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Poster 333: Improved Arousal with Frequent Zolpidem Dosing after Traumatic Brain Injury: A Case Report
Abstracts / PM R 9 (2017) S131-S290 weakness. Of note patient had recently returned from a trip to the Dominican Republic 2 weeks prior. Patient reported significant amount of mosquito bites sustained while abroad. Upon return, the patient noted fevers, rash, joint pain and flu-like symptoms which then progressed to numbness and lower extremity weakness. EMG/NCS showed diffuse demyelination, sparing of the sural nerves and involvement of the median nerves supporting the diagnosis of GBS. Zika infection was confirmed with PCR and lumbar puncture which showed albuminocytologic dissociation. During acute hospitalization, the patient was noted to have worsening dysphagia, dyspnea and respiratory fatigue and was admitted to the MICU service for respiratory monitoring and eventual intubation. Gradual improvement of respiratory function was noted after treatment with IVIg and patient began a bedside rehabilitation program until admission to acute inpatient rehabilitation. Setting: Acute Rehabilitation Hospital, outpatient ambulatory clinic. Results: Initially, the patient was noted to be max to total assist for ambulation, transfers and portions of self-care. A comprehensive rehabilitation plan was implemented to address her functional impairments. on discharge to home the patient was noted to be modified independent to with transfers and self-care. She continued with outpatient therapy and has progressed to full functional independence. Discussion: A recent editorial was published by the New England Journal of Medicine which showcased an association of GBS with Zika infection. To our knowledge, this is the first case of successful ongoing rehabilitation management of Zika virus associated GBS. Conclusions: With further study the Zika virus and advocation for rehabilitation management, this may assist with improving functional outcomes for patients presenting with Guillain Barre syndrome associated with Zika infection. Level of Evidence: Level V Poster 331: Multiple Drug Induced Parkinsonism Secondary to Chronic Risperidone Use and Lithium in an Adult with Bipolar Disorder Jenny A. Yin, DO (Schwab Rehab Hospital, Chicago, IL, United States), Wyatt Kupperman, DO, Steven Kreis, DO Disclosures: Jenny A. Yin, DO: I Have No Relevant Financial Relationships To Disclose Case/Program Description: This is a 59-year-old man with a past medical history of hypertension, bipolar disorder, chronic systolic heart failure, and chronic obstructive pulmonary disease presenting to the acute care hospital with frequent falls, bradykinesia, and urinary incontinence. Of note, he was previously seen by a movement disorder clinic for bradykinesia and gait instability. At that time he was taken off of his risperidone; he was switched to valproic acid and lithium, with subsequent improvement. On examination, the patient displayed masked facies, cogwheeling, bradykinesia, but no tremor. CT head revealed chronic microangiopathic changes. His symptom etiology was thought to be due to previous chronic risperidone use. Urinary incontinence was thought to be from being unable to reach the bathroom in time due to bradykinesia. He was transferred to the acute inpatient rehabilitation hospital setting. At this time his lithium level was checked, and adjusted to a lower dose due to a supratherapeutic level. Setting: Tertiary Care Hospital/Acute Inpatient Rehabilitation Hospital. Results: The patient completed a course of inpatient rehabilitation and was discharged home to his family at a modified independent level for his ADLs, mobility, transfers, and self-care. He had significant improvement in movement initiation and bradykinesia after his lithium dose was lowered. Discussion: This is a rare case of multiple drug induced parkinsonism caused by an atypical neuroleptic and lithium, in two separate events.
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Movement disorders can be caused any anti-dopaminergic medication, and less commonly, by atypical neuroleptics, such as risperidone. Rarely, lithium has been documented to cause a tremor similarly seen in Parkinson’s Disease. Conclusions: This is a rare case of multiple drug induced parkinsonism in an adult individual. Clinicians should be wary of the signs and symptoms of parkinsonism resulting from adverse medication effects. Level of Evidence: Level V Poster 332: Cervical Spinal Cord Stimulator Insertion Causing New Onset Tetraplegia Compromising Communication in a Hearing Impaired Family: A Case Report Jason B. Edwards (The University of Texas Health Science Center At Houston), Mark D. Fredrickson, MD Disclosures: Jason Edwards: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A hearing 72-year-old woman married to her hearing-impaired husband of 44 years underwent cervical spinal cord stimulator placement for failed back syndrome. Patient had a C4C5 corpectomy and C3-C6 fusion with instrumentation approximately 2 years prior for cervical myelopathy. She had residual bilateral upper extremity pain for which she had a cervical spinal cord stimulator trial with good results before undergoing permanent placement of a spinal cord stimulator. Patient had acute onset tetraplegia following the procedure. The stimulator was removed 1 week after placement with no improvement in symptoms. Patient was then admitted to inpatient rehabilitation. She showed minimal improvement in her fine motor skills over the course of 1 week. MRI showed a spinal cord contusion and posterior cavitation at the site of the stimulator insertion. She was evaluated by neurosurgery and underwent a C4-T1 laminectomy with concern for potential worsening cord compression. Patient was then readmitted to inpatient rehabilitation. Setting: Acute Inpatient Rehabilitation. Results: At 3 weeks post stimulator removal, patient showed minimal improvement in fine motor skills. She had worsening anxiety and insomnia secondary to impaired communication with her hearingimpaired husband. Discussion: This case is significant in that tetraplegia following spinal cord stimulator insertion is a rare event in itself. Furthermore, given this patient’s unique life circumstances, having a hearing-impaired husband as well as a hearing-impaired son and daughter-in-law, her loss of fine motor skills goes beyond functionality with activities of daily living, also impairing her ability to communicate with her immediate family. Conclusions: Spinal cord injury following spinal cord stimulator placement is a rare event. However, this case exhibits the need for careful patient selection as well as the importance of risk-benefit analysis of each patient regarding potential complications of spinal cord stimulator placement. Level of Evidence: Level V Poster 333: Improved Arousal with Frequent Zolpidem Dosing after Traumatic Brain Injury: A Case Report Ross D. Coolidge, DO (Rehabilitation Institute of Chicago, Chicago, IL, United States), Mithra B. Maneyapanda, MD, David L. Ripley, MD, MS, FAAPMR Disclosures: Ross Coolidge: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 22-year-old man with traumatic brain injury was admitted for acute inpatient rehabilitation 1 month after injury. MRI was notable for Grade 3 diffuse axonal injury with lesions in
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the bilateral crus cerebri, the left basal ganglia, and scattered areas in the subcortical white matter. Treatment with traditional neurostimulants resulted in minimal change. He was started on zolpidem 3 months after injury. An increase in arousal and participation was seen within 15 minutes of the first dose, and lasted up to an hour. Dosing was gradually increased to 15 mg six times a day, administered every 2 hours. He also had previously received a test dose of lorazepam with no effect on arousal. Setting: Inpatient Rehabilitation Hospital. Results: This patient demonstrated a transient increase in arousal, attention, and participation on zolpidem. His Coma Recovery Scale e Revised (CRS-R) score improved from 13 to 20 over the 6-week titration of zolpidem. He was discharged on zolpidem 15 mg every 2-hours six times per day without adverse effects. Discussion: High, frequent doses of zolpidem in this patient with disorder of consciousness was well-tolerated. Zolpidem’s effect on arousal may be due to selective binding to the omega- 1 site of the GABA A receptor. This patient’s lack of response to lorazepam is consistent with previous reports of no change in arousal after use of non-selective GABA agonists in patients with disorders of consciousness. Conclusions: To our knowledge, this is the first reported case of frequent, high dose use of zolpidem to improve arousal following TBI. Zolpidem may increase arousal in select patients with disorder of consciousness after brain injury. Patients may be able to tolerate higher doses and frequencies than previously reported without adverse effects. Level of Evidence: Level V Poster 334: Hashimoto Encephalopathy: Cognitive Advancement: A Case Report Ka Hoi Hui, MD (Baylor College of Medicine, Houston, Texas, United States), Mohammad A. Issa, MD, Craig DiTommaso, MD Disclosures: Ka Hoi Hui, MD: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 61-year-old woman with hypothyroidism and 3-month history of progressive confusion and memory loss presented with seizure. During her hospitalization, patient underwent extensive work up over the course of 1 month which excluded neoplasms, metabolic, infectious, and rheumatologic etiologies. She was found to have elevated antithyroid antibodies in her serum and CSF. She was eventually diagnosed with Hashimoto Thyroiditis. Patient was started on steroids and had improvement in cognition and regression of thalamic signal abnormalities on MRI. The patient was then admitted to the inpatient rehabilitation unit for 15 days with emphasis on improving her cognitive deficits using external aids and rote learning in addition to starting her on Donepezil. Setting: Hospital-based acute rehabilitation unit. Results: After completion of 15 days of inpatient rehabilitation patient demonstrated improvement in her FIM scores compared to baseline. Her FIM scores improved from 3 to 5 for memory and problem solving, 4 to 6 for expression, 5 to 6 for comprehension and social interaction, 1 to 6 for ambulation, 4 to 6 for transfer, 4 to 6 for lower extremity dressing, and 5 to 6 for upper extremity dressing. Discussion: Hashimoto encephalopathy is an uncommon clinical diagnosis associated with Hashimoto thyroiditis. It is a diagnosis of exclusion based on presence of antithyroid antibodies, neurological symptoms, and a positive response to immunotherapy. Current literature has limited information regarding cognitive and motor recovery with rehabilitation for patients with Hashimoto encephalopathy. Conclusions: External aids and rote learning may promote cognitive recovery in patients with clinical diagnosis of Hashimoto encephalopathy. Patients may also benefit from interdisciplinary rehabilitation to improve mobility and self-care skills. Level of Evidence: Level V
Poster 335: Heterotopic Ossification Extending into the Supraclavicular Notch with Resulting Shoulder Pain and Weakness in an Adult Man post Traumatic Spinal Cord Injury: A Case Report Austin L. Albright, MD (University of Virginia Physical Medicine) Disclosures: Austin Albright: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The patient presented to the AIRH setting after sustaining a traumatic C5 ASIA Impairment Scale - A SCI resulting from a 55 mph motor vehicle collision. He would develop severe left shoulder somatic and neuropathic pain, as well as external rotational weakness early in his rehabilitation course. CT ultimately would confirm the diagnosis of heterotopic ossification of a left clavicular fracture extending into the left supraclavicular notch with resulting suprascapular nerve compression. EMG/NCS would confirm a concurrent suprascapular neuropathy with resulting complete functional denervation. Multiple attempts to achieve appropriate analgesia were made including: Oral Analgesics (NSAIDs, Gabapentin, Cymbalta, Opioids), Topical Analgesics (Capsaicin, Lidoderm Patches, Fentanyl Patches), Desensitization Techniques, and a Series of Nerve Blocks. Surgical intervention was also considered at that time. Ultimately, his left shoulder pain would improve with medical management and without need for surgical intervention. Setting: Acute Inpatient Rehabilitation Hospital (AIRH). Results: At 6 years post presentation, the patient continues to demonstrate improved left shoulder pain resulting from his heterotopic ossification extending into his supraclavicular notch with resulting suprascapular neuropathy. His course has been and is complicated by multiple other concurrent somatic and neuropathic pain complaints resulting from his underlying SCI. Currently his pain is subjectively well managed with oral gabapentin, oral acetaminophen, and topical diclofenac. Discussion: This case demonstrates the complexities associated with diagnosing and treating musculoskeletal and neuropathic pain complaints in the SCI population. Conclusions: Suprascapular nerve palsy should be considered in the differential diagnosis for cervical level SCI’s with concurrent clavicular fracture presenting with shoulder pain. Level of Evidence: Level V Poster 336: Delayed Cryptogenic Functional Decline After Craniectomy with Immediate Improvement After Cranioplasty: A Case Report Deborah A. Hudleston, MD (Univ of Minnesota, Minneapolis, MN, United States) Disclosures: Deborah Hudleston: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Patient: 24-year-old man with severe traumatic brain injury (TBI). The patient was hospitalized on the inpatient rehabilitation unit from post-op week 3 through post-op week 10 after open bifrontal parietal bicoronal hemicraniectomies for significantly increased intracranial swelling and pressure. Eight weeks postoperatively he began to decline in function, with a 62% reduction in total ADL FIM scores from post-op week 8 to week 10. Workup for the etiology of his decline in function was unremarkable. He was transferred to the neurosurgery service at 10 weeks post-op for planned cranioplasty. On post-op day 1 after cranioplasty he was noted to have improved communication and safety awareness such that he no longer needed a safety assistant for the first time in 10 weeks. He was participating in therapies and readmitted to the acute rehabilitation unit on post-op day 2. Setting: Major metropolitan area level 1 trauma center.
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Movement disorders can be caused any anti-dopaminergic medication, and less commonly, by atypical neuroleptics, such as risperidone. Rarely, lithium has been documented to cause a tremor similarly seen in Parkinson’s Disease. Conclusions: This is a rare case of multiple drug induced parkinsonism in an adult individual. Clinicians should be wary of the signs and symptoms of parkinsonism resulting from adverse medication effects. Level of Evidence: Level V Poster 332: Cervical Spinal Cord Stimulator Insertion Causing New Onset Tetraplegia Compromising Communication in a Hearing Impaired Family: A Case Report Jason B. Edwards (The University of Texas Health Science Center At Houston), Mark D. Fredrickson, MD Disclosures: Jason Edwards: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A hearing 72-year-old woman married to her hearing-impaired husband of 44 years underwent cervical spinal cord stimulator placement for failed back syndrome. Patient had a C4C5 corpectomy and C3-C6 fusion with instrumentation approximately 2 years prior for cervical myelopathy. She had residual bilateral upper extremity pain for which she had a cervical spinal cord stimulator trial with good results before undergoing permanent placement of a spinal cord stimulator. Patient had acute onset tetraplegia following the procedure. The stimulator was removed 1 week after placement with no improvement in symptoms. Patient was then admitted to inpatient rehabilitation. She showed minimal improvement in her fine motor skills over the course of 1 week. MRI showed a spinal cord contusion and posterior cavitation at the site of the stimulator insertion. She was evaluated by neurosurgery and underwent a C4-T1 laminectomy with concern for potential worsening cord compression. Patient was then readmitted to inpatient rehabilitation. Setting: Acute Inpatient Rehabilitation. Results: At 3 weeks post stimulator removal, patient showed minimal improvement in fine motor skills. She had worsening anxiety and insomnia secondary to impaired communication with her hearingimpaired husband. Discussion: This case is significant in that tetraplegia following spinal cord stimulator insertion is a rare event in itself. Furthermore, given this patient’s unique life circumstances, having a hearing-impaired husband as well as a hearing-impaired son and daughter-in-law, her loss of fine motor skills goes beyond functionality with activities of daily living, also impairing her ability to communicate with her immediate family. Conclusions: Spinal cord injury following spinal cord stimulator placement is a rare event. However, this case exhibits the need for careful patient selection as well as the importance of risk-benefit analysis of each patient regarding potential complications of spinal cord stimulator placement. Level of Evidence: Level V Poster 333: Improved Arousal with Frequent Zolpidem Dosing after Traumatic Brain Injury: A Case Report Ross D. Coolidge, DO (Rehabilitation Institute of Chicago, Chicago, IL, United States), Mithra B. Maneyapanda, MD, David L. Ripley, MD, MS, FAAPMR Disclosures: Ross Coolidge: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 22-year-old man with traumatic brain injury was admitted for acute inpatient rehabilitation 1 month after injury. MRI was notable for Grade 3 diffuse axonal injury with lesions in
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the bilateral crus cerebri, the left basal ganglia, and scattered areas in the subcortical white matter. Treatment with traditional neurostimulants resulted in minimal change. He was started on zolpidem 3 months after injury. An increase in arousal and participation was seen within 15 minutes of the first dose, and lasted up to an hour. Dosing was gradually increased to 15 mg six times a day, administered every 2 hours. He also had previously received a test dose of lorazepam with no effect on arousal. Setting: Inpatient Rehabilitation Hospital. Results: This patient demonstrated a transient increase in arousal, attention, and participation on zolpidem. His Coma Recovery Scale e Revised (CRS-R) score improved from 13 to 20 over the 6-week titration of zolpidem. He was discharged on zolpidem 15 mg every 2-hours six times per day without adverse effects. Discussion: High, frequent doses of zolpidem in this patient with disorder of consciousness was well-tolerated. Zolpidem’s effect on arousal may be due to selective binding to the omega- 1 site of the GABA A receptor. This patient’s lack of response to lorazepam is consistent with previous reports of no change in arousal after use of non-selective GABA agonists in patients with disorders of consciousness. Conclusions: To our knowledge, this is the first reported case of frequent, high dose use of zolpidem to improve arousal following TBI. Zolpidem may increase arousal in select patients with disorder of consciousness after brain injury. Patients may be able to tolerate higher doses and frequencies than previously reported without adverse effects. Level of Evidence: Level V Poster 334: Hashimoto Encephalopathy: Cognitive Advancement: A Case Report Ka Hoi Hui, MD (Baylor College of Medicine, Houston, Texas, United States), Mohammad A. Issa, MD, Craig DiTommaso, MD Disclosures: Ka Hoi Hui, MD: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 61-year-old woman with hypothyroidism and 3-month history of progressive confusion and memory loss presented with seizure. During her hospitalization, patient underwent extensive work up over the course of 1 month which excluded neoplasms, metabolic, infectious, and rheumatologic etiologies. She was found to have elevated antithyroid antibodies in her serum and CSF. She was eventually diagnosed with Hashimoto Thyroiditis. Patient was started on steroids and had improvement in cognition and regression of thalamic signal abnormalities on MRI. The patient was then admitted to the inpatient rehabilitation unit for 15 days with emphasis on improving her cognitive deficits using external aids and rote learning in addition to starting her on Donepezil. Setting: Hospital-based acute rehabilitation unit. Results: After completion of 15 days of inpatient rehabilitation patient demonstrated improvement in her FIM scores compared to baseline. Her FIM scores improved from 3 to 5 for memory and problem solving, 4 to 6 for expression, 5 to 6 for comprehension and social interaction, 1 to 6 for ambulation, 4 to 6 for transfer, 4 to 6 for lower extremity dressing, and 5 to 6 for upper extremity dressing. Discussion: Hashimoto encephalopathy is an uncommon clinical diagnosis associated with Hashimoto thyroiditis. It is a diagnosis of exclusion based on presence of antithyroid antibodies, neurological symptoms, and a positive response to immunotherapy. Current literature has limited information regarding cognitive and motor recovery with rehabilitation for patients with Hashimoto encephalopathy. Conclusions: External aids and rote learning may promote cognitive recovery in patients with clinical diagnosis of Hashimoto encephalopathy. Patients may also benefit from interdisciplinary rehabilitation to improve mobility and self-care skills. Level of Evidence: Level V
Poster 335: Heterotopic Ossification Extending into the Supraclavicular Notch with Resulting Shoulder Pain and Weakness in an Adult Man post Traumatic Spinal Cord Injury: A Case Report Austin L. Albright, MD (University of Virginia Physical Medicine) Disclosures: Austin Albright: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The patient presented to the AIRH setting after sustaining a traumatic C5 ASIA Impairment Scale - A SCI resulting from a 55 mph motor vehicle collision. He would develop severe left shoulder somatic and neuropathic pain, as well as external rotational weakness early in his rehabilitation course. CT ultimately would confirm the diagnosis of heterotopic ossification of a left clavicular fracture extending into the left supraclavicular notch with resulting suprascapular nerve compression. EMG/NCS would confirm a concurrent suprascapular neuropathy with resulting complete functional denervation. Multiple attempts to achieve appropriate analgesia were made including: Oral Analgesics (NSAIDs, Gabapentin, Cymbalta, Opioids), Topical Analgesics (Capsaicin, Lidoderm Patches, Fentanyl Patches), Desensitization Techniques, and a Series of Nerve Blocks. Surgical intervention was also considered at that time. Ultimately, his left shoulder pain would improve with medical management and without need for surgical intervention. Setting: Acute Inpatient Rehabilitation Hospital (AIRH). Results: At 6 years post presentation, the patient continues to demonstrate improved left shoulder pain resulting from his heterotopic ossification extending into his supraclavicular notch with resulting suprascapular neuropathy. His course has been and is complicated by multiple other concurrent somatic and neuropathic pain complaints resulting from his underlying SCI. Currently his pain is subjectively well managed with oral gabapentin, oral acetaminophen, and topical diclofenac. Discussion: This case demonstrates the complexities associated with diagnosing and treating musculoskeletal and neuropathic pain complaints in the SCI population. Conclusions: Suprascapular nerve palsy should be considered in the differential diagnosis for cervical level SCI’s with concurrent clavicular fracture presenting with shoulder pain. Level of Evidence: Level V Poster 336: Delayed Cryptogenic Functional Decline After Craniectomy with Immediate Improvement After Cranioplasty: A Case Report Deborah A. Hudleston, MD (Univ of Minnesota, Minneapolis, MN, United States) Disclosures: Deborah Hudleston: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Patient: 24-year-old man with severe traumatic brain injury (TBI). The patient was hospitalized on the inpatient rehabilitation unit from post-op week 3 through post-op week 10 after open bifrontal parietal bicoronal hemicraniectomies for significantly increased intracranial swelling and pressure. Eight weeks postoperatively he began to decline in function, with a 62% reduction in total ADL FIM scores from post-op week 8 to week 10. Workup for the etiology of his decline in function was unremarkable. He was transferred to the neurosurgery service at 10 weeks post-op for planned cranioplasty. On post-op day 1 after cranioplasty he was noted to have improved communication and safety awareness such that he no longer needed a safety assistant for the first time in 10 weeks. He was participating in therapies and readmitted to the acute rehabilitation unit on post-op day 2. Setting: Major metropolitan area level 1 trauma center.