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Poster 160: Sjogren's Syndrome Presenting as Bilateral Foot Drop: A Case Report
PM&R
Vol. 1, Iss. 9S, 2009
S173
Conclusions: Participation in ball sports may protect against developing stress fractures, with best results provided by earlier participation over a longer length of time. Menstrual irregularities and shin splints are associated with developing stress fractures. EDI scores are not associated with stress fractures in this population. Ongoing subject recruitment to reach a target population of 300 participants and follow-up data collected on all subjects as part of an ongoing prospective study may result in demonstrating additional relationships between these variables and subsequent development of stress fractures. Keywords: Rehabilitation, Stress fractures, Running.
over time (36% at 12 months). As compared to baseline (80%), analgesic usage decreased nominally over time showing significant decreases at 6 months (33%, McNemar’s P ⫽ 00253) and increased slightly at 12 months (45%). Conclusions: VS for lumbar FJA with Hyalan GF-20 appears to be safe and shows modest efficacy that predominately lasts up to 6 months. Limitations include a small sample size and lack of both a control and blinding. Larger, randomized controlled, studies are indicated to better clarify its clinical safety, efficacy and utility. Keywords: Rehabilitation, Viscosupplementation, Facet joint, Zygapophyseal joint.
Poster 159
Poster 160
Safety and Efficacy of Viscosupplementation for the Treatment of Symptomatic Lumbar Facet Joint Arthropathy: A 12-Month Prospective Cohort Pilot Study. Michael J. DePalma, MD (Virginia Commonwealth University, Richmond, VA); Jessica M. Ketchum, PhD; Lane C. Peterson, DO; Evan D. Queler, MD; Brian Trussell, MD.
Sjogren’s Syndrome Presenting as Bilateral Foot Drop: A Case Report. Kevin Kohan, DO (Montefiore Hospiral/AECOM, Bronx, NY); Andrei Dokukin, MD; Roberta Seidman, MD; Sayed Emal Wahezi, MD.
Disclosures: M. J. DePalma, Stryker, Kyphon/Medtronic, AOI Medical,Consulting fees or other remuneration; Pfizer, Lilly, ANS, Speakers bureau; Genzyme Biosurgery, Research grants. Objective: Assess the safety and efficacy of viscosupplementation (VS) for symptomatic lumbar facet joint arthropathy (FJA). Design: Prospective, uncontrolled, pilot study. Setting: University spine center. Participants: 15 patients (12 females), mean age of 57 years (standard deviation ⫽ 12.5), with a median duration of low back pain of 24 months (interquartile range ⫽ 11 to 66). Interventions: Patients who fulfilled inclusion criteria underwent local comparative anesthetic diagnostic block injections at 1 unilateral facet joint (FJ). Those with a true positive response underwent 2 1.0-mL intra-articular Hylan GF-20 injections, 10 days apart, into the painful FJ. A 3rd Hylan GF-20 injection was offered to patients dissatisfied with the results obtained with the 1st 2 injections. Main Outcome Measures: Visual analog scale (VAS) (average, standing, walking), Oswestry Disability Index (ODI), SF-36, finger to floor distance (FTF), standing, sitting, and walking tolerance, analgesic usage, and patient satisfaction collected at baseline, 7-10 days, and at 1, 3, 6, and 12 months follow-up (FU). Results: Mixed-model ANOVAs indicated that VAS (average, standing, walking [P ⫽ .005]), ODI (P ⫽ .026), SF-36 (P ⫽ .013), FTF (P ⫽ .032), and sitting tolerance (P ⫽ .020) all showed significant changes up to 6 months and were not sustained at 12 months; with the exception of FTF (baseline to 12 months difference ⫽ 10.2, 95% CI ⫽ 1.1, 19.3). There was no evidence of changes over time in standing (P ⫽ .085) or walking (P ⫽ .084) tolerance. Satisfaction initially increased from baseline (0%) to 7/10 days (64%) but declined
Disclosures: K. Kohan, None. Patients or Programs: A 60-year-old woman with history of hypertension presented with acute onset of bilateral foot weakness and pain. Program Description: Hospital Course: Patient was admitted to the hospital with a chief complaint of dysesthesias in bilateral lower extremities of 1-week duration. Six days after clearing an upper respiratory tract infection, she described 5 days of progressive pain and numbness in both feet, followed by acute onset of foot drop. On physical examination her manual muscle testing showed bilateral ankle strength of 0/5, and proximal muscle strength of 4/5. Her ankle reflexes were absent, and there was loss of proprioception, vibration, and sensation to light touch and pin prick from the knees down. Imaging of her neuro-axis was unremarkable. A lumbar puncture revealed elevated protein, and electrodiagnostic tests demonstrated an acute severe demyelinating polyneuropathy. Initially, there was a high suspicion for a diagnosis of Guillain-Barre syndrome (GBS), that was challenged by further complaints of symmetrical arthalgias and mild dry eyes. A rheumatological work-up was performed and Anti-SSA/Ro antibodies were positive, suggesting Sjogren’s syndrome (SS). Setting: Tertiary care hospital. Results: Repeat electrodiagnostic studies showed conversion to axonal greater than myelin polyneuropathy. Subsequent biopsy of the sural nerve demonstrated fibrinoid necrosis and chronic arteritis in the epineurial arteries. These findings were consistent with a diagnosis of vasculitic neuropathy (VP). The patient was treated with prednisone and azathioprine with improvement of pain and strenght. Her foot drop was treated with ankle-foot orthosis, and with the combination of inpatient rehabilitation, she regained the ability to ambulate independently on discharge. Discussion: SS may cause inflammatory occlusion and secondary infarction of vasa vasorum leading to VP. Clinically, this presents as mononeuritis multiplex. We report an un-
S174
usual case of Sjogren’s polyneuropathy presenting as acute bilateral foot drop and resembling GBS. Conclusions: VP should be considered as a differential diagnosis in a patient with bilateral foot drop. SS and secondary VP can mimic GBS. Keywords: Rehabilitation, Foot drop, Sjogren’s syndrome, Distal symmetrical.
Poster 161 Slipped Capital Femoral Epiphysis in a Child with Developmental Coordination Delay: A Case Report. Kimberly Sackheim, DO (Mount Sinai Hospital, New York, NY); Jaishree Capoor, MD, FAAP; Arta Lahiji, MD. Disclosures: K. Sackheim, None. Patients or Programs: A 13-year-old boy with developmental coordination disorder (DCD). Program Description: A 13-year-old obese boy with history of DCD and prematurity was evaluated at an outpatient pediatric neuromuscular clinic. He had an atypical presentation complaining of a 2-month history of low back pain that radiated into his left thigh. Examination revealed an obese male with bilateral equinovarus posture and a new left lurch. Hip flexor strength had decreased 1 grade bilaterally from prior examination 3 months ago. Radiographs were obtained which showed a left SCFE. Because it was important to treat this as an orthopedic emergency to ensure non-weight bearing as soon as possible his parents were immediately contacted to bring him to the emergency department for further evaluation. His was admitted to the hospital and underwent left hip pinning that same day. Setting: Outpatient pediatric neuromuscular clinic. Results: 13 year-old boy with DCD and prematurity diagnosed with slipped capital epiphysis. Discussion: Children with DCD experience chronic pain, weakness, decreased endurance and impaired flexibility. DCD is a mulitisymptom syndrome that can masquerade and hinder proper diagnosis of other underlying problems. Slipped capital femoral epiphysis or SCFE is a common hip disorder that occurs in adolescents. It is known to be associated with trauma and obesity and presents with hip/knee pain, limp, and painful range of motion. There is increased incidence of DCD in premature children, and children with DCD are at higher risk for being overweight secondary to their inactivity. Close correlations between rising obesity and higher prevalence of painful lower extremity malalignment syndromes, such as SCFE, have been reported. However, there are no prior case reports in which DCD co-exists with SCFE. Conclusions: It is already known that prematurity increases a child’s risk of DCD and that DCD can lead to obesity, but no clear correlation between gross motor delay and SCFE has yet been concluded. DCD may mask other diagnoses; therefore, it is important to have an increased index of suspicion. In the end, prematurity leading to DCD
POSTER PRESENTATIONS
may increase the risk for SCFE and other orthopedic complications. Keywords: Rehabilitation, Slipped capital femoral epiphysis, Developmental coordination delay, Prematurity.
Poster 162 Spinal Muscular Atrophy Type II, A Progressive Congenital Muscular Debilitating Condition: A Case Report. Hector A. Miranda, MD (Jackson Memorial Hospital, Miami, FL); Kester Nedd, DO. Disclosures: H. A. Miranda, Jackson Memorial Hospital, Employment Patients or Programs: A 21-year-old Haitian man. Program Description: Case of a 21-year-old Haitian male who has had progressive muscle weakness since early age. His neonatal course was uneventful as well as his mother’s gestational period. He achieved his motor milestones within the normal age range until his mother first noticed his weakness when the patient developed difficulty walking after 18 months of age. The patient would crawl his way around until age 14, after which time he was too weak to do so. He remained bed bound since then. He has no family history of muscular dystrophy. There is no consanguinity between his parents. He had been hospitalized a few times prior to our evaluation due to respiratory compromise, secondary to failure of mucous plug expectoration. He also suffered from chronic back pain, severe kyphoscoliosis and a poor nutritional status. He was consulted to rehabilitation after he was hospitalized for an episode of community-acquired pneumonia. His muscle weakness precluded him from achieving more autonomy in most of his functional independence goals, for which reason his stay in the acute rehabilitation unit was short. Setting: Acute inpatient rehabilitation unit. Results: The patient’s debilitating condition is due to spinal muscular atrophy Type II (SMA-II). His kyphoscoliosis (directly related to his condition) severely compromises his lung vital capacity, putting him at risk of developing secondary pulmonary hypertension and recurrent pulmonary infections. Despite his condition he has thrived in life and is on his way to complete a degree in business management. Discussion: SMA-II is an autosomal recessive condition caused by loss of exons 7 and 8 of the Survival Motor Neuron 1 gene on both alleles. It is a unique kind of muscular dystrophy considering that it spares cognitive function. Nevertheless, strong determination and family support is crucial in order for these patients to thrive socially within their disability. Conclusions: SMA-II is an irreversible progressive muscular debilitating condition that renders patients totally dependent for activities of daily living but doesn’t necessarily preclude them from achieving academic success or a vocation suited to their handicap. Keywords: Rehabilitation, Spinal muscular atrophy.
Vol. 1, Iss. 9S, 2009
S173
Conclusions: Participation in ball sports may protect against developing stress fractures, with best results provided by earlier participation over a longer length of time. Menstrual irregularities and shin splints are associated with developing stress fractures. EDI scores are not associated with stress fractures in this population. Ongoing subject recruitment to reach a target population of 300 participants and follow-up data collected on all subjects as part of an ongoing prospective study may result in demonstrating additional relationships between these variables and subsequent development of stress fractures. Keywords: Rehabilitation, Stress fractures, Running.
over time (36% at 12 months). As compared to baseline (80%), analgesic usage decreased nominally over time showing significant decreases at 6 months (33%, McNemar’s P ⫽ 00253) and increased slightly at 12 months (45%). Conclusions: VS for lumbar FJA with Hyalan GF-20 appears to be safe and shows modest efficacy that predominately lasts up to 6 months. Limitations include a small sample size and lack of both a control and blinding. Larger, randomized controlled, studies are indicated to better clarify its clinical safety, efficacy and utility. Keywords: Rehabilitation, Viscosupplementation, Facet joint, Zygapophyseal joint.
Poster 159
Poster 160
Safety and Efficacy of Viscosupplementation for the Treatment of Symptomatic Lumbar Facet Joint Arthropathy: A 12-Month Prospective Cohort Pilot Study. Michael J. DePalma, MD (Virginia Commonwealth University, Richmond, VA); Jessica M. Ketchum, PhD; Lane C. Peterson, DO; Evan D. Queler, MD; Brian Trussell, MD.
Sjogren’s Syndrome Presenting as Bilateral Foot Drop: A Case Report. Kevin Kohan, DO (Montefiore Hospiral/AECOM, Bronx, NY); Andrei Dokukin, MD; Roberta Seidman, MD; Sayed Emal Wahezi, MD.
Disclosures: M. J. DePalma, Stryker, Kyphon/Medtronic, AOI Medical,Consulting fees or other remuneration; Pfizer, Lilly, ANS, Speakers bureau; Genzyme Biosurgery, Research grants. Objective: Assess the safety and efficacy of viscosupplementation (VS) for symptomatic lumbar facet joint arthropathy (FJA). Design: Prospective, uncontrolled, pilot study. Setting: University spine center. Participants: 15 patients (12 females), mean age of 57 years (standard deviation ⫽ 12.5), with a median duration of low back pain of 24 months (interquartile range ⫽ 11 to 66). Interventions: Patients who fulfilled inclusion criteria underwent local comparative anesthetic diagnostic block injections at 1 unilateral facet joint (FJ). Those with a true positive response underwent 2 1.0-mL intra-articular Hylan GF-20 injections, 10 days apart, into the painful FJ. A 3rd Hylan GF-20 injection was offered to patients dissatisfied with the results obtained with the 1st 2 injections. Main Outcome Measures: Visual analog scale (VAS) (average, standing, walking), Oswestry Disability Index (ODI), SF-36, finger to floor distance (FTF), standing, sitting, and walking tolerance, analgesic usage, and patient satisfaction collected at baseline, 7-10 days, and at 1, 3, 6, and 12 months follow-up (FU). Results: Mixed-model ANOVAs indicated that VAS (average, standing, walking [P ⫽ .005]), ODI (P ⫽ .026), SF-36 (P ⫽ .013), FTF (P ⫽ .032), and sitting tolerance (P ⫽ .020) all showed significant changes up to 6 months and were not sustained at 12 months; with the exception of FTF (baseline to 12 months difference ⫽ 10.2, 95% CI ⫽ 1.1, 19.3). There was no evidence of changes over time in standing (P ⫽ .085) or walking (P ⫽ .084) tolerance. Satisfaction initially increased from baseline (0%) to 7/10 days (64%) but declined
Disclosures: K. Kohan, None. Patients or Programs: A 60-year-old woman with history of hypertension presented with acute onset of bilateral foot weakness and pain. Program Description: Hospital Course: Patient was admitted to the hospital with a chief complaint of dysesthesias in bilateral lower extremities of 1-week duration. Six days after clearing an upper respiratory tract infection, she described 5 days of progressive pain and numbness in both feet, followed by acute onset of foot drop. On physical examination her manual muscle testing showed bilateral ankle strength of 0/5, and proximal muscle strength of 4/5. Her ankle reflexes were absent, and there was loss of proprioception, vibration, and sensation to light touch and pin prick from the knees down. Imaging of her neuro-axis was unremarkable. A lumbar puncture revealed elevated protein, and electrodiagnostic tests demonstrated an acute severe demyelinating polyneuropathy. Initially, there was a high suspicion for a diagnosis of Guillain-Barre syndrome (GBS), that was challenged by further complaints of symmetrical arthalgias and mild dry eyes. A rheumatological work-up was performed and Anti-SSA/Ro antibodies were positive, suggesting Sjogren’s syndrome (SS). Setting: Tertiary care hospital. Results: Repeat electrodiagnostic studies showed conversion to axonal greater than myelin polyneuropathy. Subsequent biopsy of the sural nerve demonstrated fibrinoid necrosis and chronic arteritis in the epineurial arteries. These findings were consistent with a diagnosis of vasculitic neuropathy (VP). The patient was treated with prednisone and azathioprine with improvement of pain and strenght. Her foot drop was treated with ankle-foot orthosis, and with the combination of inpatient rehabilitation, she regained the ability to ambulate independently on discharge. Discussion: SS may cause inflammatory occlusion and secondary infarction of vasa vasorum leading to VP. Clinically, this presents as mononeuritis multiplex. We report an un-
S174
usual case of Sjogren’s polyneuropathy presenting as acute bilateral foot drop and resembling GBS. Conclusions: VP should be considered as a differential diagnosis in a patient with bilateral foot drop. SS and secondary VP can mimic GBS. Keywords: Rehabilitation, Foot drop, Sjogren’s syndrome, Distal symmetrical.
Poster 161 Slipped Capital Femoral Epiphysis in a Child with Developmental Coordination Delay: A Case Report. Kimberly Sackheim, DO (Mount Sinai Hospital, New York, NY); Jaishree Capoor, MD, FAAP; Arta Lahiji, MD. Disclosures: K. Sackheim, None. Patients or Programs: A 13-year-old boy with developmental coordination disorder (DCD). Program Description: A 13-year-old obese boy with history of DCD and prematurity was evaluated at an outpatient pediatric neuromuscular clinic. He had an atypical presentation complaining of a 2-month history of low back pain that radiated into his left thigh. Examination revealed an obese male with bilateral equinovarus posture and a new left lurch. Hip flexor strength had decreased 1 grade bilaterally from prior examination 3 months ago. Radiographs were obtained which showed a left SCFE. Because it was important to treat this as an orthopedic emergency to ensure non-weight bearing as soon as possible his parents were immediately contacted to bring him to the emergency department for further evaluation. His was admitted to the hospital and underwent left hip pinning that same day. Setting: Outpatient pediatric neuromuscular clinic. Results: 13 year-old boy with DCD and prematurity diagnosed with slipped capital epiphysis. Discussion: Children with DCD experience chronic pain, weakness, decreased endurance and impaired flexibility. DCD is a mulitisymptom syndrome that can masquerade and hinder proper diagnosis of other underlying problems. Slipped capital femoral epiphysis or SCFE is a common hip disorder that occurs in adolescents. It is known to be associated with trauma and obesity and presents with hip/knee pain, limp, and painful range of motion. There is increased incidence of DCD in premature children, and children with DCD are at higher risk for being overweight secondary to their inactivity. Close correlations between rising obesity and higher prevalence of painful lower extremity malalignment syndromes, such as SCFE, have been reported. However, there are no prior case reports in which DCD co-exists with SCFE. Conclusions: It is already known that prematurity increases a child’s risk of DCD and that DCD can lead to obesity, but no clear correlation between gross motor delay and SCFE has yet been concluded. DCD may mask other diagnoses; therefore, it is important to have an increased index of suspicion. In the end, prematurity leading to DCD
POSTER PRESENTATIONS
may increase the risk for SCFE and other orthopedic complications. Keywords: Rehabilitation, Slipped capital femoral epiphysis, Developmental coordination delay, Prematurity.
Poster 162 Spinal Muscular Atrophy Type II, A Progressive Congenital Muscular Debilitating Condition: A Case Report. Hector A. Miranda, MD (Jackson Memorial Hospital, Miami, FL); Kester Nedd, DO. Disclosures: H. A. Miranda, Jackson Memorial Hospital, Employment Patients or Programs: A 21-year-old Haitian man. Program Description: Case of a 21-year-old Haitian male who has had progressive muscle weakness since early age. His neonatal course was uneventful as well as his mother’s gestational period. He achieved his motor milestones within the normal age range until his mother first noticed his weakness when the patient developed difficulty walking after 18 months of age. The patient would crawl his way around until age 14, after which time he was too weak to do so. He remained bed bound since then. He has no family history of muscular dystrophy. There is no consanguinity between his parents. He had been hospitalized a few times prior to our evaluation due to respiratory compromise, secondary to failure of mucous plug expectoration. He also suffered from chronic back pain, severe kyphoscoliosis and a poor nutritional status. He was consulted to rehabilitation after he was hospitalized for an episode of community-acquired pneumonia. His muscle weakness precluded him from achieving more autonomy in most of his functional independence goals, for which reason his stay in the acute rehabilitation unit was short. Setting: Acute inpatient rehabilitation unit. Results: The patient’s debilitating condition is due to spinal muscular atrophy Type II (SMA-II). His kyphoscoliosis (directly related to his condition) severely compromises his lung vital capacity, putting him at risk of developing secondary pulmonary hypertension and recurrent pulmonary infections. Despite his condition he has thrived in life and is on his way to complete a degree in business management. Discussion: SMA-II is an autosomal recessive condition caused by loss of exons 7 and 8 of the Survival Motor Neuron 1 gene on both alleles. It is a unique kind of muscular dystrophy considering that it spares cognitive function. Nevertheless, strong determination and family support is crucial in order for these patients to thrive socially within their disability. Conclusions: SMA-II is an irreversible progressive muscular debilitating condition that renders patients totally dependent for activities of daily living but doesn’t necessarily preclude them from achieving academic success or a vocation suited to their handicap. Keywords: Rehabilitation, Spinal muscular atrophy.