- Email: [email protected]
Poster 214: Heroin-induced Femoral Neuropathy and Rehabilitation: A Case Report
S196
Disclosures: A. Gupta, None. Objective: To analyze long-term functional recovery and residual deficits in patients with Guillain-Barre Syndrome (GBS). Design: Prospective longitudinal follow-up study. Setting: Neurological rehabilitation unit of tertiary care hospital. Participants: Forty-one out of 330 patients (12.42%) admitted in the institute were transferred to the neurological rehabilitation unit for inpatient rehabilitation. Twenty-six patients (M:F,14:12) reporting at 1 year follow-up (63.41%) were included in the study (between Sept. 2005-Arpil 2008). Their functional recovery and residual deficits were recorded and analyzed. Interventions: Not applicable. Main Outcome Measures: Modified Barthel Index scores, Modified Rankin Scale and Hughes Disability Scale were used to assess functional disabilities at admission, discharge and follow-up. Results: Age ranged from 4-65 years (29.69 ⫾ 17.19). At admission, 21 patients had typical GBS and 5 had AMAN variant. Eight patients had bulbar weakness, 3 had autonomic dysfunction and 17 had facial palsy (uni/ bilateral). Nineteen patients (73.07%) had neuropathic pain needing medication with 6 requiring more than one drug. Five patients (19.2%) were prescribed wrist cock-up splint (WCS) for wrist drop and 15 patients (57.6%) prescribed ankle-foot orthoses-AFO (13 bilateral AFO) for foot drop. Twenty patients (77%) needed assistive devices also for locomotion at discharge. At 1 year follow-up, wrist drop and foot drop were still present in 1 and 4 patients, respectively, using orthoses. Modified Barthel Index scores, Modified Rankin Scale and Hughes Disability Scale were used to assess functional disabilities. Significant recovery was observed at the time of discharge and after 1 year when compared with discharge scores (P⬍.001 each). Conclusions: GBS patients continue to show significant functional recovery for a long period. They have disability in the form of motor weakness even after 1 year and need to be followed up for longer duration. Keywords: Functional recovery, Guillain Barre syndrome, Inpatient rehabilitation, Residual deficits.
Poster 213 Health and Function Data From an Adult Cerebral Palsy Clinic: Initial Report. Heidi J. Haapala, MD (University of Michigan, Ann Arbor, MI); Margy A. Fox, MS; Edward A. Hurvitz, MD. Disclosures: H. J. Haapala, None. Objective: To describe health and functional status of adults and older adolescents with cerebral palsy enrolled in a specialty clinic. Design: Cross sectional. Setting: Tertiary care center.
POSTER PRESENTATIONS
Participants: 22 individuals (ages 17-53) with cerebral palsy, GMFCS I-V, 16 female. Interventions: Survey, height and weight measures. Main Outcome Measures: BMI, pain (0-10 point scale) and constipation rating scale scores, survey results, vitamin D levels. Results: BMI: 40.9% of the participants were overweight or obese, while 31.8% were underweight. Pain: Best, worst, and average pain over the past 3 months was scored. Worst pain was rated as ⱖ7/10 in 9/12 (75%). Average pain was 0-3/10 in 5 (42%), 4-6/10 in 6 (50%), and ⱖ7/10 in 1 subject. Constipation: for 16 subjects, with 5 (31%) participants scoring ⬎5. Living situation: 12 lived with their parents, 3 in group homes, 1 with an aide, and 5 with roommates or by themselves. Eight of the subjects attended school, 4 worked (including individuals in sheltered living situations), and 10 neither worked nor attended school. Bone Health: As part of an initial screen, vitamin D levels were checked on 10 subjects, with below normal vitamin D levels noted in 8/10 (80%). Mobility: 9 used manual wheelchairs, 4 used power mobility, 1 used both. GMFCS levels: 4 subjects were level 1 or 2, 10 subjects were level 3 and 8 subjects were level 4 or 5. This group was weighted toward GMFCS 3-5, accounting for the higher prevalence of wheelchair use. Conclusions: Vitamin D levels were low in most of the subjects, indicating a need for bone health assessment. Overweight, pain, constipation, depression, nutrition and community involvement should be monitored and addressed to increase function along with tone, mobility and other more commonly described issues in individuals with cerebral palsy. Keywords: Cerebral palsy, Rehabilitation, Adult.
Poster 214 Heroin-induced Femoral Neuropathy and Rehabilitation: A Case Report. Sooyeon Kim, (Montefiore Medical Center, Bronx, NY); Andrzej C. Kroszczynski, MD; Margarita Manahan. Disclosures: S. Kim, None. Patients or Programs: A 43-year-old male heroin abuser. Program Description: We present a 43-year-old otherwise healthy male who developed worsening bilateral lower extremities weakness and numbness for 4 months which started soon after intravenous heroin injection. Physical examination revealed marked atrophy of bilateral quadriceps, 1/5 strength of knee extensor with absent patellar reflexes, normal strength of hip flexor and adductor, along with the pattern of bilateral anteromedial thigh and medial lower leg sensory deficit consistent with bilateral femoral neuropathy or L3-4 nerve root pathology. EMG demonstrated severe bilateral femoral neuropathies with sensory and motor axonal loss. The lesions were distal to the branch supplying the iliopsoas, as this muscle was not affected. There was no evidence of lumbosacral root dysfunction. Laboratory examinations include CPK, autoimmune diseases and infectious
PM&R
tests include HIV were negative or non specific. MRI of lumbosacral plexus includes bilateral thigh was negative. Physical therapy was initiated for quadriceps strengthening and gait training. Setting: Outpatient rehabilitation at a university hospital. Results: Within 2 months, patient showed significant improvement in his quadricep strength which improved from 1/5 to 3/5 and in gait pattern advancing to quad-cane from rolling walker. However, patient’s sensory symptoms remained without any improvement. Discussion: The mechanism of how the neuropathies occur still remains unclear. An immunologic response to or direct toxic effect of heroin has been proposed, as well as nerve or muscle compression secondary to rhabdomyolysis. As of treatment, there are some studies that tried steroid pulse therapy, however, failed to show any improvement. This is the first case report which physical therapy showed significant functional improvement for at the chronic phase of heroin-induced bilateral femoral neuropathy. Conclusions: Even though the pathophysiology is unknown and there is no proven definite treatment recommended, this case showed a significant role of physical therapy in functional improvement. Keywords: Rehabilitation, Femoral neuropathy, Heroin.
Poster 215 Heterotopic Ossification Following TraumaAssociated Amputation: A Case Report. Jung-Woo Ma, MD & Adrian Cristian, MD (The Mount Sinai Medical Center, New York, NY). Jung-Woo Ma, MD (Mount Sinai Medical Center, New York, NY); Adrian Cristian, MD. Disclosures: J. Ma, None. Patients or Programs: A 20-year-old man with traumaassociated amputation. Program Description: The patient sustained a left transtibial amputation secondary to injuries from an improvised explosive device blast in East Baghdad. He underwent left trans-femoral amputation. However, during his post-amputation rehabilitation program, he developed heterotopic ossification (HO) in the lateral to the distal aspect of the left femur. The patient was treated conservatively and was fitted with a prosthesis. He was functioning at a high level with the prosthesis and was able to ambulate without any assistive device for long distances in the community. However, he had a significant weight gain since receiving the initial prosthesis, which was coupled with increasing residual limb pain that significantly limited his function. Setting: A tertiary care Veterans Affairs facility. Results: The residual limb revealed a palpable bony growth and tenderness along the lateral aspect of the left thigh. There was a foul smelling plaque with cerebriform surface and central erythematous erosion along the lateral aspect of the residual limb which covered the HO. The foul smelling plaque was treated with an oral antibiotic and topical antibacterial cream with complete resolution. The patient was
Vol. 1, Iss. 9S, 2009
S197
also fitted with a new socket to accommodate the increased weight gain. The pain with ambulation resolved, and no further episodes of foul smelling rash were reported. Discussion: The prevalence of bone overgrowth after amputation in the adult population is unknown. It has been observed that more soldiers with amputations in Iraq or Afghanistan develop HO than in any other previous wars. Potter et al. try to explain why HO is more common in the current wars when compared to previous wars, including rapid medical intervention, aggressive limb salvage, pulsatile lavage irrigation systems and subatmospheric pressure dressing devices used in the military treatment facilities. Conclusions: Considering the recent increased prevalence of HO in traumatic amputees returning from the wars, HO needs careful consideration when the amputees present with residual limb pain and decreased range of motion. Keywords: Heterotopic ossification, Traumatic amputation, Prosthesis.
Poster 216 Hyperthyroidism Masking as Intrathecal Baclofen Withdrawal: A Case Report. Michael Saulino, Md PhD (Moss Rehab Hospital, Elkins Park, PA); Jeffrey Degen, MD; Kathryn T. Gollotto, DO. Disclosures: M. Saulino, Medtronic, Inc, Speakers bureau. Patients or Programs: A 24-year-old man with spastic tetraplegic cerebral palsy. Program Description: A 24-year-old man with spastic tetraplegic cerebral palsy presented with tachycardia, fever and increased muscle tone following elective replacement of an intrathecal pump. His first intrathecal pump was implanted 5 years prior to presentation. His spasticity was well regulated at 500 mcg per day of intrathecal baclofen. He underwent elective pump replacement for battery replenishment. The postoperative course was initially unremarkable and the patient was discharged home. However, he subsequently returned to the acute care hospital 1 week later with tachycardia, fever and increased muscle tone. The initial clinical impression was intrathecal baclofen withdrawal. Setting: Outpatient clinic and inpatient hospital. Results: Plain radiographs revealed the catheter to be intact and properly placed. Baclofen pump dosing was increased four times without significant improvement in muscle tone. A side port access was subsequently done, with aspiration of spinal fluid suggestive of catheter continuity. Initial assessment for noxious stimuli, such as deep vein thrombosis, urinary tract infection and meningitis was negative. Subsequent laboratory results revealed the patient to be hyperthyroid. He was treated with propylthiouracil and propranolol following which his muscle tone returned to baseline. Discussion: There are many causes of increased tone following intrathecal pump replacement, including catheter dysfuction, noxious stimuli, mechanical failure of the pump, postoperative pain or infection, intrathecal baclofen toler-
Disclosures: A. Gupta, None. Objective: To analyze long-term functional recovery and residual deficits in patients with Guillain-Barre Syndrome (GBS). Design: Prospective longitudinal follow-up study. Setting: Neurological rehabilitation unit of tertiary care hospital. Participants: Forty-one out of 330 patients (12.42%) admitted in the institute were transferred to the neurological rehabilitation unit for inpatient rehabilitation. Twenty-six patients (M:F,14:12) reporting at 1 year follow-up (63.41%) were included in the study (between Sept. 2005-Arpil 2008). Their functional recovery and residual deficits were recorded and analyzed. Interventions: Not applicable. Main Outcome Measures: Modified Barthel Index scores, Modified Rankin Scale and Hughes Disability Scale were used to assess functional disabilities at admission, discharge and follow-up. Results: Age ranged from 4-65 years (29.69 ⫾ 17.19). At admission, 21 patients had typical GBS and 5 had AMAN variant. Eight patients had bulbar weakness, 3 had autonomic dysfunction and 17 had facial palsy (uni/ bilateral). Nineteen patients (73.07%) had neuropathic pain needing medication with 6 requiring more than one drug. Five patients (19.2%) were prescribed wrist cock-up splint (WCS) for wrist drop and 15 patients (57.6%) prescribed ankle-foot orthoses-AFO (13 bilateral AFO) for foot drop. Twenty patients (77%) needed assistive devices also for locomotion at discharge. At 1 year follow-up, wrist drop and foot drop were still present in 1 and 4 patients, respectively, using orthoses. Modified Barthel Index scores, Modified Rankin Scale and Hughes Disability Scale were used to assess functional disabilities. Significant recovery was observed at the time of discharge and after 1 year when compared with discharge scores (P⬍.001 each). Conclusions: GBS patients continue to show significant functional recovery for a long period. They have disability in the form of motor weakness even after 1 year and need to be followed up for longer duration. Keywords: Functional recovery, Guillain Barre syndrome, Inpatient rehabilitation, Residual deficits.
Poster 213 Health and Function Data From an Adult Cerebral Palsy Clinic: Initial Report. Heidi J. Haapala, MD (University of Michigan, Ann Arbor, MI); Margy A. Fox, MS; Edward A. Hurvitz, MD. Disclosures: H. J. Haapala, None. Objective: To describe health and functional status of adults and older adolescents with cerebral palsy enrolled in a specialty clinic. Design: Cross sectional. Setting: Tertiary care center.
POSTER PRESENTATIONS
Participants: 22 individuals (ages 17-53) with cerebral palsy, GMFCS I-V, 16 female. Interventions: Survey, height and weight measures. Main Outcome Measures: BMI, pain (0-10 point scale) and constipation rating scale scores, survey results, vitamin D levels. Results: BMI: 40.9% of the participants were overweight or obese, while 31.8% were underweight. Pain: Best, worst, and average pain over the past 3 months was scored. Worst pain was rated as ⱖ7/10 in 9/12 (75%). Average pain was 0-3/10 in 5 (42%), 4-6/10 in 6 (50%), and ⱖ7/10 in 1 subject. Constipation: for 16 subjects, with 5 (31%) participants scoring ⬎5. Living situation: 12 lived with their parents, 3 in group homes, 1 with an aide, and 5 with roommates or by themselves. Eight of the subjects attended school, 4 worked (including individuals in sheltered living situations), and 10 neither worked nor attended school. Bone Health: As part of an initial screen, vitamin D levels were checked on 10 subjects, with below normal vitamin D levels noted in 8/10 (80%). Mobility: 9 used manual wheelchairs, 4 used power mobility, 1 used both. GMFCS levels: 4 subjects were level 1 or 2, 10 subjects were level 3 and 8 subjects were level 4 or 5. This group was weighted toward GMFCS 3-5, accounting for the higher prevalence of wheelchair use. Conclusions: Vitamin D levels were low in most of the subjects, indicating a need for bone health assessment. Overweight, pain, constipation, depression, nutrition and community involvement should be monitored and addressed to increase function along with tone, mobility and other more commonly described issues in individuals with cerebral palsy. Keywords: Cerebral palsy, Rehabilitation, Adult.
Poster 214 Heroin-induced Femoral Neuropathy and Rehabilitation: A Case Report. Sooyeon Kim, (Montefiore Medical Center, Bronx, NY); Andrzej C. Kroszczynski, MD; Margarita Manahan. Disclosures: S. Kim, None. Patients or Programs: A 43-year-old male heroin abuser. Program Description: We present a 43-year-old otherwise healthy male who developed worsening bilateral lower extremities weakness and numbness for 4 months which started soon after intravenous heroin injection. Physical examination revealed marked atrophy of bilateral quadriceps, 1/5 strength of knee extensor with absent patellar reflexes, normal strength of hip flexor and adductor, along with the pattern of bilateral anteromedial thigh and medial lower leg sensory deficit consistent with bilateral femoral neuropathy or L3-4 nerve root pathology. EMG demonstrated severe bilateral femoral neuropathies with sensory and motor axonal loss. The lesions were distal to the branch supplying the iliopsoas, as this muscle was not affected. There was no evidence of lumbosacral root dysfunction. Laboratory examinations include CPK, autoimmune diseases and infectious
PM&R
tests include HIV were negative or non specific. MRI of lumbosacral plexus includes bilateral thigh was negative. Physical therapy was initiated for quadriceps strengthening and gait training. Setting: Outpatient rehabilitation at a university hospital. Results: Within 2 months, patient showed significant improvement in his quadricep strength which improved from 1/5 to 3/5 and in gait pattern advancing to quad-cane from rolling walker. However, patient’s sensory symptoms remained without any improvement. Discussion: The mechanism of how the neuropathies occur still remains unclear. An immunologic response to or direct toxic effect of heroin has been proposed, as well as nerve or muscle compression secondary to rhabdomyolysis. As of treatment, there are some studies that tried steroid pulse therapy, however, failed to show any improvement. This is the first case report which physical therapy showed significant functional improvement for at the chronic phase of heroin-induced bilateral femoral neuropathy. Conclusions: Even though the pathophysiology is unknown and there is no proven definite treatment recommended, this case showed a significant role of physical therapy in functional improvement. Keywords: Rehabilitation, Femoral neuropathy, Heroin.
Poster 215 Heterotopic Ossification Following TraumaAssociated Amputation: A Case Report. Jung-Woo Ma, MD & Adrian Cristian, MD (The Mount Sinai Medical Center, New York, NY). Jung-Woo Ma, MD (Mount Sinai Medical Center, New York, NY); Adrian Cristian, MD. Disclosures: J. Ma, None. Patients or Programs: A 20-year-old man with traumaassociated amputation. Program Description: The patient sustained a left transtibial amputation secondary to injuries from an improvised explosive device blast in East Baghdad. He underwent left trans-femoral amputation. However, during his post-amputation rehabilitation program, he developed heterotopic ossification (HO) in the lateral to the distal aspect of the left femur. The patient was treated conservatively and was fitted with a prosthesis. He was functioning at a high level with the prosthesis and was able to ambulate without any assistive device for long distances in the community. However, he had a significant weight gain since receiving the initial prosthesis, which was coupled with increasing residual limb pain that significantly limited his function. Setting: A tertiary care Veterans Affairs facility. Results: The residual limb revealed a palpable bony growth and tenderness along the lateral aspect of the left thigh. There was a foul smelling plaque with cerebriform surface and central erythematous erosion along the lateral aspect of the residual limb which covered the HO. The foul smelling plaque was treated with an oral antibiotic and topical antibacterial cream with complete resolution. The patient was
Vol. 1, Iss. 9S, 2009
S197
also fitted with a new socket to accommodate the increased weight gain. The pain with ambulation resolved, and no further episodes of foul smelling rash were reported. Discussion: The prevalence of bone overgrowth after amputation in the adult population is unknown. It has been observed that more soldiers with amputations in Iraq or Afghanistan develop HO than in any other previous wars. Potter et al. try to explain why HO is more common in the current wars when compared to previous wars, including rapid medical intervention, aggressive limb salvage, pulsatile lavage irrigation systems and subatmospheric pressure dressing devices used in the military treatment facilities. Conclusions: Considering the recent increased prevalence of HO in traumatic amputees returning from the wars, HO needs careful consideration when the amputees present with residual limb pain and decreased range of motion. Keywords: Heterotopic ossification, Traumatic amputation, Prosthesis.
Poster 216 Hyperthyroidism Masking as Intrathecal Baclofen Withdrawal: A Case Report. Michael Saulino, Md PhD (Moss Rehab Hospital, Elkins Park, PA); Jeffrey Degen, MD; Kathryn T. Gollotto, DO. Disclosures: M. Saulino, Medtronic, Inc, Speakers bureau. Patients or Programs: A 24-year-old man with spastic tetraplegic cerebral palsy. Program Description: A 24-year-old man with spastic tetraplegic cerebral palsy presented with tachycardia, fever and increased muscle tone following elective replacement of an intrathecal pump. His first intrathecal pump was implanted 5 years prior to presentation. His spasticity was well regulated at 500 mcg per day of intrathecal baclofen. He underwent elective pump replacement for battery replenishment. The postoperative course was initially unremarkable and the patient was discharged home. However, he subsequently returned to the acute care hospital 1 week later with tachycardia, fever and increased muscle tone. The initial clinical impression was intrathecal baclofen withdrawal. Setting: Outpatient clinic and inpatient hospital. Results: Plain radiographs revealed the catheter to be intact and properly placed. Baclofen pump dosing was increased four times without significant improvement in muscle tone. A side port access was subsequently done, with aspiration of spinal fluid suggestive of catheter continuity. Initial assessment for noxious stimuli, such as deep vein thrombosis, urinary tract infection and meningitis was negative. Subsequent laboratory results revealed the patient to be hyperthyroid. He was treated with propylthiouracil and propranolol following which his muscle tone returned to baseline. Discussion: There are many causes of increased tone following intrathecal pump replacement, including catheter dysfuction, noxious stimuli, mechanical failure of the pump, postoperative pain or infection, intrathecal baclofen toler-