught wound care techniques to the staff. Due to limited knowledge of pathophysiology and treatment, these shifts in the hierarchy and power dynamics in the physician-patient interaction can occur in the context of rare diseases. Parent-caregivers often tried to help the patient and staff by providing emotional support but disrupting the patient's cultivation of independence. Patient and family education was provided to facilitate adjustment to the perspective and goals of rehabilitation.

Conclusions:There is a need for additional rehabilitation literature on improving quality of life in patients with calciphylaxis and other rare diseases beyond initial diagnosis and treatment. To build trust and engage patients and families in treatment goals, physiatrists must recognize and address the psychological sequelae of prior encounters with health systems that were unprepared to meet patients' medical needs.

Upside Down: Unusual Diagnosis and Management of the Migrated Intrathecal Baclofen Pump

Dimir Abrar, MD; Prin Amorapanth, MD, PhD; Dr. Idris Amin

Diagnosis of the case:Migration with intrathecal baclofen pump and manual reduction

Case description:A 19-year-old woman with a head injury resulting in spastic tetraparesis presented to hospital for urgent fluoroscopy-guided resupply of her baclofen intrathecal pump (ITB) after several failed attempts earlier in the week. An interrogation attempt was made, which took longer than usual and required tipping the bomb. Using an AP sight to guide needle placement, initial attempts to access the reload port were unsuccessful. However, in side view, the bomb has been inverted along the horizontal axis. Manual reduction was performed to return the bomb to its original orientation, which was confirmed by repeat AP and lateral films. The second bomb resupply attempt was successful and tolerated without complications. Since the possibility of repeated pump migration was considered high, the patient was requested to have her pump re-evaluated by neurosurgery. No kinked tubes or other failures as a result of manual reduction were noted in neurosurgery and the patient's pump was replaced without complications.

discussions:Although pump migration is a known complication of ITB implantation, there are no standard protocols to diagnose and manage this specific complication. Visualization of the ABI through modalities such as ultrasound and fluorography has been described previously, but primarily for the purpose of identifying the recharging port. Here we describe a case in which fluoroscopic visualization of the side view was instrumental in diagnosing an inverted pump. We also describe a technique to manually reduce an inverted pump that has not been described before.

Conclusions:Fluoroscopic guidance may be helpful in identifying pumps that have been inverted from their original position. Manual pump reduction is possible under certain conditions, but should always be accompanied by neurosurgical evaluation.

Focal weakness precedes generalized weakness in a child after botulinum toxin injection: a case report

Suleiman Lapalme, MD; Michael Green, hacer; Frank Jackson, D.O.

Diagnosis of the case:Suspected botulism due to botulinum toxin injection

Case description:A 4-year-old girl with spastic tetraparesis secondary to childbirth-related cerebral palsy tolerated frequent botulinum injections without complications. Since then, she has achieved walker-assisted home ambulation and is Gross Motor Function Classification System for Cerebral Palsy level III. Her most recent injections included 800 units of abobotulinum toxin A split and injected into bilateral gastroc and soleus, L pronator terres and L pronator quadratus, and 7.5 mL of 6% phenol with bupivacaine used to denervate the adductors of bilateral hip and medial hamstrings. The injections were performed under anesthesia. Upon awakening from anesthesia, she presented nausea and a general malaise. Over the next few days, she developed weakness in the extensor digitorum of her left hand, which had not been injected. Over the next 2 weeks, she developed double vision, coughing while eating, new-onset snoring, weakness, and loss of ability to walk. She went to the pediatrician on day 13 after the injection and was referred to the children's hospital. She was admitted to monitor her respiratory status. Examination of her was noted for generalized weakness, low tone, and increasing and decreasing weakness of the cranial nerves. The respiratory condition remained stable and she was discharged into the care of her mother. At 3 months after the injection, her strength had partially improved. At 4 months, she regained all of her strength and the spasticity returned. The etiology of the patient's weakness was never definitively diagnosed.

discussions:To our knowledge, this is the first reported case of localized weakness in a non-injection target muscle group preceding generalized weakness after a botulinum toxin injection.

Conclusions:Weakness after botulinum toxin injections may be more common than previously thought. In this case, localized weakness in the muscles not intended for injection may be a red flag for possible systemic administration of the toxin.

Fulminant sciatic neuropathy secondary to the consumption of heroin administered through an injection technique known as 'Skin Popping': a case report

Lisa Marie Williams, MD; Min Kim, DO; Daniel Neudorf, D.O.

Diagnosis of the case:Isolated sciatic mononeuropathy secondary to subcutaneous injection of heroin by skin snap.

Case description:A 67-year-old man with a medical history of hepatitis C, alcohol, and intravenous drug abuse presents with a 4-month history of acute-onset frank weakness and sensory changes in the right lower extremity after a heroin injection episode. on the right buttock. when bursting on the skin. Examination findings included wasting of the right lower extremity and weakness of the knee flexors, ankle plantar flexors, ankle evertors, and ankle dorsi flexors. Sensation was decreased over the right medial knee and posterior lateral leg. In addition, there was evidence of large areas of healed wounds on the bilateral buttocks. Electromyography (EMG) studies revealed abnormal spontaneous activity of the right biceps femoris, tibialis anterior, and gastrocnemius with sparing of the gluteus medius and lumbar paraspinals. Right sural, tibial, and peroneal sensory motor nerves were not obtained in nerve conduction studies (NCS). Magnetic resonance imaging (MRI) of the right leg revealed a 2-3 cm segment of focal thickening of the sciatic nerve with low perineural and intraneural signal with development and evolution of fibrosis.

discussions:Skin bursting is a delivery method used to inject heroin. It can be administered intradermally, subcutaneously and intramuscularly, depending on the body constitution. This method of injecting heroin has become increasingly popular with the rapid increase in heroin use in the United States. Skin burst can cause direct mechanical trauma to nerve tissue or indirect toxic effects of heroin, both locally and systemically. In this case, the lesion was located in the sciatic nerve proximal to the branch of the long head of the biceps femoris, which was located in the area of ​​the patient's skin fissure. The time course between symptom onset and skin cracking, as well as the EMG/NCS and MRI findings, suggest an isolated sciatic mononeuropathy, probably secondary to skin cracking.

Conclusions:The current case is the first known to us of severe sciatic mononeuropathy secondary to heroin delivery. One possible explanation for this is direct mechanical injury from the skin burst, however heroin neurotoxicity cannot be ruled out. Future studies in this area are indicated, as heroin use is increasing and the potential for deleterious effects on nervous tissue is unknown.

Functional improvements for an adolescent with complex regional pain syndrome in the setting of prior spinal cord injury after completion of an interdisciplinary pain rehabilitation program: a case report

Andrew Collins, MD; Andrea L. Paulson, MD, MPH; David W. Pruitt, MD; John B. Rose, MD; Dra. Sara E. Williams

Diagnosis of the case:Complex regional pain syndrome in a patient with spinal cord injury.

Case description:JD is a 16-year-old female with a history of T5 incomplete spinal cord injury (ICS), sustained at age 1, presenting with complex regional pain syndrome (CRPS) and disability. Six months earlier, she had developed pain in her left foot after riding in a car. At presentation, the pain was tingling, sharp, distal to the bilateral ankles, and associated with discoloration and swelling. Examination revealed allodynia and mottling. Her spinal cord injury resulted in paraplegia, neurogenic bowel, and neurogenic bladder.

Since the onset of the pain, his mobility has changed from walking on forearm crutches to exclusively using a wheelchair. She started homeschooling after school attendance and grades declined. She has tried outpatient therapy, medications, acupuncture, and previous inpatient rehabilitation, with no significant long-term functional improvements.

Due to ongoing disability associated with pain, he entered an interdisciplinary functional restoration program housed in an inpatient rehabilitation unit. For two weeks, she received daily treatment with rehabilitation medicine, pain management, psychology, physical therapy, and occupational therapy.

On discharge, he walked with forearm crutches. Her score on the Functional Disability Inventory (FDI) improved from 33 at admission to 13 at discharge and 18 at month of follow-up. Their mean weekly pain intensity improved from 8/10 on admission to 6/10 on discharge and at one month of follow-up.

discussions:Intensive interdisciplinary pain management has been shown to effectively improve function in children with CRPS and pain-associated disability. In these programs, children participate in various therapies to return to typical adolescent function. However, patients with SCI have functional differences from typical adolescents, well known in an inpatient rehabilitation unit. For a patient with CRPS and prior SCI, interdisciplinary functional restoration can be effectively completed while in an inpatient rehabilitation unit.

Conclusions:Interdisciplinary pain management through inpatient rehabilitation is effective for functional restoration in a patient with CRPS and a history of SCI.

Functional recovery in transverse myelitis associated with tetanus vaccine

Alejandro J. Feng, MD; James R. Wilson, DO; Dr. Wesley Chay

Diagnosis of the case:Acute transverse myelitis secondary to tetanus vaccination

Case description:A 40-year-old man with no significant medical history presented to the Emergency Department with progressive bilateral lower extremity weakness, numbness, and urinary retention after receiving a tetanus shot for a finger laceration. A lumbar puncture showed elevated protein without leukocytosis, and spinal magnetic resonance imaging (MRI) revealed spinal cord signal changes on T2-T9 consistent with transverse myelitis. He was admitted and treated in intensive care with methylprednisolone. He demonstrated some improvement in lower extremity strength and was subsequently transferred to an acute inpatient rehabilitation unit with SCI. He continued to make steady progress throughout his acute rehabilitation course, regaining bowel and bladder control and improving core and lower extremity strength. After discharge from acute rehabilitation, the patient was functionally modified to independently perform all activities of daily living and ambulate 300 feet with a single-ended cane and supervision.

discussions:Vaccination is an important part of public health in today's healthcare environment. Rarely, they are associated with autoimmune phenomena, such as transverse myelitis, which can cause devastating functional deficits. The prognosis of post-vaccination transverse myelitis is not yet well understood, but it can be very poor and persist for long periods. Here we present a case in which intensive medical treatment and rehabilitation resulted in tremendous gains, highlighting the potential for significant recovery in this rare diagnosis of vaccine-associated transverse myelitis.

Conclusions:Tetanus vaccine-associated transverse myelitis is a serious, although rare and poorly understood, idiosyncratic reaction that has the potential for excellent functional recovery.

Functional rehabilitation after total hip arthroplasty in a patient with bilateral congenital difference of the upper limb

Chelsea R. Nichols, B.S.; Dr. Rez Farid; Jeremy L. Stanek, MD, MM

Diagnosis of the case:A 51-year-old man with bilateral upper limb congenital difference underwent right total hip arthroplasty (TCA).

Case description:This patient had bilateral congenital upper limb difference at shoulder level and skeletal dysplasia secondary to thalidomide in utero. He began living independently at the age of 17 learning to use his feet for activities of daily living (ADL). He later developed hip and knee pain as a result of advanced degenerative arthritis that interfered with functional independence. Total hip arthroplasty was performed using a posterior approach. After an 18-day hospital stay for rehabilitation, the patient achieved sufficient functional independence, as measured by an improvement in the Functional Independence Measure (FIM) score of 57 points, and returned to living independently.

discussions:Patients with bilateral upper extremity difference and severe degenerative changes in the lower extremities experience a great loss of independence after THA. Our patient required a posterior approach, despite increasing postoperative limitations, because the overgrowth deformity of the proximal femur precluded the use of an anterior approach. Patients with bilateral difference in the upper limbs have greater needs for nursing care and rehabilitation. Our patient completed 18 days of hospitalization for rehabilitation, exceeding the mean hospitalization time for primary hip arthroplasty of 9.9 days. The extended course of rehabilitation at the hospital was necessary to meet his increased need to improve the functionality of his lower extremities.

Conclusions:The primary goals of rehabilitation after THA are to improve strength and function, allowing patients to return to their previous level of independence. These goals are unique and must be individualized, especially in patients with bilateral upper limb differences. An earlier approach to THA may be associated with fewer postoperative restrictions and should be considered when possible.

Gait improvement in hereditary spastic paraplegia with C-Brace knee, ankle and foot orthosis

Ravi G. Mirpuri, DO; Russell Ward, PC

Diagnosis of the case:Hereditary spastic paraplegia.

Case description:A 39-year-old man diagnosed with hereditary spastic paraplegia had worsening gait instability and increased falls (approximately 3 times per week). The functional goals for the patient were to ambulate in the community with stability. Previously, he ambulated with Bioness L300 bilateral orthoses and a single-ended cane (SPC), but this method provided painful stimulation and inadequate stability. Motor strength on physical examination was symmetrical, showing bilateral ankle flexors/extensors 3/5, knee flexors/extensors 4/5, and hip flexion 4/5. Additional physical findings included intact sensation and proprioception, bilateral genu recurvatum, and mild plantarflexor contractures. Bilateral knee-ankle-foot orthoses (KAFO) were tested with single-point cane support. Gait was analyzed in the laboratory and compared to walking without an orthosis. With the C-Brace, the patient demonstrated improved genu recurvatum (measured subjectively), improved endurance (measured on the distance test), and improved stability when walking and sitting (measured subjectively and objectively with gait mapping). However, despite his improvement in gait performance, the patient reported functional disadvantages due to his bulk, such as the inability to get around in his stroller and difficulty putting on and taking off the device comfortably.

discussions:This case describes the functional benefit of a KAFO C-Brace in a patient with genu recurvatum, poor dorsiflexion, and instability. Compared to a typical KAFO, a C-Brace allows for easy knee flexion during the swing phase and controlled flexion during the stance phase. As such, our patient experienced greater stability when transitioning from standing to sitting (observed in the gait lab) and his ability to descend stairs and ramps, which are benefits of a C-Brace, was likely improved. However, this case also demonstrates that, despite better gait results, its practicality may be limited by its bulk.

Conclusions:A C-Brace may be considered for someone with lower extremity weakness and genu recurvatum with the goal of improving stamina, stance phase stability, toe release in the swing phase, and improving the ability to step down. stairs or ramps.

Gene expression profile of spinal cord injury patients with intractable neuropathic pain

Emre Adiguzel; Sentina Yilmaz; Ugur Mushabak; Mustafa Gulec; Arif Kenan Tan

Goals.Chronic pain is a major problem in patients with spinal cord injury (SCI). According to different studies, approximately 70% of SCI patients have persistent pain. Although previous gene expression profiling studies have been performed in animal models, gene expression profiling studies in human whole blood have not yet been reported. The aim of this study was to define the gene expression profile of neuropathic pain in patients with spinal cord injury.

Project:We performed a gene expression analysis involving 20,000 genes using Affymetrix GeneChip® Primeview™ Human Gene Expression Arrays. We confirmed the expression levels of selected genes using real-time polymerase chain reaction. We collected peripheral blood mononuclear cell samples. Data from twelve patients with intractable neuropathic pain were compared with thirteen patients without pain. All patients have complete lesions with a lesion level above T5.

Results:A total of 16 differentially expressed genes, including 9 upregulated and 7 downregulated, were obtained with a 4-fold switch cutoff. EIF1AY, RPS4Y1, DDX3Y, RPL31, ETS1, KLF3, JUN, CYorf15B and ERAP2 were in the upregulated group and HLA-C, XIST, C4BPA, FAM118A, ZNF506, OVOS2 and C1D were in the downregulated group. The KEGG pathway database showed that 14.6% of genes were enriched in immune system nodes, 13.3% of genes were enriched in signal transduction nodes, 8.8% of genes were enriched in the immune, endocrine, and transport and catabolism nodes.

Conclusions:Recently, it was established that the pathogenesis of neuropathic pain involves interactions between neurons, immune cell-derived cytokines, and chemokines. Furthermore, peripheral sensitization contributes to neuropathic pain through proinflammatory cytokines, prostaglandins, and leukotrienes. Given these data, the results of this first human gene expression study with SCI may provide valuable information for future goals to understand the pathogenesis of neuropathic pain.

Guillain Barré Syndrome (GBS), Axonal Variant

Kathleen L. Donovan, Bachelor of Science; Shernaz Hurlong, DO; Margaret A. Turk, MD

Diagnosis of the case:Acute Motor Sensory Axonal Neuropathy (AMSAN)

Case description:A 49-year-old man arrived at the local hospital with progressive weakness after gastrointestinal symptoms. Numbness, followed by weakness, began distally with progression proximal. He was treated with intravenous immunoglobulin (IVIG) for acute inflammatory demyelinating polyneuropathy (AIDP) based on the results of lumbar puncture (LP). He had a relentlessly progressive course, requiring intubation. He suffered multiple complications, including pneumonia, venous thromboembolism with significant bilateral pulmonary embolism, and diffuse tissue plasminogen activator (tPA) bleeding. He was transferred to the university hospital for plasmapheresis. Electrodiagnostic (EDX) observed severe acute polyneuropathy, AIDP vs. AMSAN. With plasmapheresis he improved slightly, tolerating extubation. He entered the Inpatient Rehabilitation Facility (IRF), participating in all rehabilitation disciplines, with limited progress. Repeat confirmed AMSAN EDX. He remained dependent on all care; his family could not provide him with the necessary support. He was discharged to a specialized nursing facility rehabilitation program for ongoing rehabilitation support.

discussions:GBS is rare, with an incidence of 1/100,000. Most cases are sporadic and usually occur after infection. Diagnosis is based on EDX or LP. Hospitalization allows treatment and monitoring of life-threatening complications. There are numerous variants of GBS, all of which are rapid-onset inflammatory peripheral nerve disorders. In addition to an autoimmune demyelination process, there may be axonal loss in one third. More than 75% of cases are AIDP, with a good prognosis. 5% of GBS cases in North America and Europe are AMSAN, with a worse prognosis. Distinguishing AMSAN from AIDP can be difficult during the initial stages. Knowing the prognosis allows planning rehabilitation objectives, both in the short and long term.

Conclusions:It is important to have early identification of the type of GBS to provide accurate prognostic information and direct appropriate support and rehabilitation programs.

Hemiplegia due to toxic leukoencephalopathy due to intrathecal administration of methotrexate

Dr. Kevin Trinh; matthew shatzer, do

Diagnosis of the case:A 42-year-old man with a medical history of ALL (acute lymphoblastic leukemia) was admitted to the hospital with neutropenic fever. With the decrease in fever, scheduled intrathecal administration of maintenance methotrexate was started. The next day, a coded stroke was called and the patient was referred to the MICU with left hemiplegia, dysarthria, and altered mental status. Head CT revealed no acute bleeding or history of infarction. Brain MRI was negative for acute ischemic infarction, but noted subtle transparencies in the splenius corpus callosum, as well as diffusion abnormalities in the right and left hemispheric white matter at the level of the corona radiata. Given the underlying disease and treatment, as well as the pattern and distribution of dissemination, the findings were consistent with methotrexate neurotoxicity. Although rare, hemiplegia may be due to toxic leukoencephalopathy due to intrathecal administration of methotrexate.

Case description:A 42-year-old man with a medical history of acute lymphoblastic leukemia on CALBG Cycle 10403 (cytarabine, vincristine, IT methotrexate, prednisone, cyclophosphamide, mercaptopurine) Cycle #2, Day 20, develops a fever of 101.5 degrees Fahrenheit. He had leukopenia with leukocytes of 1.2 k/uL and treatment was started with IV levaquine and diflucan prophylactically. Blood and urine cultures were negative. Chest CT showed scattered linear atelectasis, without pulmonary nodules or parenchymal consolidation. When the fever subsided, scheduled maintenance intrathecal methotrexate was administered. The next day, he developed dysarthria, altered mental status, and left hemiplegia. A code stroke began and he was intubated and transferred to the UCIM. A lumbar puncture found clear CSF with 45% lymphocytes, 37% neutrophils with 18% monocytes/macrophages. Protein and glucose levels were normal at 37 mg/dL and 48 mg/dL, respectively. CSF cultures for acid-fast bacilli and fungi were negative. Head CT scan revealed lucency involving the splenius corpus callosum, but no hemorrhage or history of infarction. Neck MRI found no evidence of carotid or vertebral stenosis. In addition, intracranial circulation was normal in the circle of Willis, with no evidence of cerebral stenosis or vasculitis. MRI of the brain reported diffusion restriction of the right corona radiata and splenius corpus callosum. The location of the diffusion restriction, as well as its nature in the right corona radiata, makes an ischemic etiology unlikely. However, given the history of leukemia and prior intrathecal administration of methotrexate, the findings were consistent with methotrexate-induced leukodystrophy. During his hospitalization, a physiatrist was consulted and therapies were started, resulting in an improvement in the weakness of the left lower limb.

discussions:Due to the intensification of the chemotherapy regimen and central nervous system (CNS) prophylaxis, the prognosis of acute lymphoblastic leukemia (ALL) has improved in recent years. Intrathecal methotrexate is an essential component of CNS prophylactic therapy, which has decreased the incidence of CNS relapse in ALL. However, the success of this therapy was mitigated by neurotoxicity related to its administration. The clinical manifestations of neurotoxicity after the use of intrathecal methotrexate vary from meningeal irritation, seizures, encephalopathy to paresis or transient or permanent paralysis of the upper and/or lower extremities. Although rare, hemiplegia is not unexplained, since the neurotoxicity of intrathecal administration of methotrexate can be nonspecific. Metabolic disturbances, such as elevated levels of homocysteine ​​and its excitatory amino acid neurotransmitter metabolites, may be the cause of methotrexate neurotoxicity. Nuclear magnetic imaging is valuable in the early diagnosis and treatment of treatment-induced leukoencephalopathy. The mechanism of MRI abnormalities may be metabolic, transient vasospasm, increased capillary permeability, occlusion of small vessels, or the demyelination process itself. Our patient had left-sided hemiplegia consistent with corona radiata involvement. As for his altered mental state, neurotoxic effects on the corpus callosum could be the cause.

Conclusions:Intrathecal administration of methotrexate is an essential component of chemotherapy for acute lymphoblastic leukemia, as it is effective in preventing CNS relapses. Its administration should be considered with caution, since the neurotoxic effects of methotrexate are well documented. Here we report a rare case in which stroke-like symptoms of hemiplegia, dysarthria, and altered mental status may be the result of toxic leukoencephalopathy due to intrathecal administration of methotrexate.

How we streamline our consulting service using the A3 methodology

Subhadra Nori, MD; Mariam Zakhary, DO

Our Rehabilitation department is a 600-bed, full-service urban hospital in New York City. Our Department provides inpatient, outpatient and consultation services and is affiliated with a prestigious institution. In the initial state, our service received excessive inquiries. Some of them did not have a clinical question and still needed PT information. Normally 5 days would elapse between the initial request and the effective provision of PT services. This was causing delays in obtaining services, thus prolonging the length of stay in medical-surgical services. In order to improve efficiency. We assess the situation carefully. We follow the A3 process and perform a gap analysis. we designed a query logarithm and created three portals. This facilitated and improved access to the PT. The end result was faster access to the PT, greater efficiency in discharge planning, and patient satisfaction. Now 90% of our patients are treated by PT and in the first 3 days we will discuss this A3 methodology and the details of this process.

'If you fail at first, try, try again': initial lack of response to zolpidem followed by paradoxical arousal after repeat dosing in a pediatric patient with traumatic brain injury

Lauren Cámaras, DO; Tobias J. Tsai, MD; Maria E. McClanahan, MD; Genevieve C. Jacobs, WHO IV

Diagnosis of the case:Impaired responsiveness in a pediatric patient with traumatic brain injury (TBI).

Case description:A 17-year-old male with TBI after a motor vehicle collision was admitted for pediatric rehabilitation. On admission, his baseline Coma Recovery Scale-Revised score was 2 and he had only a generalized response to stimulation. During the first month of his stay he remained in a vegetative state. During this month they gave him 10 mg of zolpidem in the hope that it would have the paradoxical effect of increasing rather than decreasing his arousal. With the first dose there was no change in his responsiveness, but he was no more sleepy than at baseline. On subsequent non-consecutive days, repeat doses of 10 mg zolpidem were administered. After the fifth dose, thirty minutes after administration, he verbally responded to "yes" or "no" questions, identified family members, said and spelled his name, and solved simple mathematical problems. After approximately four hours, he could no longer verbalize in response to stimulation, and there was a decrease in arousal. In the following days, he adjusted his zolpidem dose to 10 mg twice daily. Each dose was associated with clear but transient increases in patient responsiveness.

discussions:The paradoxical effect of zolpidem, a gamma-aminobutyric acid (GABA) agonist, on arousal in patients with impaired consciousness has been increasingly described, but reports of its use in the pediatric population are few. Furthermore, the limited data in the adult population suggest that only a small percentage of people with impaired consciousness will respond to this intervention. Our experience suggests that repeated trials of zolpidem may improve arousal, even if an initial dose does not.

Conclusions:Zolpidem may improve arousal in pediatric patients with altered consciousness secondary to TBI; repeated dosing may be beneficial even if there is no initial response.

Impact of electronic medical record-based monitoring of pressure ulcer risk factors and nutritional status in patients with traumatic brain injury

Michael Vishnevetsky, Bachelor of Science; Anne Felicia Ambrose, MD, MS

Goals.Patients with traumatic brain injury (TBI) are at high risk of developing pressure ulcers (PUs), which can increase morbidity and mortality. The Braden scale is a screening tool used to identify patients at risk of developing PUs. The aim of our study was to evaluate initiatives based on electronic medical records (EMR) to monitor the risk of PU through periodic evaluations of the Braden scale in patients with TBI in an acute rehabilitation unit. A secondary objective was to determine whether clinical metrics, such as the Braden scale, which reflect the risk of PUs, predict functional outcomes.

Project:This retrospective chart review examined data, including Braden scores, PU development, and FIM scores at admission and discharge, for patients admitted to an acute rehabilitative brain injury unit for moderate to severe TBI. from January 2013 to July 2015.

Results:Our study reviewed the medical records of 50 patients with TBI, whose mean age was 57.2 years, and the most frequent imaging finding was SDH (72%). Four PUs were reported in these patients, but only 1 PU developed during rehabilitation of 36 TBI patients admitted in 2013. Braden scale scores improved by an average of 2 points in 2013, prior to the latest initiatives in which the evaluation is completed each turn. For 14 patients seen on the unit after the initiatives were implemented, Braden scores improved by an average of 2.64 points (not significant). The change in Braden score over the course of each patient's hospitalization was found to modestly predict (R²=0.294, p < 0.05) the FIM score.

Conclusions:More frequent pressure ulcer risk assessments using the Braden scale may not prevent pressure ulcers, which can already be reduced with comprehensive skin care and other preventive measures. Changes in the Braden scale throughout rehabilitation can partially predict functional improvements. Additional studies may examine the prognostic value of such evaluations for patients with other conditions.

Implications of late diagnosis of piriformis syndrome

Nathan Kenyon, MD; Dr. Mohammad Agha

Diagnosis of the case:The piriformis originates anterior to the S2-S4 vertebrae and inserts on the greater trochanter of the femur. It is innervated by branches from L5, S1, and S2 and can cause pain in an S1 distribution. The challenge test is performed with hip flexion, adduction, and internal rotation (FAIR).

Case description:A 50-year-old man presented to a spine clinic with left mid-buttock pain with radiation to the calf. He had no history of trauma or surgery in or around the hip joint. Previously, the patient was unresponsive to gabapentin, prednisone, tramadol, hydrocodone, baclofen, physiotherapy, or intra-articular hip injection. Anterior lumbar magnetic resonance imaging (MRI) showed severe neural foraminal stenosis at L4-5, L5-S1 and the patient underwent epidural steroid injection and medial branch block. In our clinic, a diagnostic ultrasound was performed that revealed inflammation of the obturator internus; a steroid injection was given, but it did not lessen the patient's pain. Previously, the patient had a normal left lower limb electromyogram (EMG). We then considered ischiofemoral impingement (IFI) and therefore obtained an MRI of the pelvis, which showed abnormal signal in the left sciatic nerve. We repeated the EMG and found evidence of chronic denervation in the left gastrocnemius and the short head of the biceps femoris. Subsequently, the patient was referred to orthopedics and the left piriformis tendon was released with complete resolution of the pain.

discussions:Our patient received various medications and procedures that failed to identify and treat the pain generator. Concern about the IFI led us to request a pelvic MRI and repeat EMG, which led to a definitive diagnosis of piriformis syndrome.

Conclusions:Piriformis syndrome can be a challenging diagnosis and difficult to treat. Delay in the recognition and treatment of piriformis syndrome can result in unnecessary and useless treatments and prolong the suffering of the patient.

Improving communication about training diabetics in preparation for discharge: a quality improvement pilot project

Lindsay N. Ramey, MD; Amanda Cosgrove, RN; Margaret Loeper Vasquez, MS, RD, LDN

Diabetes is a known risk factor for vascular disease and stroke. It is essential to prepare diabetics in the stroke hospitalization service to manage their own diabetic regimen with maximum independence after discharge. Recent patient surveys and interdisciplinary meetings have reflected dissatisfaction with the last-minute nature of this training. The goal of this quality improvement project was to increase by 20% the frequency with which discharge planning related to diabetes care was discussed at the interdisciplinary team conference (ITC). Three PDSA (Plan-Do-Study-Act) cycles were completed in the stroke unit of an inpatient rehabilitation unit from October 2014 to January 2015. The first cycle involved nursing education with positive reinforcement. Cycle two involved the creation of a formal checklist completed by nurses in the ITC with a notice for the diabetes management plan. The third cycle involved a formal education session for medical residents. Data on the percentage of diabetics whose discharge agreements were discussed in the ITC were collected twice weekly by a silent observer before any intervention and after each PDSA cycle for a total of 3 months. Discharge planning discussion rates for diabetics improved from 50% at baseline to 81%, 75%, and 92%, respectively, after each PDSA cycle. Using nursing and resident education, positive reinforcement, and written instructions, interdisciplinary discussions of diabetes discharge planning were successfully facilitated earlier and more consistently, with a sustained improvement rate ranging from 25% to 42%. % every 3 months after starting. This has the potential to improve patient satisfaction and clinical outcomes.

Incidence, Characterization, and Predictors of Sleep Apnea in a Consecutive Sample of Acute Brain Injury Rehabilitation Admissions

Erin Marie Holcomb, PhD; Dr. Daniel Schwartz; Marissa McCarthy, MD; Bryan A. Thomas, MD; Scott Barnett, PhD; Risa Nakase-Richardson, PhD

Goals.To prospectively examine the incidence, characterization, and potential risk factors of sleep apnea in a consecutive sample of inpatient brain injury rehabilitation admissions.

Project:Participants were assessed for the presence of sleep-disordered breathing using level 1 or 2 polysomnography (PSG) during admission. Demographics, injury characterization, and injury course were extracted from medical records using VA TBIMS procedures. Descriptive statistics, logistic regression, and hierarchical general linear models were used to examine the incidence of sleep apnea and its relationship to traditional risk factors.

Results:Of the 86 participants, 49 percent were diagnosed with predominantly obstructive sleep apnea (OSA) at an average of 133 days post-injury and a mean AHI of 20.1 (16). Subgroup analyzes revealed an incidence of 37% in TBI participants (n=60) with a mean AHI of 15.7 and 70% in non-TBI participants with a mean AHI of 24.8. Univariate analyzes revealed that older age and the presence of hypertensive episodes during hospitalization were associated with OSA status and severity. Body mass index and diabetes were not associated. There was no indication that the drugs administered at the time of the PSG had an effect on the results.

Conclusions:There is an extraordinarily high incidence rate of OSA in hospitalized patients with brain injury, and traditional risk profiles may not help detect the disorder in this population. However, this study has implications for improving neurorehabilitation treatment, as a better understanding of the prevalence of sleep-related breathing disorders will help inform sleep management strategies and potentially improve outcome.

Independent Navigation with High Quadriplegia Using Sip and Puff Adaptations

Salomón Rojhani, MD; Steven Stiens, MD, MS; Dr. Albert Recio, RPT, PTRP

Diagnosis of the case:Adaptive navigation in a patient with upper cervical tetraplegia.

Case description:We present a systematic retrospective case review of a 27-year-old man with a history of traumatic spinal cord injury in 2008, which resulted in complete C3 tetraplegia. With no prior sailing knowledge, the participant initially received an introductory sailing course, followed by instruction in the sip and puff control mechanism. He then independently navigated a course on the water in conditions of moderate winds ranging from 5 to 15 knots and ambient temperatures of 21 to 23 degrees (Celsius).

discussions:To the best of our knowledge, adaptive navigation using sip and puff techniques has not been previously discussed in the scientific literature. The success of the participants provides a model for adaptive navigation techniques, whether using traditional controls or the sip and puff mechanism, and contributes to the continued advancement of therapeutic recreation in the lives of patients with spinal cord injuries and people with disabilities.

Conclusions:While the beneficial effects of sport for patients with spinal cord injuries have achieved significant growth and understanding, high-level injury participation is often restricted due to safety concerns, lack of adaptability, high technology costs, and poor accessibility. This case of adaptive navigation in high quadriplegia injury provided the individual with a chance for safe recreation, quality social interaction and improved self-esteem. In addition, the added benefit of reintegration into the community is vital in helping quadriplegic patients combat feelings of depression and social isolation as a result of the injury.

Moderate systemic hypothermia induced after traumatic spinal cord injury: a case report

Meghan E. Cochrane, DO; Miguel Escalon, MD, MPH

Diagnosis of the case:A previously healthy 33-year-old man sustained a flexion injury while diving, resulting in immediate tetraplegia.

Case description:A previously healthy 33-year-old man sustained a flexion injury after shallow water diving, resulting in a C5 AIS B incomplete quadriplegia. His images demonstrated a C5 flexion teardrop fracture with spinal cord compression. The patient was systemically cooled to 33.5 degrees Celsius via the right femoral catheter for 48 hours and underwent anterior decompression and C5 fusion. He was classified as C5 ASIA B approximately 24 hours after the injury. Gradual rewarming was performed over 24 hours. Nine days after starting the hypothermia cord protocol, the patient progressed to a C5 AIS D. On admission to the intensive care unit, 14 days after the diving incident, the patient demonstrated a 75-foot ambulation with RW and assist as well as standard 4-step negotiation with bilateral handrails and minimal assistance.

discussions:Since the 1960s, the application of hypothermia in large animal models of acute SCI has been shown to promote long-term functional recovery. In the 1970s, local cooling techniques were applied in the first human trials. There are currently a finite number of human studies demonstrating the effectiveness of moderate systemic cooling in people with traumatic spinal cord injury. Currently, induced hypothermia has not yet been approved as a potential treatment due to its therapeutic value in traumatic spinal cord injuries. Our patient demonstrated rapid recovery after traumatic spinal cord injury, supporting the beneficial effects of systemic hypothermia.

Conclusions:This case study is a clear example of how implementing moderate hypothermia in addition to traditional therapies in traumatic IBS leads to better outcomes compared to IBS patients receiving only traditional forms of treatment.

Initial Report of the AAP Working Group on the Development of PMR-Specific Observable Practice Activities (OPA) and Trusted Professional Activities (PAA)

Dr. Heather Baer; Michael malva, MD; Alex Moroz, MD; Dr. Vu Nguyen

Under the Next Accreditation System (NAS), Physical Medicine and Rehabilitation (PMR) residency programs have been asked to re-examine the way residents are assessed for competency. Programs are currently required to submit aggregate performance information to the ACGME in the form of milestones. However, best practices regarding how programs should acquire the information necessary to adequately reflect resident performance against milestones have not been established, nor do we have adequate tools to assess the degree to which data can be trusted. for residents to perform. activities. To that end, we created a list of potential PMR-specific Observable Practice Activities (OPAs) to share with PMR residency programs as part of developing an assessment toolbox. Ultimately, these OPAs are intended to be useful for formative assessments. In addition, we have created a separate list of PMR-specific Trusted Professional Activities (PAAs) that will be available for use in summative assessments and, potentially, high-stakes decision-making. Our team created lists of potential takeover bids and EPAs. These lists were then distributed within our institutions, at national meetings, and then among PMR program managers for constructive feedback. The lists were later modified to reflect consensus feedback on face appearance and content validity. The overall goals of the project, as well as the current list of proposed OPAs and EPAs, will be presented at the AAP conference prior to completion. Through an iterative process, a list of proposed PMR-specific OPAs and EPAs was constructed. Upon completion, our team will begin the process of preparing the content for these tools for further feedback and eventually beta testing. We anticipate that, once completed, these OPA and EPA will be very useful for formative and summative assessments of our residents.

Inpatient rehabilitation after placement of a cervical spinal cord stimulator: a case report

Ryan W. Clark, DO; Alan Anschel, MD; Kristen T. McCormick, DO, MS

Diagnosis of the case:Ventilation dependent C2 ASIA A state of tetraplegia after cervical spinal cord stimulator implantation

Case description:A 34-year-old man with no significant medical history sustained a spinal cord injury after a trampoline accident resulting in ventilator-dependent C2 ASIA A tetraplegia. The patient underwent a C3-5 cervical discectomy and anterior spinal fusion complicated by autonomic dysfunction, bradycardia, and code blue, requiring resuscitation and intubation. Subsequent MRI showed spinal cord edema requiring repeat surgical decompression, C4-5 laminectomy, and posterior spinal fusion. The initial course of inpatient rehabilitation was further complicated by multiple infections, deep vein thrombosis, a sacral ulcer requiring a flap, and failure to place a diaphragmatic pacemaker. Upon discharge from hospital rehabilitation, the patient showed no functional improvement or change in the ASIA level. Disappointed with his progress, he traveled to Thailand to receive experimental epidural and intravenous stem cell injections, followed by implantation of a cervical spinal cord stimulator with specific programs designed to facilitate voluntary motor function. The patient then returned for further internal rehabilitation.

discussions:To our knowledge, this is the first documented case of an acute inpatient rehabilitation course after cervical spinal cord stimulator placement in a patient with spinal cord injury. Spinal cord stimulators have been shown to be successful in modulating chronic pain conditions and recent studies have shown striking benefits of lumbar spinal cord stimulators in improving function in complete paraplegics. Additionally, there may be applications for cervical spinal cord stimulators in patients with incomplete spinal cord injury.

Conclusions:The patient demonstrated new voluntary motor control in bilateral finger flexion, bilateral wrist extension, and bilateral triceps extension with specific stimulation patterns. However, the cervical spinal cord stimulator did not change measures of functional improvement or allow the patient to initiate spontaneous breaths off the ventilator. Spinal cord stimulators are challenging the idea of ​​complete spinal cord injuries, and as technology improves, they may allow patients to perform functional tasks that were previously impossible.

Is it safe to add amphetamine to non-invasive brain stimulation for post-stroke aphasia?

Dr. Zafer Keser; Michelle W. Dehgan, MA, CCC-SLP, BCS-S; Shaparak Shadravan, CCC-SLP, MS; Kelley Shaw, MS, CCC-SLP; Mia Maegan Marrow, MT-BC; Amy Marroquín, MT-BC; Nuray Yozbatiran, PhD; Gerard E. Francisco, MD

Goals.There is a growing need for a variety of effective adjunctive treatment options for speech recovery after stroke. The pharmacological agent combined with non-invasive brain stimulation has not been previously reported for post-stroke aphasia recovery.

Project:In this "proof of concept" study, we aimed to test the safety of a combined intervention consisting of dextroamphetamine (D-AMP), transcranial direct current stimulation (tDCS), and speech-language therapy (SLT) in subjects with chronic noncommunicable diseases. Fluid aphasia due to stroke. Ten native English speakers with chronic nonfluent aphasia underwent two experiments in which they received 10 mg D-AMP (active trial) or placebo (placebo trial) along with 1.5 mA anodal tDCS and SLT on two separate days. . The Western Aphasia Battery Header Form (WAB-R) was used to monitor changes in speech performance.

Results:No serious adverse events were observed. There was no significant increase in blood pressure with amphetamine and no impairment in speech and language performance. The WAB-R ® aphasia quotient (AQ) and language quotient (LQ) showed a statistically significant increase in the active experiment. Comparison of the proportional changes of AQ and LQ in the active experiment with AQ and LQ in the placebo experiment showed a significant difference.

Conclusions:We show that triple combination therapy is safe and implementable and appears to induce positive changes in speech and language performance in patients with chronic nonfluent aphasia due to stroke. We believe that this pilot study will shed light on future clinical trials of combination therapies with a larger sample size.

Isolated involvement of the thoracic column in a child with spinal cord injury without radiographic abnormality: a case report

Bi-Ying Yeh, MD; Tony CT Lo, DO, MS; Xing Zhao, MD

Diagnosis of the case:Isolated spinal cord injury of the thoracic column without radiographic abnormality secondary to deceleration injury

Case description:A 14-year-old boy is admitted to the emergency room with acute onset of bilateral upper and lower extremity numbness after being thrown face down and landing on his back during wrestling practice. He experienced lower extremity numbness and loss of coordination with symptoms subsequently progressing to the trunk and shoulders bilaterally. The MRI of the brain and spine showed nothing remarkable. On examination, motor power was intact. However, there was a reduction in proprioception, vibratory sensation, temperature, and light touch from T5-6 for the bilateral lower extremities. He also presented a positive Babinski sign and poor bilateral finger-nose coordination. The patient required maximum support to stand and walk. He was diagnosed with acute myelopathy with involvement of the dorsal columns secondary to a deceleration injury. After two weeks of hospitalization, his ataxia and sensory deficits had improved significantly and he was able to walk with minimal assistance.

discussions:Spinal cord injury without radiographic abnormality (SCIWORA) usually occurs in children because the immature spine is elastic. Therefore, it is more susceptible to external forces that cause transient disc bulge and significant intersegmental movement. The injuries generally involve the cervical region and are the result of traumatic events. Thoracic spine involvement is less common due to the presence of the ribcage and abdomen that protect the thoracic vertebrae from forced movement. The presentation can be diverse, depending on the particular lesion. However, isolated spinal cord injury, as seen in this case report, is rare. The mechanism of injury likely involved blunt force trauma to the ground resulting in transient segmental movement, resulting in contusion of the dorsal column of the spinal cord.

Conclusions:This is a unique presentation of isolated involvement of the thoracic column in a child diagnosed with spinal cord injury without radiographic abnormalities. As illustrated in this case, patients with these injuries recover remarkably with intensive inpatient rehabilitation.

Klippel Trenaunay syndrome: Effective treatment of conservative rehabilitation of sciatica induced by arteriovenous malformation

Dr. A.S. Daniel Kao; Ashish Kumar, DO; Dr. A.S. Dimir Open

Diagnosis of the case:Trenaunay de Klippel syndrome.

Case description:Klippel Trenaunay syndrome: Effective treatment of conservative rehabilitation of sciatica induced by arteriovenous malformation.

discussions:The patient initially presented to the emergency department with severe back pain and lower extremity weakness due to a long history of left lower extremity overgrowth and lymphedema. During evaluation, the patient developed rapidly progressive bilateral lower limb radiculopathy, paraparesis, and paresthesia. MRI of the spine showed dural arteriovenous malformations spanning multiple thoracic and lumbar levels with evidence of intradural hemorrhage. The patient was diagnosed with Klippel-Trenaunay Syndrome. Spinal angiography was notable for AVM at T10 associated with intralidal aneurysm with significant contribution from the L4 left radiculomedullary artery. After emergent AVM embolization and coiling of the aneurysm, the patient experienced continuous lower extremity pain, severely limiting her mobility. The patient was enrolled in a comprehensive inpatient rehabilitation program that included physical, occupational, and neuropsychiatric therapy. Restoration of the patient's initial functional capacity was greatly affected by pain, which was managed with a combination of mobility training, oral pharmacological agents, and neuropsychiatric treatment. With this multimodal approach, the patient's functional abilities improved to a level sufficient to allow safe discharge home.

Improvement of the patient's lower extremity radicular pain with functional mobility exercises and pharmacological treatment played an integral role in improving the patient's functional capacity and quality of life.

Conclusions:Functional mobility therapy augmented by oral pharmacological agents is an essential treatment modality for radicular pain after nerve root damage caused by dural thoracolumbar arteriovenous malformations in patients with Klippel-Trenaunay syndrome.

Model System of Care for Limb Loss: Proven Ways to Improve the Care of Patients with Limb Loss!

Jorge Gondo, MA; Sheehan Terrence, MD

People with limb loss represent a growing and underserved population within today's healthcare system. Fragmented care increases cost, mortality, and disability relative to other major disability groups. The goals of the National Institute on Disability and Rehabilitation Research (NIDRR) Model Systems program are to improve long-term physical, functional, vocational, cognitive, psychological, and quality of life outcomes and care for people with spinal cord injury. spinal cord injury (SCI), traumatic brain injury (TBI), and burns. The Model System approach is based on research demonstrating the superiority of comprehensive care over fragmented care. Currently, 14 SCI centers and 16 TBI have produced hundreds of peer-reviewed articles supporting the effectiveness of care for their respective populations. Model Systems has proven to be an effective method of conducting research to improve the quality of care and outcomes for patients with IBS, TBI, and burns, establishing best practices and standardizing care across the healthcare system. The data provided by these centers improved care, affected reimbursement, and provided stakeholders with the information to make evidence-based decisions. Now is the time to create a much-needed program for people with limb loss. This three part presentation; 1) describe the model systems approach to care, 2) review the value of existing model systems of care, illustrating the value to clinicians and stakeholders, and 3) describe the process of creating a model system of care for limb loss and how the prosthetic profession will be an important partner in the system

Lumbar pseudomeningocele in the context of lumbar neuroarthropathy

Stacey A. Bennis, MD; James Spendley, hacer; Dr. David Chen

Diagnosis of the case:Pseudomeningocele L3-L4 y neuroartropatia.

Case description:A 52-year-old male with chronic stage AIS T11 A spinal cord injury after T9-L2 spinal fusion who presented to an acute care hospital with severe headaches, fluctuating lumbar mass, fever, and stage sacral pressure injury. IV. The MRI of the thoracic spine was worrisome due to CSF ​​leakage; however, neurosurgical intervention was not recommended. After transfer to acute rehabilitation, consultations for neurosurgery and plastic surgery were obtained. Repeat neuroimaging with CT and MRI of the thoracic/lumbar spine showed evidence of spinal neuroarthropathy at L3-L4 with severe spinal cord involvement and multiple collections of connecting fluid at L3-L4 suggestive of pseudomeningocele, with no evidence of hardware failure or fracture. The patient was transferred to an acute care hospital for urgent three-stage surgical repair (stage I: lumbar laminectomy with thecal sac ligation; stage II: sacral pressure wound debridement and flap closure; stage III: posterior spinal fusion of the ilium T9 and L3 - Corpectomy L4).

discussions:Spinal neuroarthropathy (SNA) was first described in 1884 by Kronig (neurosyphilis induced by tabetic neuroarthropathy) and since then it has been little reported in the literature in relation to SCI. Clinical presentations may include pain, changes in neurologic status (spasticity, bowel/bladder changes), spinal instability, and autonomic instability. Early X-ray, CT, and MRI findings can mimic degenerative joint changes, while late findings implicate destruction of the disc, vertebral bodies, and facet joints. A recent study provided level IV evidence to recommend circumferential fusion for the treatment of ANS. The natural history of ANS managed conservatively is unknown. Regarding our particular case, lumbar pseudomeningocele in the context of SNA was not reported in the literature.

Conclusions:Classic ANS symptoms may be missed in patients with complete spinal cord injuries, but the presence of a pseudomeningocele may suggest an underlying ANS with dural involvement. Interdisciplinary management between physiatrists and neurosurgeons plays a fundamental role in the management of ANS.

Lyme disease arthralgias superimposed on chronic pain syndrome: a case report

Patricio Martone, DO; Dr. Eric Scholten; Arthur Jason DeLuigi, DO

Diagnosis of the case:Lyme disease arthralgias superimposed on chronic pain syndrome.

Case description:The patient is a 41-year-old woman with a history of chronic pain syndrome after placement of a spinal cord stimulator. She had a complex history of left lower extremity neuropathy secondary to multiple knee surgeries, compartment syndrome, and complex regional pain syndrome. She presented for follow-up with a recent worsening of her previous arthralgia along with a new distribution of pain.

discussions:The patient's lower extremity pain was controlled with various medications and various interventions, including selective nerve root blocks, a femoral nerve block, and a spinal cord stimulator. Despite these treatments, she experienced worsening pain in her knee, as well as arthralgia in her left hip and elbows, and worsening symptoms of neuropathy. This new presentation led to further investigation of polyarthralgia. Laboratory tests were completed to look for rheumatologic causes of polyarthralgia. The IgG Western Blot test resulted in a progressive increase in positive values, revealing that Lyme disease probably contributed to the evolution of symptoms. Multidisciplinary management (pain control, infectious diseases, and rheumatology) included long-acting intravenous antibiotics and anti-inflammatories, as well as prior analgesics.

Lyme disease is known as "the great imitator" due to its ability to mimic other diseases. It is known to cause generalized fatigue, arthralgia, and neuropathy. This patient had pre-existing arthralgia and lower limb neuropathy. However, further investigation was required due to the greater severity of the patient's pain and the new distribution of pain. Her positive assessment of Lyme disease was likely responsible for the evolution of his symptoms, given the various manifestations of new-onset Lyme disease.

Conclusions:Chronic pain syndrome can be difficult for healthcare professionals to manage. It is important that rehabilitation professionals consider alternative etiologies for worsening pain, even if the causes have been previously established. In this case, serological follow-up for Lyme disease was necessary for one year to confirm the diagnosis.

Management of lymphedema in Klippel-Trenaunay-Weber syndrome after spinal surgery

Neal Washburn, DO, MS; Kenten Wang, DO, MS

Diagnosis of the case:Right lower limb hemihypertrophy due to Klippel-Trenaunay-Weber syndrome with spinal arteriovenous malformation of the conus medullaris.

Case description:A 21-year-old male patient with a history of hemihypertrophy of the right lower limb due to Klippel-Trenaunay-Weber syndrome (KTWS), who presented numbness and progressive weakness in both lower extremities, as well as in the perineal/penile area. region. MRI of the lumbar spine showed significant intradural vascularity and vasogenic edema in the spinal canal, extending from the lower thoracic spine to the conus medullaris, suggesting an arteriovenous fistula. Ultrasound on the right side did not show deep vein thrombosis. He underwent multilevel laminoplasty and resection of an arteriovenous malformation of the conus medullaris. He was transferred to acute inpatient rehabilitation postoperatively for residual lower extremity weakness, bowel/bladder dysfunction, and management of lymphedema. During acute rehabilitation, lymphedema in the right lower extremity was initially treated with techniques of manual lymphatic drainage, application of pressure stockings, and elevation. Shortly after initiating these strategies, the patient's lymphedema showed modest improvement, however, he developed increased drainage from the incision site on his back, as well as significant scrotal edema. As a result, the incision site did not heal as expected and the patient had scrotal discomfort, which made it difficult for him to progress during the therapies. After repeat MRI of the spine, it was decided that the fluid at the incision site was most likely lymphatic drainage resulting from lymphedema treatments on the right leg. After removing the pressure stocking and reducing the frequency of lymphedema treatments, the fluid removed from the incision site decreased and the scrotal edema resolved. The incision site showed better healing and the patient was able to fully participate in the therapies.

discussions:SKTW is a rare genetic condition that involves vascular malformations, venous abnormalities, and hypertrophy of the extremities. Arteriovenous malformations (AVMs) are a known complication in SKTW, with only a few cases reported in the spine. The limb hypertrophy that occurs in SKTW has been attributed to a combination of factors including vascular, venous, and lymphatic abnormalities. The hypertrophy tends to be asymmetric, commonly affecting the lower limbs. The goal of treatment for lymphedema in SKTW is to reduce secondary complications of edema (ie, pain, wounds/ulcers, bleeding, cellulitis) in addition to improving the patient's gait pattern. Treatment of lymphedema in SKTW tends to be conservative, using compression garments and pumps, in addition to basic lifting techniques. The lymphatic drainage patterns indicate that the watershed on the back, the inguinal nodes, and the scrotum are potential areas of lymphatic drainage from the leg. The current report presents some complications of the use of lymphatic drainage techniques for the leg in a rare case of SKTW that required spinal surgery.

Conclusions:KTWS is a rare congenital condition that often presents with substantial unilateral hypertrophy of the lower extremities due to lymphedema. Lymphedema is generally treated conservatively, with the goal of minimizing secondary complications. In some cases, spinal arteriovenous malformations can develop in SKTW patients and require surgical intervention due to spinal cord injury. In such patients who have undergone spinal surgery, standard lymphatic drainage techniques may need to be reduced or even delayed to allow the surgical wound to heal completely. In addition, SKTW patients may be at increased risk of developing scrotal edema as a complication of lymphedema treatments due to the volume of fluid displaced from the leg. The conclusions of this rare case could potentially be applied to similar cases related to the treatment of deep lymphedema of the lower extremities.

Management of back pain in a patient with axially involved psoriatic spondyloarthropathy after surgical fusion of the thoracic spine

Stephen Schaaf, MD; Dra. Beth Stepanczuk

Diagnosis of the case:Management of back pain in a patient with axially involved psoriatic spondyloarthropathy after surgical fusion of the thoracic spine.

Case description:A 70-year-old man presented for inpatient rehabilitation after T4-T8 fusion for an unstable fracture of T6 due to a fall. The patient complained of 8 out of 10 mid-back pain without radiation and morning stiffness < 2 hours. On examination, there was tenderness of the midthoracic spine and right paraspinal muscles, with no pain in the sacroiliac joint. Psoriatic plaques were observed on the elbows, knees, and scalp. Postoperative CT scan of the thoracic spine demonstrated ankylosis of the costovertebral facet, anterior syndesmophytes, and partial ankylosis of the vertebral body throughout the thoracic spine. The patient's back pain was effectively controlled with oxycodone and gabapentin. He returned home functionally independent.

discussions:Treatment of back pain in patients with inflammatory arthritis after spinal fusion surgery can be challenging, as pain often results from a combination of inflammatory, mechanical, and neurological causes. In this case, the association of ankylosing spondylitis and psoriasis establishes the diagnosis of psoriatic spondyloarthropathy with axial involvement, which can cause inflammatory low back pain. This patient also had a recent thoracic fusion, a mechanical cause of back pain. His symptoms of morning stiffness lasting less than 2 hours, absence of synovitis, and intermittent activity-related pain were more suggestive of a mechanical cause of his back pain. NSAIDs may be useful for acute and chronic mechanical low back pain, but should be avoided in the setting of bone healing. Steroids were avoided as they may exacerbate psoriasis when discontinued and may prevent bone healing. Therefore, potential pharmacologic agents to treat this patient's back pain included acetaminophen, neuropathic analgesics, muscle relaxants, and opioid analgesics.

Conclusions:Back pain after thoracic fusion in a patient with psoriatic spondyloarthropathy affecting the axial spine can be optimally managed with opioid analgesics and neuropathic analgesics.

Maximizing Functional Outcomes in Hypoxic-Ischemic Encephalopathy Using an Interdisciplinary Team Approach

Jacob Fehl, MD; Blessen C. Eapen, MD

Diagnosis of the case:Hypoxic-ischemic encephalopathy.

Case description:A 35-year-old male veteran with a significant medical history of familial hyperlipidemia and a prior myocardial infarction at the age of 30 suffered cardiac arrest following rigorous activity during a crossfit class. CPR was performed on site and the patient received intensive care at a local hospital. Initial neuroimaging suggested anoxic brain injury versus posterior reversible encephalopathy syndrome. The patient had persistent cortical blindness, spastic dysarthria, bradykinesia, visual deficits interfering with fine motor coordination, and cognitive deficits associated with lesions in the basal ganglia and bilateral occipital regions; however, he has demonstrated significant gains in oral-pharyngeal dysphagia, ambulation, reduced spasticity, and intact ability to make personal medical decisions. Due to the persistence of symptoms and her cognitive profile, imaging follow-up was obtained and the identified lesions confirmed Hypoxic-Ischemic Encephalopathy (HIE).

discussions:HIE can affect multiple parts of the brain, resulting in deficits that are unique to each patient. This variability represents a challenge for rehabilitation teams, especially when dealing with patients with severe communication deficits. An interdisciplinary team approach allows for a greater understanding of a patient's weaknesses and strengths and spreads communication, allowing for a personalized treatment plan that is best suited to a patient's unique needs.

Conclusions:HIE can have a complex and variable clinical presentation and is therefore best evaluated and managed by an interdisciplinary team of rehabilitation professionals to maximize functional patient outcomes.

Providing medical care to triathletes at the 2005 International Triathlon Union Age Group Triathlon World Championships in Honolulu, Hawaii

John S. Georgy, MD, MBA; Lawrence Lai, MD, MS; Dr. A.S. Jeffrey Shilt

Diagnosis of the case:Care provided to US athletes during the 2005 International Triathlon Union (ITU) Age Triathlon World Championships in Honolulu, Hawaii.

Case description:This study determined the rate and extent of medical problems experienced by triathletes prior to competing in the 2005 Short Track Age Triathlon World Championships in Honolulu, Hawaii. Unlike previous studies, this report examined non-emergent medical issues that plague triathletes immediately before the race rather than during the race. This study included a review of all non-emergent medical problems for which the United States of America Triathlon (USAT) medical team provided care to 554 (327 men and 227 women) triathletes at the Group Triathlon World Championships. Age 2005 in Honolulu. , Hawaii before the event. This will better prepare healthcare providers and career managers to report the need for healthcare and management.

discussions:Musculoskeletal injuries are the most studied health problems among triathletes. The reported incidence of musculoskeletal injuries in this group ranges from 47% to 50%. Studies have found that factors associated with increased risk of overuse injuries in triathletes were more years of experience, longer training distances, previous injury history, and poor warm-up and cool-down periods. In contrast, age and gender do not appear to be risk factors for triathlon injuries.

Conclusions:Around a sixth of the triathletes had some medical problems before the race. Musculoskeletal injuries were the most common complaint, and more than two-thirds of the medical problems were chronic. Most received chiropractor treatments. Knowing the types of injuries prior to the race will help medical providers and the race director determine the equipment and personnel needed to care for triathletes.

Early Medical Alert System for the Rehabilitation of Acute Hospitalized Patients - Design and Implementation Process

Dr. Jessica Justmann; Rucha Kharod, MD; Jeremy Hartman, MD; dr. Prateek Grover, Doctor of Medicine; Valleck Angela; dr. david carr

We describe a quality improvement (QI) process that has been implemented at our center to address acute care transfer (ACT) rates. ACTs are common in rehab centers, with a national rate of 11%, and result in lost therapy time, increased medical costs, and lost hospital reimbursement for ACT occurring within 30 days of admission and stress for patients and families. With the increasing acuity of patients admitted to our center from our tertiary referral hospital, we have an above average ACT rate of 14%. To address this, we implemented a Medical Early Warning System (MEWS) tool to identify patients most at risk for ACT, to enable early identification and possible stabilization of their emerging acute medical conditions. An extensive literature review of MEWS was conducted showing some possible efficacy in acute care hospitals, and multi-group discussions were conducted by our Acute Rehabilitation Institutional QI Committee to identify vital sign parameters. and the patient's symptoms that can be highly associated with an ACT. These parameters were used to create a paper MEWS tool, in which (0–2) points are awarded for changes in vital signs, depending on the abnormality, and (1–2) points are added for symptoms associated with the patient, such as decreased oral intake, weight change, increased restlessness or weakness. The MEWS tool is activated when nursing supervisors identify abnormal EMR vital sign parameters for the entire rehab floor or nurses use the tool at the point of care. Higher MEWS point totals result in additional nursing actions, including notification of supervisor and medical staff, closer follow-up of the patient, and possible involvement of a hospitalist. Ongoing work includes evaluating the feasibility of successfully implementing the MEWS tool. Future work will focus on studying the impact of the tool on ACT rates.

Drug Prescribing Patterns in a Concussion Cohort by Category and Time Course

Marline Sangli, MD; Richard D. Wilson, MD; Kevin G. Vargo, Bachelor of Science; Mary M. Vargo, MD

Goals.To examine medication prescribing patterns and associated factors in patients seen at a physiatric concussion clinic.

Project:Retrospective study of 262 patients who received physiatric treatment for concussion at an academic medical center. Medications were evaluated individually and by category (pain, sleep, antidepressant/anxiolytic, antiemetic, antivertigo, benzodiazepines, antipsychotics, stimulants, and therapeutic injection), collected throughout each patient's treatment, up to a maximum of 10 outpatient visits. Data collected at the time of the initial visit included age, gender, time since injury, Sports Concussion Assessment Tool 2 (SCAT2) symptom score, whether hospitalized, related to the job, the type of insurance, the mechanism of injury and the presence of psychiatric and cognitive problems. /learning history, concussion or migraine diagnoses.

Main outcome measures: 1) Frequency of prescriptions for each drug category, in total and over time. 2) Factors associated with the prescription of medications.

Results:The majority (57.6%) of the patients received prescribed medication. Analgesics were the most frequently prescribed category (38.5%), followed by sleeping pills (31.3%) and antidepressants/anxiolytics (17.6%). An assessment of the prescribing at each visit revealed that analgesics and sedatives were prescribed more frequently at the first visit, and new prescriptions decreased at each subsequent visit. Univariate analysis revealed that the following variables were significantly (p≤0.05) associated with the prescription of at least one medication: higher SCAT2 symptom score, female gender, older age, longer time since injury, type of insurance, history migraine and psychiatric history. After multivariable logistic regression analysis, the highest SCAT2 symptom score and female gender remained significant.

Conclusions:Most of the patients received a prescription for at least one medication. Pain relievers were prescribed more frequently. Higher SCAT2 symptom score and female gender were associated with medication prescription after concussion. The findings of this study provide clinicians with the spectrum of potential medication management needs in the course of concussion recovery. A possible future study could incorporate data from other institutions.

Review of risks and fractures of osteoporosis induced by methadone and heroin

Joseph Rabbi, MD; Zeina Rabbi, MD; Dr. A.S. Michael Koniuch

Diagnosis of the case:Opioid-induced osteoporosis.

Case description:A 46-year-old woman with a history of heroin abuse for decades who is enrolled in a methadone clinic presented to the hospital with pain in her left hip. She was walking regularly and her leg gave way, causing severe pain in her hip. She denied a history of trauma, smoking or alcoholism. In the emergency department, she had an X-ray that showed an intertrochanteric fracture and osteopenic changes of the femur. Her evaluation included a level of TSH, iron, ferritin, calcium, magnesium, and PTH that was within normal limits. She had a vitamin D level of 11 ng/mL. In the subsequent history, it was noted that she has oligomenorrhea. She ended up having a screw placed for her hip fracture and she had an outpatient DEXA which confirmed osteoporosis. Given all of her normal work, she blamed herself as the suspect for decades of heroin and methadone use that caused osteoporosis, leading to a fragility fracture.

The patient was able to complete acute rehabilitation without complications. Further therapeutic work for the patient included weaning from methadone, vitamin D supplementation, and consideration of a future bisphosphonate with repeat DEXA scans.

discussions:With the increased use of opioids for chronic pain, the incidence of opioid-induced osteoporosis is increasing. Opioid-induced osteoporosis is beginning to become a known cause of fractures. Opioids can lower estrogen, which can lead to osteoporosis. Opioids can also interfere with bone formation independent of hormonal changes, as opioids decrease serum osteocalcin levels in patients using opioids. Furthermore, opioid receptors on osteoblasts inhibit osteocalcin formation. Opioids can affect the hypothalamic-pituitary-adrenal and gonadal tracts, leading to opioid endocrinopathy. Symptoms that may be seen in opioid endocrinopathy include amenorrhea/oligomenorrhea, nausea, vomiting, weakness, hypotension, and fatigue.

Conclusions:Opioid-induced osteoporosis should be suspected in patients taking high doses of opioids for a long period of time. Physiatrists should be aware of this side effect. Further studies are needed to determine which opioids are most likely to cause opioid-induced osteoporosis and whether