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Poster 285 Systemic Infection Presenting as Acute on Chronic Low Back Pain. Making the Diagnosis: A Case Report
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side-to-side variation. Needles examination was performed on the bilateral upper extremities and left lower extremity. The examination displayed no spontaneous activity but had giant motor unit activity in the right upper extremity, ranging from 6mV to 42mV, most prominent in the distal extremity in the C7-T1 myotomes. Given the above, monomyelic amyotrophy was suspected despite the late onset and male onset preference. Cervical MRI was recommended to exclude other disorders. Discussion: This is an unusual case of chronic distal weakness limited to a unilateral upper extremity. The patient’s clinical presentation and electromyographic results are consistent with monomyelic amyotrophy; however, the age of onset and gender of the patient in this case is unusual. Despite unilateral symptoms, electrically the findings were more widespread. Conclusions: Monomyelic amyotrophy is a diagnosis of exclusion; however, it should be considered in patients in all age groups with unilateral upper extremity weakness with no sensory involvement. Poster 283 Comparative Functional Outcomes for Autologous Blood Injection for Tendinopathy: Does the Particular Tendon Matter? Erin C. Andrade; Doctor of Medicine (University of Washington, Seattle, WA, United States); Debbie Tan; Doctor of Medicine; Alfred C. Gellhorn, MD. Disclosures: E. C. Andrade, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To compare patient reported functional outcomes following autologous blood injection for chronic painful tendinosis in different anatomic locations. Design: Retrospective cohort study. Setting: Academic medical center sports medicine clinic. Participants: 19 patients with chronic tendinosis. Interventions: We performed ultrasound guided tenotomy and autologous blood injection (ABI) for patients with chronic (>6 months) tendinosis not responsive to conservative treatment. Patient reported outcomes of pre-injection and post-injection functional impairment were retrospectively analyzed. Main Outcome Measures: Self-reported functional impairment for pre-injection and post-injection time periods. Results or Clinical Course: We were able to complete follow up on 14 of the 19 patients. Sites treated with ABI included rotator cuff (infraspinatus and supraspinatus n¼4), forearm (extensor carpi radialis brevis and extensor carpi ulnaris n¼4), gluteus medius (n¼6), and conjoint hamstring tendon (n¼5). Pre-injection functional impairment across all sites ranged from 2 to 9 (mean 5.9). Site-specific functional limitation pre-injection means were: rotator cuff 6.0, forearm 7.0, gluteus medius 5.4, and hamstrings 6.5. Mean functional improvement post-injection at 6 month follow-up were: hamstrings 1.0, rotator cuff 2.5, forearm 3.3, and gluteus medius 3. Conclusions: This is the first report of functional outcomes following autologous blood injection in tendons beside the epicondylar tendons of the elbow, patellar and Achilles tendons. ABI is a well-tolerated procedure to treat chronic tendinosis with significant patient functional improvement. Our results suggest there may be a differential response to this procedure based on anatomic location, specifically with greatest improvement for forearm and
PRESENTATIONS
gluteus medius tendinopathies and less for conjoint hamstring tendinopathy. In this cohort of patients with chronic tendinosis, there was a mean change in functional impairment of 2.9 across all sites. Poster 284 Sarcopenic Obesity and Functional Implication in Poliomyelitis Patients. Hyunkyung Do (Seoul National University Bundang Hospital, SungNam City, Korea, Republic of); Jae-Young Lim; Joong Hoon Lee. Disclosures: H. Do, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To evaluate the morbidity of obesity by different criteria, body mass index (BMI) and percent body fat(%fat) and to compare the short physical performance battery (SPPB) score between sarcopenic obesity group (SOG) and non-sarcopenic obesity group (NSOG) in poliomyelitis survivors. Design: Cross-sectional study. Setting: Out-patient clinic in university hospital. Participants: 52 poliomyelitis survivors (F¼35, M¼17) Main Outcome Measures: Basic measurements include height, weight, circumference of chest and waist. Body composition test by dual X-ray absorptiometry, BMI, %fat, skeletal muscle mass index (SMI), and knee strength with Biodex, SPPB Results or Clinical Course: In the classification of sarcopenic obesity of the polio survivors, 59.6% (women 48.6%, men 82.4%) of them were classified as sarcopenic obesity by ASM/ht2 criteria and %fat. 94.2% (women 91.4%, men 100%) of the patients were classified as sarcopenic obesity by SMI criteria and %fat. The SOG revealed low SPPB score compared to NSOG (8.62 vs 5.8), especially in walking (3.19 vs 1.93) and chair standing (2.86 vs 0.94) score. The SOG had lower knee strength compared to NSOG and the differences were more prominent in uninvolved side. Conclusions: Sarcopenia and sarcopenic obesity are highly prevalent in polio survivors. BMI may be an inappropriate index to assess adiposity status in disabled people such as polio survivors. Sarcopenic obese polio survivors showed significantly low level of function in SPPB score. It is necessary to be concerned in the potential harmful consequences of longstanding sarcopenic obesity in polio survivors. Poster 285 Systemic Infection Presenting as Acute on Chronic Low Back Pain. Making the Diagnosis: A Case Report. Nicole Burns; Doctor of Osteopathic Medicine (OSU Wexner Medical Center, Columbus, OH, United States); Jonathan Pedrick, MD. Disclosures: N. Burns, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 44-year-old man was hospitalized for evaluation of acute on chronic back pain. He had a history of chronic back pain following a thoracic spinal fracture requiring multiple surgeries over the past three years. Three months prior to admission, he underwent a spinal cord stimulator trial with subsequent worsening of symptoms. On admission, no neurologic deficits were noted. MRI of the cervical, thoracic, and lumbar spine revealed multilevel degenerative disc disease and conservative management was recommended by the neurosurgical consultants. Due to the patient’s persistent pain unrelieved by rest, positioning,
PM&R
or steroid /opioid medication, the physiatry consultants recommended infectious and metabolic work up. Setting: Inpatient Consult at Tertiary Hospital Results or Clinical Course: Although preliminary blood work including CBC and chemistries were negative, the chest CT revealed multiple apparent pulmonary septic emboli which worsened over a 48 hour period. He developed low grade fevers, an increased oxygen requirement, and blood cultures grew Staphylococcus aureus sp. He was treated with appropriate antibiotics and had an uneventful recovery. It was postulated that bacterial contamination from the spinal cord stimulator trial 10 weeks prior may have been the source of dormant infectious etiology. Discussion: Acute back pain unrelieved by position, rest, or medication raises concern for a more serious condition. Recognizing these “red flags” will lead to more timely diagnosis and treatment of serious and potentially fatal conditions associated with back pain. Concomitant chronic back pain in the absence of sensory, motor, or bladder/bowel changes complicates the diagnostic evaluation and a high index of suspicion is critical. Conclusions: Early recognition of acute back pain due to more serious conditions is critical to successful treatment and avoidance of morbidity or mortality. Complicated cases of back pain associated with limited findings makes evaluation difficult and a high index of suspicion is essential. Poster 286 Osteoporosis Reduction after a High Intensity Weight-Training Program: A Case Report. Cleo D. Stafford, MD (Emory University School of Medicine, Atlanta, GA, United States); Bamidele O. Adeyemo, MD; Robert Bowers, DO, PhD; David Burke. Disclosures: C. D. Stafford, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: Two women ages 29 (subject A) and 53 years (subject B) with Dual-Energy X-ray Absorptiometry (DEXA) scan evidence of osteoporosis. Program Description: This series reviews the cases of two women with a diagnosis of osteoporosis, who participated in a unique weightlifting program (Gravitational Wellness); lifting over 1200 pounds each in weekly 30 minute training sessions. Both women had their bone mineral density (BMD) assessed before and after 10 weeks of training, during which time neither altered intervention for their osteoporosis. Setting: Community Results or Clinical Course: Both subjects attained notable gains in bone health and strength. Subject A progressed in strength, lifting 1298 lbs at the final session, while subject B achieved a final lift of 1246 lbs. The results of the DEXA bone scan revealed that the lumbar spine BMD increased 11.1% in subject A and 6.7% in subjects B. Additionally, the improvement in femur BMD was 8.1% and 26.6%, respectively. Discussion: A focused review of literature was performed on the efficacy of Gravitational Wellness weight lifting programs. Previous studies have demonstrated increased weight carrying capacity attained during this regimen. However, to our knowledge, this is the first case series demonstrating the effect of these weights on
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BMD in women. Given the use of bisphosphonates portend an average 1.5% increase in BMD, this case report may be pivotal by suggesting a potential alternative to pharmacotherapy is attainable through this weight lifting technique. Further studies are required to re-determine effect, dose, intensity, timing, and association of this program and BMD. Conclusions: This case series demonstrates that high weights lifted in the Gravitational Wellness training system may be effective in improving bone mineral density among women. Poster 287 The Value of Combined Electrodiagnosis and Ultrasound in the Assessment of a Superficial Radial Sensory Nerve Compression from a Complex Ganglion Cyst: A Case Report. Beth Shaker, MD (The Ohio State University, Columbus, OH, United States); Jeffrey A. Strakowski, MD. Disclosures: B. Shaker, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Design: Case Report Case Description: The patient presented with a nine-month history of a large volar-radial wrist mass with a two-month history of sensory disturbance affecting the thumb and the index finger. He had an implanted spinal stimulator that prohibited assessment with MRI. His examination showed sensory loss at the dorsum of the thumb, 1st web space and index finger as well as loss of 2-point discrimination in the volar thumb, index and long finger, but not the palm. There was weakness of the abductor pollicis brevis but otherwise normal strength in the limb. The remainder of the examination was unremarkable. Program Description: Institutions: The Ohio State University, Riverside Methodist Hospital, and the McConnell Spine, Sport and Joint Center. Setting: Academic Medical Center. Results or Clinical Course: Electrodiagnostic testing revealed an absent superficial radial sensory nerve action potential on the ipsilateral side, and a normal one on the contralateral side. There was also evidence of a moderate median neuropathy at the wrist. Ultrasonography showed a 3.5 2.5 1.5 cm complex cyst with continuity with the radial scaphoid joint. Compression of both the superficial radial sensory nerve and radial artery was seen. The course of both structures were mapped in detail to assist with surgical planning. Ultrasound also revealed a median nerve compression at the level of the carpal tunnel with no encroachment from the mass. The findings led to detailed surgical planning and ultimate recovery from both neuropathies after successful removal of the ganglion and release of the transverse carpal ligament. Discussion: Treatment of volar wrist ganglion cyst can be challenging and is often deferred due to the inherent risks from proximity to the radial artery. Combining electrophysiologic information with the anatomic information gained from high frequency ultrasound provided more precise identification and localization of the compressive neuropathies and enhanced the safety of the surgical approach. Conclusions: This case of a superficial radial sensory neuropathy from a volar ganglion cyst illustrates the value of combining the functional information of electrodiagnosis with the anatomic assessment of high frequency ultrasound.
side-to-side variation. Needles examination was performed on the bilateral upper extremities and left lower extremity. The examination displayed no spontaneous activity but had giant motor unit activity in the right upper extremity, ranging from 6mV to 42mV, most prominent in the distal extremity in the C7-T1 myotomes. Given the above, monomyelic amyotrophy was suspected despite the late onset and male onset preference. Cervical MRI was recommended to exclude other disorders. Discussion: This is an unusual case of chronic distal weakness limited to a unilateral upper extremity. The patient’s clinical presentation and electromyographic results are consistent with monomyelic amyotrophy; however, the age of onset and gender of the patient in this case is unusual. Despite unilateral symptoms, electrically the findings were more widespread. Conclusions: Monomyelic amyotrophy is a diagnosis of exclusion; however, it should be considered in patients in all age groups with unilateral upper extremity weakness with no sensory involvement. Poster 283 Comparative Functional Outcomes for Autologous Blood Injection for Tendinopathy: Does the Particular Tendon Matter? Erin C. Andrade; Doctor of Medicine (University of Washington, Seattle, WA, United States); Debbie Tan; Doctor of Medicine; Alfred C. Gellhorn, MD. Disclosures: E. C. Andrade, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To compare patient reported functional outcomes following autologous blood injection for chronic painful tendinosis in different anatomic locations. Design: Retrospective cohort study. Setting: Academic medical center sports medicine clinic. Participants: 19 patients with chronic tendinosis. Interventions: We performed ultrasound guided tenotomy and autologous blood injection (ABI) for patients with chronic (>6 months) tendinosis not responsive to conservative treatment. Patient reported outcomes of pre-injection and post-injection functional impairment were retrospectively analyzed. Main Outcome Measures: Self-reported functional impairment for pre-injection and post-injection time periods. Results or Clinical Course: We were able to complete follow up on 14 of the 19 patients. Sites treated with ABI included rotator cuff (infraspinatus and supraspinatus n¼4), forearm (extensor carpi radialis brevis and extensor carpi ulnaris n¼4), gluteus medius (n¼6), and conjoint hamstring tendon (n¼5). Pre-injection functional impairment across all sites ranged from 2 to 9 (mean 5.9). Site-specific functional limitation pre-injection means were: rotator cuff 6.0, forearm 7.0, gluteus medius 5.4, and hamstrings 6.5. Mean functional improvement post-injection at 6 month follow-up were: hamstrings 1.0, rotator cuff 2.5, forearm 3.3, and gluteus medius 3. Conclusions: This is the first report of functional outcomes following autologous blood injection in tendons beside the epicondylar tendons of the elbow, patellar and Achilles tendons. ABI is a well-tolerated procedure to treat chronic tendinosis with significant patient functional improvement. Our results suggest there may be a differential response to this procedure based on anatomic location, specifically with greatest improvement for forearm and
PRESENTATIONS
gluteus medius tendinopathies and less for conjoint hamstring tendinopathy. In this cohort of patients with chronic tendinosis, there was a mean change in functional impairment of 2.9 across all sites. Poster 284 Sarcopenic Obesity and Functional Implication in Poliomyelitis Patients. Hyunkyung Do (Seoul National University Bundang Hospital, SungNam City, Korea, Republic of); Jae-Young Lim; Joong Hoon Lee. Disclosures: H. Do, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To evaluate the morbidity of obesity by different criteria, body mass index (BMI) and percent body fat(%fat) and to compare the short physical performance battery (SPPB) score between sarcopenic obesity group (SOG) and non-sarcopenic obesity group (NSOG) in poliomyelitis survivors. Design: Cross-sectional study. Setting: Out-patient clinic in university hospital. Participants: 52 poliomyelitis survivors (F¼35, M¼17) Main Outcome Measures: Basic measurements include height, weight, circumference of chest and waist. Body composition test by dual X-ray absorptiometry, BMI, %fat, skeletal muscle mass index (SMI), and knee strength with Biodex, SPPB Results or Clinical Course: In the classification of sarcopenic obesity of the polio survivors, 59.6% (women 48.6%, men 82.4%) of them were classified as sarcopenic obesity by ASM/ht2 criteria and %fat. 94.2% (women 91.4%, men 100%) of the patients were classified as sarcopenic obesity by SMI criteria and %fat. The SOG revealed low SPPB score compared to NSOG (8.62 vs 5.8), especially in walking (3.19 vs 1.93) and chair standing (2.86 vs 0.94) score. The SOG had lower knee strength compared to NSOG and the differences were more prominent in uninvolved side. Conclusions: Sarcopenia and sarcopenic obesity are highly prevalent in polio survivors. BMI may be an inappropriate index to assess adiposity status in disabled people such as polio survivors. Sarcopenic obese polio survivors showed significantly low level of function in SPPB score. It is necessary to be concerned in the potential harmful consequences of longstanding sarcopenic obesity in polio survivors. Poster 285 Systemic Infection Presenting as Acute on Chronic Low Back Pain. Making the Diagnosis: A Case Report. Nicole Burns; Doctor of Osteopathic Medicine (OSU Wexner Medical Center, Columbus, OH, United States); Jonathan Pedrick, MD. Disclosures: N. Burns, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 44-year-old man was hospitalized for evaluation of acute on chronic back pain. He had a history of chronic back pain following a thoracic spinal fracture requiring multiple surgeries over the past three years. Three months prior to admission, he underwent a spinal cord stimulator trial with subsequent worsening of symptoms. On admission, no neurologic deficits were noted. MRI of the cervical, thoracic, and lumbar spine revealed multilevel degenerative disc disease and conservative management was recommended by the neurosurgical consultants. Due to the patient’s persistent pain unrelieved by rest, positioning,
PM&R
or steroid /opioid medication, the physiatry consultants recommended infectious and metabolic work up. Setting: Inpatient Consult at Tertiary Hospital Results or Clinical Course: Although preliminary blood work including CBC and chemistries were negative, the chest CT revealed multiple apparent pulmonary septic emboli which worsened over a 48 hour period. He developed low grade fevers, an increased oxygen requirement, and blood cultures grew Staphylococcus aureus sp. He was treated with appropriate antibiotics and had an uneventful recovery. It was postulated that bacterial contamination from the spinal cord stimulator trial 10 weeks prior may have been the source of dormant infectious etiology. Discussion: Acute back pain unrelieved by position, rest, or medication raises concern for a more serious condition. Recognizing these “red flags” will lead to more timely diagnosis and treatment of serious and potentially fatal conditions associated with back pain. Concomitant chronic back pain in the absence of sensory, motor, or bladder/bowel changes complicates the diagnostic evaluation and a high index of suspicion is critical. Conclusions: Early recognition of acute back pain due to more serious conditions is critical to successful treatment and avoidance of morbidity or mortality. Complicated cases of back pain associated with limited findings makes evaluation difficult and a high index of suspicion is essential. Poster 286 Osteoporosis Reduction after a High Intensity Weight-Training Program: A Case Report. Cleo D. Stafford, MD (Emory University School of Medicine, Atlanta, GA, United States); Bamidele O. Adeyemo, MD; Robert Bowers, DO, PhD; David Burke. Disclosures: C. D. Stafford, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: Two women ages 29 (subject A) and 53 years (subject B) with Dual-Energy X-ray Absorptiometry (DEXA) scan evidence of osteoporosis. Program Description: This series reviews the cases of two women with a diagnosis of osteoporosis, who participated in a unique weightlifting program (Gravitational Wellness); lifting over 1200 pounds each in weekly 30 minute training sessions. Both women had their bone mineral density (BMD) assessed before and after 10 weeks of training, during which time neither altered intervention for their osteoporosis. Setting: Community Results or Clinical Course: Both subjects attained notable gains in bone health and strength. Subject A progressed in strength, lifting 1298 lbs at the final session, while subject B achieved a final lift of 1246 lbs. The results of the DEXA bone scan revealed that the lumbar spine BMD increased 11.1% in subject A and 6.7% in subjects B. Additionally, the improvement in femur BMD was 8.1% and 26.6%, respectively. Discussion: A focused review of literature was performed on the efficacy of Gravitational Wellness weight lifting programs. Previous studies have demonstrated increased weight carrying capacity attained during this regimen. However, to our knowledge, this is the first case series demonstrating the effect of these weights on
Vol. 6, Iss. 9S, 2014
S285
BMD in women. Given the use of bisphosphonates portend an average 1.5% increase in BMD, this case report may be pivotal by suggesting a potential alternative to pharmacotherapy is attainable through this weight lifting technique. Further studies are required to re-determine effect, dose, intensity, timing, and association of this program and BMD. Conclusions: This case series demonstrates that high weights lifted in the Gravitational Wellness training system may be effective in improving bone mineral density among women. Poster 287 The Value of Combined Electrodiagnosis and Ultrasound in the Assessment of a Superficial Radial Sensory Nerve Compression from a Complex Ganglion Cyst: A Case Report. Beth Shaker, MD (The Ohio State University, Columbus, OH, United States); Jeffrey A. Strakowski, MD. Disclosures: B. Shaker, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Design: Case Report Case Description: The patient presented with a nine-month history of a large volar-radial wrist mass with a two-month history of sensory disturbance affecting the thumb and the index finger. He had an implanted spinal stimulator that prohibited assessment with MRI. His examination showed sensory loss at the dorsum of the thumb, 1st web space and index finger as well as loss of 2-point discrimination in the volar thumb, index and long finger, but not the palm. There was weakness of the abductor pollicis brevis but otherwise normal strength in the limb. The remainder of the examination was unremarkable. Program Description: Institutions: The Ohio State University, Riverside Methodist Hospital, and the McConnell Spine, Sport and Joint Center. Setting: Academic Medical Center. Results or Clinical Course: Electrodiagnostic testing revealed an absent superficial radial sensory nerve action potential on the ipsilateral side, and a normal one on the contralateral side. There was also evidence of a moderate median neuropathy at the wrist. Ultrasonography showed a 3.5 2.5 1.5 cm complex cyst with continuity with the radial scaphoid joint. Compression of both the superficial radial sensory nerve and radial artery was seen. The course of both structures were mapped in detail to assist with surgical planning. Ultrasound also revealed a median nerve compression at the level of the carpal tunnel with no encroachment from the mass. The findings led to detailed surgical planning and ultimate recovery from both neuropathies after successful removal of the ganglion and release of the transverse carpal ligament. Discussion: Treatment of volar wrist ganglion cyst can be challenging and is often deferred due to the inherent risks from proximity to the radial artery. Combining electrophysiologic information with the anatomic information gained from high frequency ultrasound provided more precise identification and localization of the compressive neuropathies and enhanced the safety of the surgical approach. Conclusions: This case of a superficial radial sensory neuropathy from a volar ganglion cyst illustrates the value of combining the functional information of electrodiagnosis with the anatomic assessment of high frequency ultrasound.