Poster 293 Pain and Weakness Due to Scurvy and Other Vitamin Deficiencies: A Case Report

Abstracts / PM R 8 (2016) S151-S332 Participants: A total of 134 patients (abobotulinumtoxinA, n¼89; placebo, n¼45) were randomized and 129 (abobotulinumtoxinA, n¼84; placebo, n¼45) completed the W4 primary endpoint evaluation. Interventions: CD patients were randomized (2:1) to abobotulinumtoxinA or placebo. Toxin-naı¨ve abobotulinumtoxinA patients received 500 units/2 mL in 2 affected neck muscles. AbobotulinumtoxinA CD subjects who had previously received botulinum treatment (non-naı¨ve) received 250-500 units/2 mL (2.5:1 abobotulinumtoxinA: previous onabotulinumtoxinA [BotoxÒ] dose) into muscles injected during prior treatments. Main Outcome Measures: The primary endpoint was change from baseline to Week 4 (W4) in Toronto Western Spasmodic Torticollis Rating Oasis, The Online Abstract Submission System Scale (TWSTRS) total score. Safety was assessed over the 12-week study period. Results: Versus placebo, abobotulinumtoxinA patients experienced significantly greater changes from baseline in TWSTRS score at W4 (-2.5 versus -10.8, P<.001; based upon the modified intent-to-treat population). Adverse events (AEs) occurred in 41% and 22% of abobotulinumtoxinA and placebo patients, respectively. Dysphagia was reported in 9% of treated patients. Other AEs in treated patients were muscle weakness, neck pain, and headache, none of which were reported with placebo. Conclusions: Data from this study indicate a 2 mL dilution of abobotulinumtoxinA was significantly more effective than placebo in CD patients. No unexpected AEs were observed relative to previous studies that used the 1 mL dilution volume in this patient population. Level of Evidence: Level II Poster 291 Improved Upper Extremity Spasticity During Continuous Intrathecal Baclofen Trial with High Cervical Catheter Placement: A Case Report Melissa Roscher, MD (University of Pittsburgh Medical Center, Pittsburgh, PA, United States), Michael C. Munin, MD Disclosures: Melissa Roscher: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 50-year-old man with history of right basal ganglia hemorrhage experienced left arm spastic dystonia for a year following his stroke. Poor kidney function precluded adequate spasticity management with oral baclofen, thus he was admitted for continuous intrathecal baclofen (ITB) trial with an external pump. He initially underwent standard trial placement with the catheter terminating in the thoracolumbar region. With titration to 225 mcg/24 hour dose, he noted improved spasticity in his left leg based on Modified Ashworth Scale (MAS). However, significant spastic dystonia of the left arm was unchanged. He subsequently underwent replacement of the catheter with termination at C5-6. Setting: Tertiary care hospital. Results: Prior to the trial, MAS of the left arm was 2/4 at the worst. It improved to 0/4 after catheter replacement. Importantly, subjective improvement was reported as he could extend and maintain his left arm at his side while standing and ambulating. He denied adverse reactions due to ITB or cervical catheter placement. Due to increased risk of infection from the 6-day catheter trial, the patient was discharged home and returned for definitive placement 2 weeks later. Discussion: Distal catheter placement may limit the efficacy of ITB on upper extremity spasticity. This case is an example of the increased benefit to upper limb spasticity that cranial catheter placement may provide. Conclusions: While ITB is widely used to address lower extremity spasticity, continuous ITB trial with high cervical catheter placement may demonstrate improvement in upper limb spasticity. Level of Evidence: Level V

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Poster 292 Improvement of Spasticity Following AbobotulinumtoxinA (DysportÒ) Injections in Shoulder Muscles in Hemiparetic Patients with Upper Limb SpasticityeSub-Analysis of a Prospective, Long-Term, Open-Label Study with Single and Repeated Injection Cycles Fatma Gul, MD (The University of Texas Southwestern Medical Center, Dallas, Texas, USA, Dallas, Texas, United States), Michael O’Dell, Robert Jech, MD, PhD, Marta Banach, MD, PhD, Claire Vilain, MD, Anne-Sophie AS. Grandoulier, MD, Jean-Michel Germain, PhD, Jean-Michel Gracie`s Disclosures: Fatma Gul: Consulting fees or other remuneration (payment) - Medtronic, Consulting fees or other remuneration (payment) Medforce, Consulting fees or other remuneration (payment) - Allergan, Consulting fees or other remuneration (payment) - IPSEN Objective: Descriptive analysis of the effect of single and repeated injections of abobotulinumtoxinA into shoulder extensors and internal rotators on spasticity, in hemiparetic patients with upper limb spasticity (ULS). Design: Open-label extension (OLE) to a double-blind study. Setting: Phase III, international, multicenter. Participants: Subpopulation of patients who received abobotulinumtoxinA injection in shoulder muscles during OLE. Interventions: Patients received 1000 Units (U) or 1500U of abobotulinumtoxinA per cycle in the upper limb for up to 4/5 cycles. This included single or repeated injections in shoulder muscles at a maximum dose of 500U per cycle. Main Outcome Measures: Spasticity assessed by Tardieu Scale: passive range of motion [XV1], angle of catch [XV3]) and spasticity angle (X¼XV1-XV3) in shoulder muscles at week 4 of each cycle. Cycle 3 data are presented due to small n numbers at Cycles 4 and 5. Results: A substantial proportion of patients were injected in 1 shoulder muscle: 96 (38%) across cycles. Two thirds of these (n¼60) received 2 injections in their shoulder muscles. The most commonly injected shoulder muscle was pectoralis major (mean dose injected across cycles ranged from 170U-290U) followed by latissimus dorsi (150Ue200U), triceps brachii (150Ue200U) and subscapularis (100Ue175 U). In patients with only one shoulder injection, mean change from baseline (SD) at Week 4 of Cycle 3 was +11.6 (19.8) and +18.2 (23.5) for XV1 and XV3, respectively and -6.7 (24.5) for X. In patients receiving shoulder injections repeatedly, no further improvement was observed for XV1 while greater improvement was observed in XV3 and X at Week 4 of cycle 3 [mean change from baseline (SD) of +19.8 (24.3), and -11.3 (26.8) respectively]. Safety analysis did not generate any unexpected safety findings. Conclusions: These data show the potential benefit of abobotulinumtoxinA injections in shoulder extensors and internal rotators in patients with ULS in which spasticity progressively improved with repeated injection cycles. Level of Evidence: Level II Poster 293 Pain and Weakness Due to Scurvy and Other Vitamin Deficiencies: A Case Report Christine Chan, DO (Sinai Hospital of Baltimore/University of Maryland, Baltimore, MD, United States), Sarah Eby, MD Disclosures: Christine Chan: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 26-year-old woman with history of morbid obesity status post gastric bypass surgery, depression, anxiety presented to acute rehabilitation unit with generalized weakness and impaired mobility. Patient had a progressively increasing

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Abstracts / PM R 8 (2016) S151-S332

fear of being “fat” and gaining weight for the last 9 months resulting in self starvation. She also self discontinued her post surgery recommended vitamins 1 year ago. She weighed 350 lbs prior to gastric by pass surgery 3 years ago and at the time of admission patient weighed 110 lbs. She was admitted initially at Tertiary care hospital for generalized weakness and malnutrition; she was recommended for an inpatient eating disorder clinic. However, the patient was not eligible for the clinic due to her physical/functional deficit as their patients are required to be independent. Upon rehab admission, she complained of ankle pain with weight bearing and right elbow soreness with any lifting activity. She also complained of numbness in her feet and hands with intermittent burning pain radiating from feet to thighs. There were also a non-pruriginous, non-tender erythematous punctate macular skin changes on upper extremities, areas of diffuse ecchymosis lower extremities, and minor gum bleeding with teeth brushing. Setting: Rehabilitation Hospital. Results: BMI was 19.1 on admission. Xray of elbow negative for fracture. Laboratory testing showed low vitamin D (27 ng/mL), hypokalemia, low albumin, hypomagnesia, vitamin C, zinc, MMA, B1, and B12 were pending. Treatment for scurvy and other vitamin deficiencies was initiated with oral and IV magnesium, oral potassium chloride, vitamin D, zinc, folate, thiamine, B12, multivitamin with minerals, and vitamin C. After 1 week, rash resolved, gum bleeding improved, and joint pain improved. After improved oral intake and supplements, patient improved with traditional physical and occupational therapy. There was emphasis on education regarding food for functional gain in contrast to solely weight gain. She achieved modified-independence level for bed mobility, transfers, CGA for ambulation and stairs, supervision-modified independence for ADLs. Her BMI on discharge was 20. Discussion: The patient was not responding to traditional physical and occupational therapy due to generalized weakness and pain. After gastric bypass surgery, patients are prone to deficiencies with fat soluble vitamins, calcium, iron, vitamin B12, and folate. In cases with increased vomiting, thiamine may be deficient. Poor nutrition intake can lead to vitamin C deficiency also known as Scurvy. Vitamin C is integral in the formation of collagen and deficiency due to poor intake can lead to malaise, fatigue, gum bleeding, poor wound healing, joint pain, and capillary fragility. The recommended daily allowance of Vitamin C is 60 mg. Usual cases of anorexia nervosa do not have the physical and neurological deficits this patient exhibited secondary to decreased vitamin absorption combined with poor nutrition intake. After improved oral intake and vitamin supplementation, the patient was more responsive to therapies and achieved her functional goals. Conclusions: Generalized weakness and joint pain after gastric bypass surgery should include evaluation of all vitamins and not just fat soluble vitamins especially when the patient has history of psychiatric diagnoses and an eating disorder. Level of Evidence: Level V Poster 294 Conversion Disorder Rehabilitation: A Case Report Carrie McShane, MD (East Carolina University / Vidant Medical Center, Greenville, NC, United States), William L. Doss, MD Disclosures: Carrie McShane: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 31-year-old woman with history of borderline personality disorder and post-traumatic stress disorder (PTSD) presented with 2-month history of right-sided hemiparesis. Her medical work-up did not find a source of stroke or MRI brain abnormalities. She was diagnosed with conversion disorder and sent to a skilled nursing facility since her parents could not provide total assistance. Her family reported that due to the negative connotation of conversion disorder, therapists did not provide adequate treatment and she became weaker. She was subsequently sent to inpatient

rehabilitation. On physical exam, patient had right upper extremity paresis and right lower extremity paralysis but was able to demonstrate full range of motion when distracted. Setting: Inpatient Rehabilitation of Academic Medical Center. Results: She progressed in therapies with encouragement and improved overall strength and Functional Independence Measure (FIM) scores. She was discharged home independent with ambulation and required supervision with activities of daily living. She followed up with outpatient physical therapy, occupational therapy, and aquatic therapy. Discussion: Conversion disorder is defined by Diagnostic and Statistical Manual of Mental Disorders as one or more neurological deficits that cannot be explained by a medical condition. The classic presentation of conversion disorder is a sudden neurologic deficit after a significantly stressful event, such as our patient’s recurrent PTSD since age 13. Complete stroke work-up includes head computed tomography, carotid ultrasound, echocardiography, hypercoagulable blood tests, and brain magnetic resonance imaging. Our patient was diagnosed with conversion disorder since the symptoms continued for greater than 24 hours, no source of stroke was found, and there was an absence of imaging abnormalities. Conclusions: Conversion disorder should not be confused with factitious disorder or malingering since the symptoms are not intentionally feigned. Patients can benefit from inpatient rehabilitation to avoid debility and improve FIM scores. Level of Evidence: Level V Poster 296 AbobotulinumtoxinA Injection Patterns in Patients with Cervical Dystonia from the ANCHOR-CD Registry Study Cynthia L. Comella, MD (Rush University Medical Center, Chicago, IL, United States), George C. Camba, BA, Daniel Truong, MD, Alberto J. Espay, MD, Daniel Snyder, PhD, Dominic Marchese, RPH, Richard Trosch, MD Disclosures: Cynthia Comella: Research Grants - Allergan, Ipsen, Merz, Consulting fees or other remuneration (payment) - Allergan, Merz Objective: To assess treatment patterns of abobotulinumtoxinA from the ANCHOR-CD registry of patients with cervical dystonia (CD). Design: A prospective, open-label, non-interventional, “real-world” post-marketing registry study of CD patients treated with abobotulinumtoxinA. Setting: 41 US Clinical Sites. Participants: BoNT-naı¨ve and non-naı¨ve patients 18 years of age with a diagnosis of idiopathic cervical dystonia were eligible. Interventions: Patients were treated with Dysport, abobotulinumtoxinA according to the investigator’s usual medical practice. The muscles injected, dose per muscle, number of sites into the muscle, and use of guidance technique were at the investigator’s discretion. Patients continued in the study for 4 treatment cycles. Main Outcome Measures: The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), Pain Numeric Rating Scale (NRS), Clinical Global Impression of Change (CGIC), Patient Global Impression of Change (PGIC), and Treatment Satisfaction Questionnaire for Medication (TSQM). Results: Of the 347 patients who completed the study, 75% were female, mean age 59.013.6 years, and mean age at symptoms onset 48.915.6 years. 73% had previous treatment with BoNT. The most common types of CD treated were mixed postures (68%). The most frequent single predominant posture was torticollis (25.6%); other forms accounted for <5% each. Median abobotulinumtoxinA dose was 500U (range 100U-2000U) during 4 cycles. Median time between retreatment intervals was 14 weeks, with 25% having been reinjected >14 weeks. 4-5 muscles across 11-12 injection points were injected during each cycle. The most frequently injected muscles across cycles included splenius capitis (91.6%-92.5%), levator scapulae (68.8%-71.5%), trapezius (68.0%70.4%), and sternocleidomastoid (56.2%-61.4%). The most common