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Poster 35: “Influenza Vaccine Shoulder”- Vaccination-Related Traumatic Injury to the Infraspinatus: A Case Report
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plantation, albeit limited by insufficient donor hearts. VADs are mechanical devices that are used to partially or completely replace the function of a failing heart. They can be used as a bridge to transplant or as destination therapy with no plan for heart transplant. Patients with ESHD are severely restricted in activity for extended periods, leading to muscle atrophy, vulnerabilities for sensory and motor neuropathies, respiratory compromise and significant loss of quality of life (QOL). With focused rehabilitation, this patient increased exercise tolerance, decreased symptoms and was optimized for transplant. Conclusions: Acute rehabilitation plays a significant role for patients with VADs, by improving strength, endurance and functional capacity. The physiatrist’s knowledge of cardiac rehabilitation is essential in caring for patients with VADs. Keywords: Rehabilitation, Physical medicine and rehabilitation, Ventricular assist device.
CLINICAL OUTCOMES Poster 35 “Influenza Vaccine Shoulder”- VaccinationRelated Traumatic Injury to the Infraspinatus: A Case Report. Neeti A. Bathia, MD (New Jersey Medical School, Newark, NJ); Todd Stitik, MD. Disclosures: N. A. Bathia, None. Patients or Programs: A 34-year-old woman with shoulder pain after an influenza vaccination. Program Description: Patient reported 3 weeks of right shoulder pain beginning during an intramuscular (IM) influenza vaccination in the deltoid region. She noted more pain than usual during the vaccination and stabbing, 9/10 right shoulder pain with internal/external rotation and adduction afterwards. She denied any instability, clicking/popping, neurologic symptoms in the arm/hand, or any new repetitive activity. On examination, active internal/external rotation, resisted external rotation both with the shoulder adducted and abducted to 90° and shoulder impingement maneuvers were painful. Reflexes, strength, sensation and AC joint provocative maneuvers were normal. Traumatic infraspinatus and/or teres minor tendon injury was suspected as the cause of her pain. Setting: Outpatient musculoskeletal clinic. Results: She received little benefit from oral anti-inflammatory medication, a diagnostic subacromial lidocaine injection and 6 physical therapy sessions. T2-weighted shoulder MRI showed infraspinatus tendinosis consistent without frank tear. She is scheduled to undergo ultrasound-guided diagnostic lidocaine injection of the infraspinatus tendon sheath. Discussion: The deltoid muscle is a common site of IM injections. As per prior case reports, the greatest risk of injury is to the axillary nerve, subdeltoid bursa, and circumflex humeral artery. Despite prior studies examining skinfold thickness over the deltoid to estimate correct needle length for such injections and anatomic studies to determine struc-
POSTER PRESENTATIONS
tures at risk and the optimal site of needle placement, a study of both general practitioners and nurses questioning deltoid IM injection techniques showed a lack of understanding of deltoid region anatomy and, in general practitioners, a lack of formal training in administering IM injections. In this case, improper injection proximally into the deltoid muscle resulted in infraspinatus tendon injury, which has not been reported in the literature previously. Conclusions: Iatrogenic infraspinatus tendon injury during deltoid IM injection is a rare complication. Knowledge of shoulder anatomy and correct injection techniques is important for health care workers who administer IM injections. Keywords: Rehabilitation, Infraspinatus, Iatrogenic, Vaccine.
Poster 36 Botulinum Toxin Type-A (BoNT-A) Treatment Interventions in Stroke, Traumatic Brain Injury and Adults with Cerebral Palsy Related Muscle Overactivity: A Six-Year Retrospective Review. Albert Esquenazi, MD (MossRehab, Elkins Park, PA); Matteo Cioni; Stella Kim, MPA; Nathaniel H. Mayer, MD; Theera Vachranukunkiet, MD, BS. Disclosures: A. Esquenazi, Allergan, Research grants. Objective: To determine the patterns of Botulinum Toxin Type-A (BoNT-A) injection muscle selection, dosing and frequency of intervention associated with muscle overactivity in stroke, traumatic brain injury (TBI) and adult cerebral palsy (ACP) patients. Design: Retrospective review of data collected from 20032008. Setting: Gait and motor control analysis laboratories in a tertiary rehabilitation hospital. Participants: Data on 461 patients (1,430 sessions). Interventions: Clinically indicated BoNT-A injections for muscle overactivity. Main Outcome Measures: Patient demographics, limbs treated, muscle selection, treatment dose and frequency of treatment over time. Results: Data comprised of 461 patients (57.7% stroke, 27.5% TBI and 14.8% ACP). Average age at initial visit was 49 years (range, 18-89 y). More than half of the patients were men (53.8%). Over 40% of the patients had right side involvement, but for the stroke group 28.9% had left hemiparesis. There was no statistical significance between diagnosis and dose. However, the average number of muscles injected was less in ACP and TBI patients compared to stoke patients. Average BoNT-A treatment dose for the lower limb was 300.0 ⫾ 122.4 and 288.7 ⫾ 149.0 units for the upper limb. Commonly treated patterns in the upper and lower limbs included: flexed wrist/fingers and the equinovarus foot. The flexor digitorum superficialis (FDS) was the most commonly injected muscle (26.5%) for the treatment of flexed wrist/ fingers. The medial/lateral gastrocnemius muscles (40.3%) were the most frequently treated muscles for the equinovarus
plantation, albeit limited by insufficient donor hearts. VADs are mechanical devices that are used to partially or completely replace the function of a failing heart. They can be used as a bridge to transplant or as destination therapy with no plan for heart transplant. Patients with ESHD are severely restricted in activity for extended periods, leading to muscle atrophy, vulnerabilities for sensory and motor neuropathies, respiratory compromise and significant loss of quality of life (QOL). With focused rehabilitation, this patient increased exercise tolerance, decreased symptoms and was optimized for transplant. Conclusions: Acute rehabilitation plays a significant role for patients with VADs, by improving strength, endurance and functional capacity. The physiatrist’s knowledge of cardiac rehabilitation is essential in caring for patients with VADs. Keywords: Rehabilitation, Physical medicine and rehabilitation, Ventricular assist device.
CLINICAL OUTCOMES Poster 35 “Influenza Vaccine Shoulder”- VaccinationRelated Traumatic Injury to the Infraspinatus: A Case Report. Neeti A. Bathia, MD (New Jersey Medical School, Newark, NJ); Todd Stitik, MD. Disclosures: N. A. Bathia, None. Patients or Programs: A 34-year-old woman with shoulder pain after an influenza vaccination. Program Description: Patient reported 3 weeks of right shoulder pain beginning during an intramuscular (IM) influenza vaccination in the deltoid region. She noted more pain than usual during the vaccination and stabbing, 9/10 right shoulder pain with internal/external rotation and adduction afterwards. She denied any instability, clicking/popping, neurologic symptoms in the arm/hand, or any new repetitive activity. On examination, active internal/external rotation, resisted external rotation both with the shoulder adducted and abducted to 90° and shoulder impingement maneuvers were painful. Reflexes, strength, sensation and AC joint provocative maneuvers were normal. Traumatic infraspinatus and/or teres minor tendon injury was suspected as the cause of her pain. Setting: Outpatient musculoskeletal clinic. Results: She received little benefit from oral anti-inflammatory medication, a diagnostic subacromial lidocaine injection and 6 physical therapy sessions. T2-weighted shoulder MRI showed infraspinatus tendinosis consistent without frank tear. She is scheduled to undergo ultrasound-guided diagnostic lidocaine injection of the infraspinatus tendon sheath. Discussion: The deltoid muscle is a common site of IM injections. As per prior case reports, the greatest risk of injury is to the axillary nerve, subdeltoid bursa, and circumflex humeral artery. Despite prior studies examining skinfold thickness over the deltoid to estimate correct needle length for such injections and anatomic studies to determine struc-
POSTER PRESENTATIONS
tures at risk and the optimal site of needle placement, a study of both general practitioners and nurses questioning deltoid IM injection techniques showed a lack of understanding of deltoid region anatomy and, in general practitioners, a lack of formal training in administering IM injections. In this case, improper injection proximally into the deltoid muscle resulted in infraspinatus tendon injury, which has not been reported in the literature previously. Conclusions: Iatrogenic infraspinatus tendon injury during deltoid IM injection is a rare complication. Knowledge of shoulder anatomy and correct injection techniques is important for health care workers who administer IM injections. Keywords: Rehabilitation, Infraspinatus, Iatrogenic, Vaccine.
Poster 36 Botulinum Toxin Type-A (BoNT-A) Treatment Interventions in Stroke, Traumatic Brain Injury and Adults with Cerebral Palsy Related Muscle Overactivity: A Six-Year Retrospective Review. Albert Esquenazi, MD (MossRehab, Elkins Park, PA); Matteo Cioni; Stella Kim, MPA; Nathaniel H. Mayer, MD; Theera Vachranukunkiet, MD, BS. Disclosures: A. Esquenazi, Allergan, Research grants. Objective: To determine the patterns of Botulinum Toxin Type-A (BoNT-A) injection muscle selection, dosing and frequency of intervention associated with muscle overactivity in stroke, traumatic brain injury (TBI) and adult cerebral palsy (ACP) patients. Design: Retrospective review of data collected from 20032008. Setting: Gait and motor control analysis laboratories in a tertiary rehabilitation hospital. Participants: Data on 461 patients (1,430 sessions). Interventions: Clinically indicated BoNT-A injections for muscle overactivity. Main Outcome Measures: Patient demographics, limbs treated, muscle selection, treatment dose and frequency of treatment over time. Results: Data comprised of 461 patients (57.7% stroke, 27.5% TBI and 14.8% ACP). Average age at initial visit was 49 years (range, 18-89 y). More than half of the patients were men (53.8%). Over 40% of the patients had right side involvement, but for the stroke group 28.9% had left hemiparesis. There was no statistical significance between diagnosis and dose. However, the average number of muscles injected was less in ACP and TBI patients compared to stoke patients. Average BoNT-A treatment dose for the lower limb was 300.0 ⫾ 122.4 and 288.7 ⫾ 149.0 units for the upper limb. Commonly treated patterns in the upper and lower limbs included: flexed wrist/fingers and the equinovarus foot. The flexor digitorum superficialis (FDS) was the most commonly injected muscle (26.5%) for the treatment of flexed wrist/ fingers. The medial/lateral gastrocnemius muscles (40.3%) were the most frequently treated muscles for the equinovarus