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Evaluation of Diaphragm Dysfunction in a Patient with Dyspnea: A Case Report
PM&R
Case Description: We present a case series of 3 patients with severe, non-traumatic rotator cuff arthropathy, who were not responsive to conservative pharmacological treatment, occupational therapy, and were either not amenable to orthopedic surgical interventions or declined by patients. Each of these patients also had contraindications to use of repeated corticosteroid injections (for example, further risk of rotator cuff atrophy, worsening tendinopathy, rupture or delayed pressure ulcer wound healing and increased risk for infection in a spinal cord injury patient). Setting: Musculoskeletal outpatient clinic. Results or Clinical Course: After a series of 3 to 5 hyaluronic acid ultrasound-guided glenohumeral joint injections, each patient reported near complete resolution of their chronic shoulder pain and gained greater range of motion, tolerance to occupational therapy, and improved activities of daily living. Discussion: The existing literature for viscosupplementation for chronic shoulder pain secondary to shoulder osteoarthritis has been encouraging, but inconclusive. Moreover, there is limited data on the effect of hyaluronic acid on patients who have severe arthropathy with complete, full thickness rotator cuff tears. Conclusions: Viscosupplementation is a viable treatment option and adjunct for patients with chronic rotator cuff arthropathy who are not surgical candidates, decline surgery, or have pain refractory to traditional conservative measures. Poster 220 Evaluation of Diaphragm Dysfunction in a Patient with Dyspnea: A Case Report. Ravi A. Patel, MD (UMDNJ-NJMS, Newark, NJ, United States); Jeffrey Cole, MD. Disclosures: R. A. Patel, No Disclosures: I Have Nothing To Disclose. Case Description: A 63-year-old woman with history of breast cancer, hypertension, and sleep apnea presented to the emergency room for difficulty with breathing. Chest x-ray showed elevation of the right hemidiaphragm. Spiral CT and stress test revealed no evidence of pulmonary embolus or myocardial ischemia, respectively. Sniff test showed an elevated right diaphragm with decreased amplitude motion. MRI C-spine showed degenerative changes and C4-C5 central disk herniation. After discharge, she was referred to us for evaluation of diaphragm dysfunction. Setting: Outpatient physiatric clinic. Results or Clinical Course: During review of systems, she complained of difficulty with sneezing but denied numbness, tingling, or difficulty swallowing. Physical examination revealed 5/5 strength with intact sensation in all four extremities. Chest auscultation was significant for diminished breath sounds at the right lower lobe. Electromyography (EMG) and Nerve Conduction Study (NCS) of the upper extremities, paraspinals, and phrenic nerves including the diaphragm EMG was conducted to localize the injury site. Motor NCS of the phrenic nerves (at Erb’s point) revealed decreased amplitude of diaphragmatic muscle action potentials (right ¼ 0.14mV, left ¼ 0.17mV). In addition, the EMG was significant for denervation changes in C4, C5 paraspinals and polyphasic potentials in right and left diaphragm. The results correlate with bilateral phrenic nerve chronic axonal and demyelinating injuries, right more than left, that most likely represent
Vol. 5, Iss. 9S, 2013
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asymmetrical re-organizational changes from a chronic polyradicular injury. Discussion: Even though rare, dyspnea in a patient with negative cardiopulmonary studies can stem from polyradiculopathy caused by disk herniation. The patient was referred for a surgical evaluation. Conclusions: EMG/NCS results with associated imaging findings proved helpful to determine this unusual cause of dyspnea that will benefit in forming a multi-disciplinary plan for the patient. Poster 221 Variation in Rehabilitation Treatment Patterns for Patients with Hip Fracture Treated with Arthroplasty. Hilary Siebens (Siebens Patient Care Communications, Seal Beach, CA, United States); Phoebe Sharkey, PhD; Harriet U. Aronow, PhD; Susan Horn, PhD; Daniel Deutscher, PT, PhD; Pamela Roberts, PhD, MSHA, OTR/L, CPHQ; Michael C. Munin, MD; Craig Radnay, MD, MPH. Disclosures: H. Siebens, No Disclosures: I Have Nothing To Disclose. Objective: To compare patient and treatment characteristics for three hip fracture rehabilitation subgroups that differ by rate of initial recovery trajectory (IRT). Design: Practice-based evidence multicenter prospective observational cohort study. Univariate and bivariate comparisons of patient and treatment characteristics among 3 groups defined by initial recovery rate from surgery to rehabilitation admission (1¼slow, 2¼fast, 3¼fastest), including measures of medical severity, function, and both exposure and intensity of therapistdocumented treatment activities. Setting: Eighteen skilled nursing (SNF) and inpatient rehabilitation (IRF) facilities. Participants: Patients with hip fractures (N¼226) treated with hip arthroplasty and post-operative inpatient rehabilitation. Interventions: Not applicable. Main Outcome Measures: Types and amount of care processes, including 16 physical (PT) and 28 occupational therapy (OT) activities, reported at the case level. Results or Clinical Course: At admission, Group 1 were oldest, had greater medical acuity, more cognitive impairment, and lower functional status; Group 2 had less medical acuity and higher functional status; Group 3 had the least medical acuity and highest cognitive and functional status. Differences persisted at discharge. Group 3 had the most home discharges and shortest duration of stay. PT and OT therapy activities were not utilized uniformly, ranging from use in 80% or more of patients to less than 20%. Activities involving basic physical functioning were provided more to Group 1; those involving higher functioning more to Group 3. Average minutes per activity per week varied (highest [147 min/wk] to lower [14 min/wk or less]). Relatively few therapy sessions included family. Physician visits and some therapy barriers were least for Group 3. Recommended discharge services were similar across groups with more durable medical equipment recommended for Groups 2 and 3. Conclusions: Three IRT groups of hip fracture patients treated with arthroplasty had meaningful differences in clinical characteristics and some rehabilitation treatments. These groups may be useful to determine treatments associated with better outcomes.
Case Description: We present a case series of 3 patients with severe, non-traumatic rotator cuff arthropathy, who were not responsive to conservative pharmacological treatment, occupational therapy, and were either not amenable to orthopedic surgical interventions or declined by patients. Each of these patients also had contraindications to use of repeated corticosteroid injections (for example, further risk of rotator cuff atrophy, worsening tendinopathy, rupture or delayed pressure ulcer wound healing and increased risk for infection in a spinal cord injury patient). Setting: Musculoskeletal outpatient clinic. Results or Clinical Course: After a series of 3 to 5 hyaluronic acid ultrasound-guided glenohumeral joint injections, each patient reported near complete resolution of their chronic shoulder pain and gained greater range of motion, tolerance to occupational therapy, and improved activities of daily living. Discussion: The existing literature for viscosupplementation for chronic shoulder pain secondary to shoulder osteoarthritis has been encouraging, but inconclusive. Moreover, there is limited data on the effect of hyaluronic acid on patients who have severe arthropathy with complete, full thickness rotator cuff tears. Conclusions: Viscosupplementation is a viable treatment option and adjunct for patients with chronic rotator cuff arthropathy who are not surgical candidates, decline surgery, or have pain refractory to traditional conservative measures. Poster 220 Evaluation of Diaphragm Dysfunction in a Patient with Dyspnea: A Case Report. Ravi A. Patel, MD (UMDNJ-NJMS, Newark, NJ, United States); Jeffrey Cole, MD. Disclosures: R. A. Patel, No Disclosures: I Have Nothing To Disclose. Case Description: A 63-year-old woman with history of breast cancer, hypertension, and sleep apnea presented to the emergency room for difficulty with breathing. Chest x-ray showed elevation of the right hemidiaphragm. Spiral CT and stress test revealed no evidence of pulmonary embolus or myocardial ischemia, respectively. Sniff test showed an elevated right diaphragm with decreased amplitude motion. MRI C-spine showed degenerative changes and C4-C5 central disk herniation. After discharge, she was referred to us for evaluation of diaphragm dysfunction. Setting: Outpatient physiatric clinic. Results or Clinical Course: During review of systems, she complained of difficulty with sneezing but denied numbness, tingling, or difficulty swallowing. Physical examination revealed 5/5 strength with intact sensation in all four extremities. Chest auscultation was significant for diminished breath sounds at the right lower lobe. Electromyography (EMG) and Nerve Conduction Study (NCS) of the upper extremities, paraspinals, and phrenic nerves including the diaphragm EMG was conducted to localize the injury site. Motor NCS of the phrenic nerves (at Erb’s point) revealed decreased amplitude of diaphragmatic muscle action potentials (right ¼ 0.14mV, left ¼ 0.17mV). In addition, the EMG was significant for denervation changes in C4, C5 paraspinals and polyphasic potentials in right and left diaphragm. The results correlate with bilateral phrenic nerve chronic axonal and demyelinating injuries, right more than left, that most likely represent
Vol. 5, Iss. 9S, 2013
S215
asymmetrical re-organizational changes from a chronic polyradicular injury. Discussion: Even though rare, dyspnea in a patient with negative cardiopulmonary studies can stem from polyradiculopathy caused by disk herniation. The patient was referred for a surgical evaluation. Conclusions: EMG/NCS results with associated imaging findings proved helpful to determine this unusual cause of dyspnea that will benefit in forming a multi-disciplinary plan for the patient. Poster 221 Variation in Rehabilitation Treatment Patterns for Patients with Hip Fracture Treated with Arthroplasty. Hilary Siebens (Siebens Patient Care Communications, Seal Beach, CA, United States); Phoebe Sharkey, PhD; Harriet U. Aronow, PhD; Susan Horn, PhD; Daniel Deutscher, PT, PhD; Pamela Roberts, PhD, MSHA, OTR/L, CPHQ; Michael C. Munin, MD; Craig Radnay, MD, MPH. Disclosures: H. Siebens, No Disclosures: I Have Nothing To Disclose. Objective: To compare patient and treatment characteristics for three hip fracture rehabilitation subgroups that differ by rate of initial recovery trajectory (IRT). Design: Practice-based evidence multicenter prospective observational cohort study. Univariate and bivariate comparisons of patient and treatment characteristics among 3 groups defined by initial recovery rate from surgery to rehabilitation admission (1¼slow, 2¼fast, 3¼fastest), including measures of medical severity, function, and both exposure and intensity of therapistdocumented treatment activities. Setting: Eighteen skilled nursing (SNF) and inpatient rehabilitation (IRF) facilities. Participants: Patients with hip fractures (N¼226) treated with hip arthroplasty and post-operative inpatient rehabilitation. Interventions: Not applicable. Main Outcome Measures: Types and amount of care processes, including 16 physical (PT) and 28 occupational therapy (OT) activities, reported at the case level. Results or Clinical Course: At admission, Group 1 were oldest, had greater medical acuity, more cognitive impairment, and lower functional status; Group 2 had less medical acuity and higher functional status; Group 3 had the least medical acuity and highest cognitive and functional status. Differences persisted at discharge. Group 3 had the most home discharges and shortest duration of stay. PT and OT therapy activities were not utilized uniformly, ranging from use in 80% or more of patients to less than 20%. Activities involving basic physical functioning were provided more to Group 1; those involving higher functioning more to Group 3. Average minutes per activity per week varied (highest [147 min/wk] to lower [14 min/wk or less]). Relatively few therapy sessions included family. Physician visits and some therapy barriers were least for Group 3. Recommended discharge services were similar across groups with more durable medical equipment recommended for Groups 2 and 3. Conclusions: Three IRT groups of hip fracture patients treated with arthroplasty had meaningful differences in clinical characteristics and some rehabilitation treatments. These groups may be useful to determine treatments associated with better outcomes.