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Poster 142 Rehabilitation for Landau-Kleffner syndrome: A case report
1068
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Van Nes rotationplasty and replantation was used following traumatic amputation. In this patient, the proximal femur and proximal tibia were osteosynthesized with 1800 of rotation so that the calcaneus was anterior and the ankle was aligned slightly below the contralateral knee, anticipating alignment with the knee with future growth. Coaptations of the femoral nerve to the tibial nerve and of the sciatic nerve to the peroneal nerve were performed; vascular anastomosis was done between the superficial femoral artery and the popliteal artery. During acute rehabilitation, the patient lacked motor control of his ankle and remained insensate distal to the rotationplasty. Nonetheless, after adequate wound healing, he was able to ambulate with a modified Van Nes prosthesis with a locked knee. Limb function gradually improved subsequently so that, by eight months postoperatively, strength was greater than antigravity in ankle dorsiflexion and plantarflexion, sensation was present, including proprioception, and the patient was ambulating with the knee lock removed from the prosthesis and no assistive devices. Knee range of motion in the prosthesis was from full extension (ankle plantar-flexion 60 °) to 75 ° of flexion (anNe dorsiflexion 15°). Use of the modified Van Nes rotationplasty and replantation in our patient resulted in conversion of a high above knee level of amputation to a functional below knee level. This procedure can result in good rehabilitation outcome when applied to traumatic amputation.
Poster 142 "Rehabilitation for Landau-Kleffner Syndrome: A Case Report." Mark E. Huang, MD (Rehabilitation Institute of Chicago, Chicago, IL); Lisa S. Godbold, MD. Landau-Kleffner Syndrome is a rare disorder characterized by acquired aphasia with temporal lobe epilepsy. Little has been published in the literature concerning rehabilitation for these patients. We discuss a case of a 7-year-old boy with Landau-Kleffner syndrome who was admitted to our rehabilitation hospital following a subpial transection to treat his temporal lobe epilepsy. On admission, he presented with a severe receptive and expressive aphasia. His oral expression was limited to the word "key," he understood a few basic signs, and inconsistently followed one-step commands. He also had hypotonocity, impulsivity, distractibility, and decreased safety awareness in ambulation and mobility. He underwent a rehabilitation program consisting of sensory integration and behavioral modification techniques with an emphasis on verbal and nonverbal forms of communication. After 6 weeks, he was able to use 10 to 12 words to appropriately express himself verbally and was following one-step directions. He showed increased consistency and accuracy of head nodding as well as increased safety with ambulation in distracting environments. Discussion of the case includes the clinical features, diagnosis, treatment, and natural progression of this disorder. In addition the rehabilitation plan and goals used to maximize functional outcome for this unusual disorder are addressed.
Pharmacology Poster 143 "Tremor Exacerbation in a Patient with Chronic Lithium Toxicity." Aubrey Ku, MD (The New York Hospital-Cornell Medical Center, New York, NY); Elisabeth A. Lachmann, MD; Willibaid Nagler, MD. Chronic neurological symptoms from lithium toxicity are not well recognized. We report a 57-year-old bipolar patient, wheelchair-bound as a result of lithium toxicity 20 years ago, who experienced worsening tremor for 1 month. He had been maintained on therapeutic dosage of prozac, lithium, and stellazine. One month before admission, he was started on klonopin for better tremor control, which resulted in increased spontaneous movements of his limbs. He could no longer independently transfer in and out his wheelchair or self-feed. The klonopin was slowly tapered; however, 2 days after the patient was off the medication, he exhibited increased limb movements with rhythmic, rabbit-like movement of his mouth. MRI showed marked atrophy of cerebellum and vermis. His symptoms improved on beta-blocker, stellazine, and prozac taper, and physical and occupational therapy. A combination of benzodiazepine withdrawal and phenothiazine toxicity probably caused the exacerbation of his baseline tremor. Clinically evident cerebellar damage from lithium toxicity for 20 years has not been previously documented. We wish to alert physiatrists to this rare entity and the need to exercise
Arch Phys Med Rehabil Vol 76, November 1995
caution when using benzodiazepine and phenothiazine in patients with chronic neurological dysfunction from lithium toxicity.
Poster 144 "Improvement of Post-Traumatic Agitation Associated with Withdrawal of Propranolol." Anand Joshi, MD (Baylor College of Medicine, Houston, TX); Stuart A. Yablon, MD; Cindy H. Ivanhoe, MD; Bernard V. Silver, PhD. Propranolol has been used effectively in the treatment of agitation among patients with traumatic brain injury (TBI). We present a case in which the withdrawal of propranolol resulted in dramatic improvement of agitation. A 44-year-old man with TBI recovered considerably until he developed bifrontal subdural hematomas which required surgical evacuation 5 months after the initial injury. Following drainage, the patient was combative and verbally abusive. During a 1-week period of observation 7 months after injury, his Agitated Behavior Scale (ABS) (potential range from 14 to 56) had a mean value of 35.2 based on 29 recordings by the clinical staff. The addition of propranolol to a maximum dose of 460 mg per day did not produce significant modification of behavior, but during the 2-week period of withdrawal (9 months postinjury), substantial improvement of behavior was noted, corresponding with a mean ABS score of 20.78 based on 23 observations. This report suggests that the administration of propranolol to reduce agitation can produce paradoxical behavioral effects which resolve upon discontinuation of the drug. A propranolol trial for patients with TBI who have agitation should be halted if improvement does not occur.
Poster 145 "Spontaneous Bladder Rupture in Association with the Use of Oxybutynin Chloride: A Case Report." Kathleen Fink, MD (Rehabilitation Institute of Chicago, Chicago, IL); Denise A. Walsh-McMonagle, MD. Oxybutynin chloride is a well established treatment for uninhibited, neurogenic bladder. The drug decreases symptoms of frequency, urgency, and incontinence through its anesthetic, antispasmodic and anticholinergic effects. Frequently noted side effects include urinary retention, dry mouth, flushing, itching, and abdominal complaints. Rarely reported adverse effects include increased bladder spasms and urinary obstruction. Another potential and serious side effect that has not been reported is spontaneous bladder rupture. A review of the action, side effects, and uses of oxybutynin chloride will be presented, as well as a case that uniquely illustrates spontaneous bladder rupture associated with its use. We present a 66-year-old woman with a history of chronic spastic paraparesis with complaints of urgency and frequency, treated with oxybutynin chloride. Within days, she presented with hematuria, abdominal pain, fever, chills, and, subsequently, with acute peritonitis and septic shock. Exploratory laparotomy revealed a hemorrhagic necrotic ruptured bladder, necessitating repair and suprapubic cystostomy. This is the only reported case of spontaneous, atraumatic bladder rupture associated with oxybutynin chloride. Accurate diagnosis of bladder pathology and identification of risk factors for bladder rupture may aid in the appropriate and safe prescription of oxybutynin chloride.
Poster 146 "Venous Thromboembolism in Association with Cancer (Trousseau's Syndrome): The Role of Low-Molecular-Weight Heparin." Denise A. Walsh-McMonagle, MD (Rehabilitation Institute of Chicago, Chicago, IL); David Green, MD, PhD. Migratory venous thromboembolism associated with malignancy, as first described by Trousseau in 1865, remains a major cause of morbidity and mortality in approximately 15% of patients with cancer. Thromboembolism not responsive to warfarin frequently predates the diagnosis of cancer, making Trousseau's syndrome both a diagnostic and treatment dilemma, often with ominous prognosis. We review the literature and cases of four patients with unusual presentations of thromboembolism, newly diagnosed malignancy, and their successful treatment with enoxaparin, a low-molecular-weight heparin (LMWH). The first patient presented with cerulea phlegmasia dolens, shortly following diagnosis of ovarian cancer. The second patient presented with recurrent pulmonary embolism, recalcitrant to warfarin therapy, in the setting of adenocarcinoma of the lung. A third patient presented with superior vena cava syndrome, pulmonary embolism, and metastatic carcinoid. The fourth patient presented with multiple strokes, developed bilateral deep vein
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Van Nes rotationplasty and replantation was used following traumatic amputation. In this patient, the proximal femur and proximal tibia were osteosynthesized with 1800 of rotation so that the calcaneus was anterior and the ankle was aligned slightly below the contralateral knee, anticipating alignment with the knee with future growth. Coaptations of the femoral nerve to the tibial nerve and of the sciatic nerve to the peroneal nerve were performed; vascular anastomosis was done between the superficial femoral artery and the popliteal artery. During acute rehabilitation, the patient lacked motor control of his ankle and remained insensate distal to the rotationplasty. Nonetheless, after adequate wound healing, he was able to ambulate with a modified Van Nes prosthesis with a locked knee. Limb function gradually improved subsequently so that, by eight months postoperatively, strength was greater than antigravity in ankle dorsiflexion and plantarflexion, sensation was present, including proprioception, and the patient was ambulating with the knee lock removed from the prosthesis and no assistive devices. Knee range of motion in the prosthesis was from full extension (ankle plantar-flexion 60 °) to 75 ° of flexion (anNe dorsiflexion 15°). Use of the modified Van Nes rotationplasty and replantation in our patient resulted in conversion of a high above knee level of amputation to a functional below knee level. This procedure can result in good rehabilitation outcome when applied to traumatic amputation.
Poster 142 "Rehabilitation for Landau-Kleffner Syndrome: A Case Report." Mark E. Huang, MD (Rehabilitation Institute of Chicago, Chicago, IL); Lisa S. Godbold, MD. Landau-Kleffner Syndrome is a rare disorder characterized by acquired aphasia with temporal lobe epilepsy. Little has been published in the literature concerning rehabilitation for these patients. We discuss a case of a 7-year-old boy with Landau-Kleffner syndrome who was admitted to our rehabilitation hospital following a subpial transection to treat his temporal lobe epilepsy. On admission, he presented with a severe receptive and expressive aphasia. His oral expression was limited to the word "key," he understood a few basic signs, and inconsistently followed one-step commands. He also had hypotonocity, impulsivity, distractibility, and decreased safety awareness in ambulation and mobility. He underwent a rehabilitation program consisting of sensory integration and behavioral modification techniques with an emphasis on verbal and nonverbal forms of communication. After 6 weeks, he was able to use 10 to 12 words to appropriately express himself verbally and was following one-step directions. He showed increased consistency and accuracy of head nodding as well as increased safety with ambulation in distracting environments. Discussion of the case includes the clinical features, diagnosis, treatment, and natural progression of this disorder. In addition the rehabilitation plan and goals used to maximize functional outcome for this unusual disorder are addressed.
Pharmacology Poster 143 "Tremor Exacerbation in a Patient with Chronic Lithium Toxicity." Aubrey Ku, MD (The New York Hospital-Cornell Medical Center, New York, NY); Elisabeth A. Lachmann, MD; Willibaid Nagler, MD. Chronic neurological symptoms from lithium toxicity are not well recognized. We report a 57-year-old bipolar patient, wheelchair-bound as a result of lithium toxicity 20 years ago, who experienced worsening tremor for 1 month. He had been maintained on therapeutic dosage of prozac, lithium, and stellazine. One month before admission, he was started on klonopin for better tremor control, which resulted in increased spontaneous movements of his limbs. He could no longer independently transfer in and out his wheelchair or self-feed. The klonopin was slowly tapered; however, 2 days after the patient was off the medication, he exhibited increased limb movements with rhythmic, rabbit-like movement of his mouth. MRI showed marked atrophy of cerebellum and vermis. His symptoms improved on beta-blocker, stellazine, and prozac taper, and physical and occupational therapy. A combination of benzodiazepine withdrawal and phenothiazine toxicity probably caused the exacerbation of his baseline tremor. Clinically evident cerebellar damage from lithium toxicity for 20 years has not been previously documented. We wish to alert physiatrists to this rare entity and the need to exercise
Arch Phys Med Rehabil Vol 76, November 1995
caution when using benzodiazepine and phenothiazine in patients with chronic neurological dysfunction from lithium toxicity.
Poster 144 "Improvement of Post-Traumatic Agitation Associated with Withdrawal of Propranolol." Anand Joshi, MD (Baylor College of Medicine, Houston, TX); Stuart A. Yablon, MD; Cindy H. Ivanhoe, MD; Bernard V. Silver, PhD. Propranolol has been used effectively in the treatment of agitation among patients with traumatic brain injury (TBI). We present a case in which the withdrawal of propranolol resulted in dramatic improvement of agitation. A 44-year-old man with TBI recovered considerably until he developed bifrontal subdural hematomas which required surgical evacuation 5 months after the initial injury. Following drainage, the patient was combative and verbally abusive. During a 1-week period of observation 7 months after injury, his Agitated Behavior Scale (ABS) (potential range from 14 to 56) had a mean value of 35.2 based on 29 recordings by the clinical staff. The addition of propranolol to a maximum dose of 460 mg per day did not produce significant modification of behavior, but during the 2-week period of withdrawal (9 months postinjury), substantial improvement of behavior was noted, corresponding with a mean ABS score of 20.78 based on 23 observations. This report suggests that the administration of propranolol to reduce agitation can produce paradoxical behavioral effects which resolve upon discontinuation of the drug. A propranolol trial for patients with TBI who have agitation should be halted if improvement does not occur.
Poster 145 "Spontaneous Bladder Rupture in Association with the Use of Oxybutynin Chloride: A Case Report." Kathleen Fink, MD (Rehabilitation Institute of Chicago, Chicago, IL); Denise A. Walsh-McMonagle, MD. Oxybutynin chloride is a well established treatment for uninhibited, neurogenic bladder. The drug decreases symptoms of frequency, urgency, and incontinence through its anesthetic, antispasmodic and anticholinergic effects. Frequently noted side effects include urinary retention, dry mouth, flushing, itching, and abdominal complaints. Rarely reported adverse effects include increased bladder spasms and urinary obstruction. Another potential and serious side effect that has not been reported is spontaneous bladder rupture. A review of the action, side effects, and uses of oxybutynin chloride will be presented, as well as a case that uniquely illustrates spontaneous bladder rupture associated with its use. We present a 66-year-old woman with a history of chronic spastic paraparesis with complaints of urgency and frequency, treated with oxybutynin chloride. Within days, she presented with hematuria, abdominal pain, fever, chills, and, subsequently, with acute peritonitis and septic shock. Exploratory laparotomy revealed a hemorrhagic necrotic ruptured bladder, necessitating repair and suprapubic cystostomy. This is the only reported case of spontaneous, atraumatic bladder rupture associated with oxybutynin chloride. Accurate diagnosis of bladder pathology and identification of risk factors for bladder rupture may aid in the appropriate and safe prescription of oxybutynin chloride.
Poster 146 "Venous Thromboembolism in Association with Cancer (Trousseau's Syndrome): The Role of Low-Molecular-Weight Heparin." Denise A. Walsh-McMonagle, MD (Rehabilitation Institute of Chicago, Chicago, IL); David Green, MD, PhD. Migratory venous thromboembolism associated with malignancy, as first described by Trousseau in 1865, remains a major cause of morbidity and mortality in approximately 15% of patients with cancer. Thromboembolism not responsive to warfarin frequently predates the diagnosis of cancer, making Trousseau's syndrome both a diagnostic and treatment dilemma, often with ominous prognosis. We review the literature and cases of four patients with unusual presentations of thromboembolism, newly diagnosed malignancy, and their successful treatment with enoxaparin, a low-molecular-weight heparin (LMWH). The first patient presented with cerulea phlegmasia dolens, shortly following diagnosis of ovarian cancer. The second patient presented with recurrent pulmonary embolism, recalcitrant to warfarin therapy, in the setting of adenocarcinoma of the lung. A third patient presented with superior vena cava syndrome, pulmonary embolism, and metastatic carcinoid. The fourth patient presented with multiple strokes, developed bilateral deep vein