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ACADEMY ANNUAL ASSEMBLY ABSTRACTS Discussion: These cases confirm the presence of a polio-like syndrome causing flaccid paralysis with physical and electrodiagnostic findings of anterior horn cell disease. Of note, the neurologic findings may exhibit a step-wise decline similar to acute polio prior to recovery. Conclusions: The polio-like syndrome of WNV encephalitis is now present outside the southern United States, and may be a relatively common finding (3 cases in 1 rehabilitation facility in 1mo). This syndrome may be easily detected using electromyography. Key Words: Electromyography; Motor neuron disease; Rehabilitation; West Nile virus. Poster 41 Distal Weakness in a Missionary With a History of Asthma. Farha S. Ikramuddin, MD (University of Minnesota, Minneapolis, MN); Marie-Christine Leisz, DO, e-mail: [email protected]. Disclosure: None. Setting: Tertiary care hospital. Patient: A 59-year-old male missionary in South Africa with adult-onset asthma. Case Description: The patient developed a small spot on his right foot. 2 days later, he had a fever, multiple joint pains, and pain and swelling of both legs. He presented to a Cote d’Ivoire hospital, was diagnosed with “insect bite” and treated with steroids. This progressed to severe neuropathic pain involving the upper extremities and weakness of hands and foot drop bilaterally. He returned to the United States for further workup. Assessment/Results: Extensive work-up was done to exclude infectious causes, including malaria, Lyme titre, venereal disease, blood cultures, human immunodeficiency virus, and lumbar puncture; all were negative. White blood count was 29.1 with 27% eosinophils. Lead, arsenic, mercury, folate, and B12 levels were normal. Total complement levels were reduced. Immunoglobulin E was high, creatine kinase was high, and antineutrophil cytoplasmic antibody (ANCA) was persistent with pANCA (myeloperoxidase). A chest radiograph showed calcified granuloma in the left midlung. A muscle and nerve biopsy revealed prominent perivascular inflammatory infiltrate (T-cells) with eosinophils. Extensive perivascular and endoneural macrophages were seen. Electromyography was consistent with severe multifocal axonal sensorimotor polyneuropathy. Sensory nerve action potentials of the bilateral sural, right ulnar, and median nerves were unobtainable. Compound muscle action potential (CMAP) of the bilateral peroneal, left tibial, right median, radial, and ulnar nerves were unobtainable. CMAP of the right tibial, musculocutaneous, and left axillary were attenuated. Electromyography demonstrated abnormal spontaneous activity in all muscles studied. Discussion: This is a rare cause of peripheral neuropathy Churg-Strauss syndrome. Diagnostic criteria are peak eosinophils ⬎1500/mm3, adult-onset asthma, systemic vasculitis involving 2 or more organs, with peripheral neuropathy dominating the clinical picture. Conclusion: It is important to familiarize physiatrists with this characteristic albeit rare cause of peripheral neuropathy. Early recognition and treatment has a good overall prognosis. When consulted, the patient was doing poorly in therapies; the cause was poor management of neuropathic pain. Once pain was treated, the patient’s FIM™ instrument scores improved dramatically. Key Words: Churg-Strauss syndrome; Electromyography; Peripheral neuropathies; Rehabilitation. Poster 42 Electrodiagnosis of Suprascapular Nerve Entrapment With Negative Shoulder Magnetic Resonance Imaging: A Report of 3 Cases. David S. Schneider, DO (Lake Cook Orthopedic Associates, Barrington, IL); Craig A. Cummins, MD, e-mail: [email protected]. Disclosure: None. Setting: Private practice. Patients: 3 adults with painful shoulders. Case Description: All 3 patients presented with chronic posterior shoulder pain. One complained of pain radiating distally past the shoulder, but that patient also had a diagnosis of a cervical radiculopathy. Another patient was also diagnosed with a cervical myelopathy. All 3 had weakness and atrophy in the supraspinatus and/or infraspinatus. All 3 patients had magnetic resonance imaging (MRI), which did not show any lesion of the suprascapular nerve. However, 2 had partial supraspinatus tears. Electrodiagnostically, 2 had delayed latencies of the compound motor action potential (CMAP): one to the infraspinatus and the other to the supraspinatus. Electomyographic findings in all 3 patients showed increased spontaneous potentials in the form of fibrillations and positive waves with reduced recruitment. Assessment/Results: Postoperatively, 2 patients had immediate reduction or elimination in pain and improved range of motion. The third patient was scheduled for suprascapular nerve decompression. Discussion: Suprascapular nerve injuries result from trauma, overuse, or a mass lesion. Common symptoms are posterior shoulder pain, weakness, and atrophy in the supraspinatus or infraspinatus. Injury at the suprascapular notch will cause abnormal nerve conduction studies (NCSs) or electomyographic findings at the supraspinatus and infraspinatus. The spinoglenoid notch is the distal site of injury and abnormalities are found only at the infraspinatus. MRI is useful in evaluating for ganglion cysts or denervation of muscle; but these abnormalities were not identified in these case reports. Conclusion: Suprascapular nerve injuries are uncommon, but should be strongly considered in patients with significant pain and weakness of the shoulder. False negative MRIs are seen commonly. Electomyography and NCS are specific and sensitive to help localize the site of injury for surgical decompression. Key Words: Electromyography; Magnetic resonance imaging; Rehabilitation.

Poster 43 Severe Carpal Tunnel Syndrome Improves With Conservative Management in a Polio Survivor With Only 1 Functional Upper Extremity Who Refused Surgery: A Case Report. Julie K. Silver, MD (Harvard Medical School, Framingham, MA); Dorothy D. Aiello, PT, MS; Maria Cole, OTR/L, e-mail: [email protected]. Disclosure: None. Setting: Outpatient rehabilitation clinic. Patient: A 47-year-old man with a history of polio and paralysis of his right arm. Case Description: The patient complained of numbness and tingling in his left hand both with activity and at night. His 2-point discrimination was 3 to 4mm, grasp strength was 70lb, lateral pinch was 22lb, and tip pinch was 15lb. Nerve conduction studies (NCSs) revealed an absent left median sensory nerve action potential (SNAP) and a prolonged motor nerve action potential (MNAP) equal to 6.1ms with a normal amplitude. The patient refused electromyography

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and was diagnosed with median neuropathy at the wrist, which appeared to be severe given the limited testing. A surgical consultation was recommended, but the patient refused, and conservative treatment was initiated. Treatment included lifestyle modifications, anti-inflammatory medications, vitamin B supplements, and a nocturnal wrist splint. He also began to use voice-activated software, speakerphone, large grip pen, and reduced-tension car steering. Assessment/Results: A repeat NCS was done at 6-month follow-up and it showed significant improvement of his left median neuropathy. The SNAP was present but prolonged at 4.7ms (normal, ⬍3.7ms) and the MNAP had decreased from 6.1 to 5.0ms (normal, ⬍4.3ms). Clinically, he reported no paresthesias, all measures of strength testing improved and 2-point discrimination was unchanged. Discussion: This is an impressive case due to the patient’s marked improvement in a short period of time after instituting multiple conservative interventions. Surgical treatment was strongly advocated initially because of the catastrophic consequences of the loss of functional use of his nonparalyzed arm and the typically excellent surgical outcomes. However, the patient steadfastly refused surgery and a conservative plan was initiated. Conclusion: As in this case, an aggressive conservative plan might be beneficial to patients for whom surgery is initially considered the most appropriate treatment. Key Words: Carpal tunnel syndrome; Median neuropathy; Rehabilitation. Poster 44 Occult Anterior Interosseous Nerve Entrapment After Carpal Tunnel Release: A Report of 2 Cases. William L. Doss III, MD (Hampton Roads Institute for Performance and Sports Medicine, Portsmouth, VA), e-mail: [email protected]. Disclosure: None. Setting: Outpatient. Patients: A 41-year-old woman (patient 1) with carpal tunnel syndrome (CTS) and a 65-year-old man (patient 2) with previous carpal tunnel release (CTR). Case Descriptions: Patient 1 initially presented with diffuse numbness in all fingers of the right hand. She had a negative magnetic resonance imaging of her cervical spine, and electromyography and nerve conduction study (NCS) revealed moderate CTS. She underwent CTR. Postoperatively, she was asymptomatic for 2 months when her symptoms returned. This time she had localized presentation of numbness in the first 3 fingers in the same hand. Physical exam revealed weakness of the pronator quadratus, a positive “OK” sign, and normal strength of the pronator teres. A repeat NCS revealed improvement of median motor and sensory latencies compared with the initial study. However, there was a prolonged anterior interosseous nerve (AIN) latency when compared with the contralateral side. Electromyography revealed increased spontaneous activity in the pronator quadratus. Patient 2 had metal plating of the left radius after sustaining radial fracture. Afterward, he developed CTS, which required CTR. The patient remained asymptomatic for 2 years until a fall, at which time numbness returned to his left hand. Physical examination revealed weak pronator quadratus, and a positive OK sign. Electromyography and NCS revealed normal median motor and sensory latencies, but showed positive fibrillation potentials of the pronator quadratus. Assessment/Results: Patients 1 and 2 had AIN entrapment. Discussion: AIN entrapment has been reported with supracondylar fractures of the radius. In the case of radial fractures, this presentation is usually immediate. These cases suggest a stenosis of the space for the AIN after CTR creating a compartment syndrome of the AIN. Conclusion: Special consideration must be paid to proximal median nerve entrapment after CTR other than assuming a return of CTS. Key Words: Carpal tunnel release; Compartment syndromes; Rehabilitation. Poster 45 Comparison of Electrodiagnostic Findings in Peroneal Neuropathy Due to Gunshot Wounds and Other Trauma.Okezie Okezie, MD (Baylor College of Medicine, Houston, TX); Ayse Dural, MD; Dan Graves, PhD, e-mail: [email protected]. Disclosure: None. Objective: To characterize the location and the nature of the nerve injury to the peroneal nerve in subjects with gunshot wound as compared with trauma due to other etiology. Design: Retrospective study analyzing the results of electrodiagnostic examination data in patients with peroneal nerve injury between January and December 2002. Setting: Outpatient electrodiagnostic clinic in a county hospital. Participants: 83 patients (46 women, 37 men) who had undergone electrodiagnostic examinations. Interventions: Not applicable. Main Outcome Measures: Peroneal nerve injuries diagnosed by electrodiagnostic examination, age, gender, and etiology of the nerve injury (local trauma, n⫽16; other, n⫽36). The locations of the nerve lesion were divided into proximal to the fibular head and at the fibular head. Results: 1-way analysis of variance showed no difference in the location of peroneal nerve injury or in gender between the 2 etiology groups. However, there was a difference in age, with younger subjects having a higher proportion of local trauma as etiology of nerve injury (F82⫽3.52, P⫽.034). Conclusion: Injuries to the peroneal nerve due to trauma were mostly axonal in nature and the younger age group appeared to sustain local trauma as etiology. Key Words: Electrodiagnosis; Peroneal neuropathy; Rehabilitation; Trauma.

Geriatrics Poster 46 Immunohistochemical Evidence of Immature Myosin Expression in Aged Rat Skeletal Muscle. LeAnn M. Snow, MD (University of Minnesota, Minneapolis, MN); LaDora Thompson, PhD, PT, e-mail: [email protected]. Disclosure: None. Objective: To evaluate 2 hindlimb skeletal muscles in young and aged rats for presence of immature myosin heavy chain (MHC) isoforms. Design: Randomized controlled trial. Setting: Basic science laboratory. Animals: Fisher 344 Brown Norway F1 hybrid rats, ages 12 and 36 months. Interventions: The soleus and extensor digitorum longus (EDL) muscles of young (12mo old) and aged (36mo old) sedentary rats were excised, quick frozen, and stained immunohistochemically for the developmental MHC isoform. Muscle cross-sections were then evaluated for the number of developmental positive fibers per unit area. Main Outcome Measures: Number of muscle fibers per unit cross-sectional area expressing developmental MHC. Results: The soleus

Arch Phys Med Rehabil Vol 84, September 2003