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Poster 94 Bilateral Hip Pain and Limited Functional Recovery in Guillain Barre Syndrome: A Case Report
PM&R
spontaneous movements and responded to painful stimuli. On the third day, she was more awake and alert and was transferred to the general medical floor and was eventually discharged home upon resolution of symptoms. Discussion: Patients undergoing rehabilitation tend to be on several serotonergic agents. This case study highlights the importance of considering the possibility serotonin syndrome when patients are on serotonergic agents especially if they have chronic kidney disease. Conclusions: One dose of duloxetine in a chronic kidney disease patient while on trazodone may cause serotonin syndrome. Poster 92 Persistent Fainting with Nausea and Vomiting: A Case Report. Don Mathew (Marianjoy Rehabilitation Hospital, Wheaton, IL, United States); Padma Srigiriraju, MD. Disclosures: D. Mathew, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 40-year-old woman with depression and anxiety who worked as an accountant, presented with several episodes of fainting lasting less than a minute, along with bouts of nausea and vomiting for over 1 week’s duration. The patient described these episodes as sporadic and sometimes without preceding symptoms. Other times, she reported feeling light headed. These would occur with positional changes, typically from supine to sit or sit to stand. She also experienced nausea and vomiting upon eating, which eventually led to unintentional weight loss and deconditioning. She presented to a University Medical Center, where she was extensively worked up without any promising leads. Subsequently, the patient was seen by neurology and evaluated in an autonomic laboratory. The patient’s findings appeared to be consistent with seronegative autoimmune subacute autonomic neuropathy with severe orthostatic hypotension. It described the process to be at the level of the cardiac vasomotor and pseudo motor fibers, more so than cardiac vagal fibers. Patient was then placed on midodrine and fludrocortisone to help alleviate the orthostatic hypotension along with nutritional supplementation and Marinol to aid with appetite. She also received a plasma exchange, with only moderate relief. The patients symptoms persisted and led to difficulty in ambulating, balance issues, and difficulty transferring. In addition to medical therapy, the patient was sent to acute inpatient rehabilation. Setting: Acute Inpatient Rehabilitation Hospital, Results or Clinical Course: Since her admission in rehabiliation, the patient’s hospital course continued to be complicated; however, there were significant gains acheieved that medical management alone could not provide. The patient demonstrated improvements in all aspects of rehab, including strength and functional mobility. Moreover, she achieved more endurance, better balance, and independence in managing her own symptoms. Conclusions: Innovative techniques, such isometric exercises to help improve orthostasis and cardiovascular retraining to help stabilize autonomic dysfunction, in addition to balance and strength training, are all essential rehabilitation components which complement medical managment when treating the complexities of seronegative autoimmune subacute autonomic neuropathy.
Vol. 6, Iss. 9S, 2014
S215
Poster 93 Lipedema, Lymphedema and Lipolymphedema: A Case Report. Abir Naguib (Montefiore, Bronx, NY, United States); Anna M. Lasak, MD. Disclosures: A. Naguib, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 34-year-old woman presented with bilateral lower extremity (BLE) swelling and pain for 3 years. She had been seen by various practitioners; extensive workup had been done and she was diagnosed with primary lymphedema. She had been on diuretics but did not show any improvement. On examination, there was BLE swelling and erythema of the legs with skin induration. The swelling was especially prominent from the mid leg to the ankles. There was non-pitting edema on the dorsum of both feet. Stemmer’s sign was positive and there was tenderness to palpation. Limb circumference measurements were done at the metatarsophalangeal joint, heel, 10cm proximal to the lateral malleolus and at 10 cm increments up to 70 cm from the lateral malleolus. Body mass index was 55.7 kg/m2 and so weight loss was encouraged. Setting: Outpatient rehab clinic. Results or Clinical Course: Based on the clinical findings, the patient was diagnosed as lipolymphedema. She underwent complete decongestive therapy (CDT) which included manual lymphatic drainage, compression bandaging and compression stockings. Sessions were 2-3 times a week and each session lasted 90 minutes and so it was decided to initiate therapy on one extremity at a time. A home exercise program was taught. After 3 months of therapy, there was a significant improvement in the left LE swelling and pain compared to before and compared to the right LE. Discussion: Lipedema is the bilateral symmetrical deposition of fatty tissues in the lower extremities, extending from the hips to the ankles, sparing the feet. It is believed to be genetic and hormonal in origin being almost exclusively limited to females. It is an underdiagnosed condition as it is commonly mistaken for lymphedema or obesity and so diagnosis is usually late. It results in decreased mobility and disfigurement leading to depression and eating disorders. Lipolymphedema is a complication of lipedema which involves secondary lymphedema. Thus, early diagnosis and management of lipedema with CDT is important to prevent complications. Conclusions: Although there is no definitive treatment for lipedema, patients may benefit from CDT, diet and exercise. It is a chronic condition, therefore physiatrists must educate patients on maintenance therapy and self management in order to prevent progression. Poster 94 Bilateral Hip Pain and Limited Functional Recovery in Guillain Barre Syndrome: A Case Report. Abir Naguib, (Montefiore, Bronx, NY, United States); Huma H. Naqvi, MD. Disclosures: A. Naguib, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 47-year-old man presented with acute onset of bilateral upper and lower extremity numbness and weakness. He reported viral illness a week prior. Muscle strength was 1/5
S216
throughout, deep tendon reflexes were unobtainable and cranial nerves were intact. Suspicion was high for Guillain Barre Syndrome (GBS) and the patient was transferred to the ICU and started on a high dose of IVIG for 2 days. He was intubated for respiratory compromise. CSF and electrodiagnostic studies suggested Acute Inflammatory Demyelinating Polyneuropathy. During his ICU course he had failed an extubation and remained intubated for 3 weeks. Despite a second course of IVIG infusion no significant improvement was noted in his condition. Setting: Hospital in-patient and subacute rehabilitation. Results or Clinical Course: Repeat EMG was performed which was consistent with the diagnosis of acute motor axonal neuropathy (AMAN) variant of GBS. This explained why the patient was making very slow progress in rehabilitation. Also contributing to this was bilateral hip pain and stiffness which had gradually developed despite no history of trauma. Initial radiographs of the hips were negative for pathology. On follow up radiographs and CT scan of the hips there was evidence of bilateral heterotopic ossification (HO) of the hips. Bisphosphonates were offered to the patient but he declined. The patient continued intensive therapy and has currently regained near normal strength in the upper extremities. Recovery has been slow in the lower extremities; he is able to stand supported but unable to walk due to pain and stiffness in the hips. Discussion: HO is usually seen in the context of central nervous system disorders as traumatic brain injuries or spinal cord injuries. To date, there have been very few case reports of HO in GBS. Previous studies have found the incidence of HO to be higher in cases of GBS who have been in the ICU and on mechanical ventilation as well as immobilization for prolonged periods; this usually occurs in the AMAN variant of GBS. Conclusions: Physicians should be aware of the possibility of HO in GBS. Joint pain and limited ROM is an important indicator of underlying pathology. A high index of suspicion is required to detect HO early in the course of GBS to prevent further progression as it may have a significant impact on functional recovery. Poster 95 SAPHO Syndrome, a Rare Spondyloarthropathy: A Case Report. Manish Mammen, MD (SUNY Downstate Medical Center, Brooklyn, NY, United States); Anatoly Shnayder, MD; Raj Raval, MD; Sanjeev Agarwal, MD. Disclosures: M. Mammen, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: Patient presented to outpatient clinic with complaints of neck pain and decreased range of motion of her neck in all planes. She noticed these symptoms approximately 8 years ago after giving birth. After having a caesarean section, her incision did not heal for two years due to skin pustules. Over the next 6 years she developed decreased range of motion in her neck and paraspinal muscle cramps. She also developed alopecia. Imaging of her spine showed paravertebral hyperostosis. She had full range of motion in her neck without any significant muscle or joint complaints prior to getting pregnant. She was later diagnosed with SAPHO syndrome. Program Description: A 34-year-old woman. Setting: Outpatient clinic.
PRESENTATIONS
Results or Clinical Course: The patient was prescribed a nonsteroidal anti-inflammatory drug (NSAID), physical therapy and was advised to follow up in 6 weeks for re-evaluation. Discussion: SAPHO syndrome is a rare autoimmune disease. The acronym SAPHO represents Synovitis, Acne, Pustolosis, Hyperostosis, and Osteitis that are clinical features of the syndrome. It is a type of spondyloarthropathy, with an obscure pathogenesis, similar to psoriatic arthritis. Unlike Diffuse Idiopathic Skeletal Hyperostosis (DISH) which affects mostly men over 50, SAPHO affects mostly women between the ages of 10 and 50. Early recognition of SAPHO syndrome can be challenging as it can present in many different ways. The mainstay of treatment is symptomatic relief as there is currently no cure. The most common initial presentations include osteitis and palmoplantar pustulosis and first line treatments are with NSAIDs and antibiotics. The long term prognosis is usually good however symptoms may recur. Rehabilitation may play a role in improving range of motion from paravertebral hyperostosis by frequent stretching and isometric exercises to preserve strength. Conclusions: SAPHO syndrome may present with a combination of various musculoskeletal syndromes along with cutaneous involvement. SAPHO syndrome should be considered as a differential diagnosis in young female patients presenting with paravertebral hyperostosis. It is important to recognize and begin appropriate treatment early to control pain and avoid unnecessary and invasive treatments. Poster 96 Functional Status as a Better Predictor of Acute Care Readmissions as Compared to Comorbidities in Medically Complex Inpatient Rehabilitation Patients. Shirley Shih, MD (Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States); Paul Gerrard, MD; Richard Goldstein, PhD; Margaret A. DiVita, MS, PhD; Colleen M. Ryan, M.D; Jacqueline M. Mix, MPH; Paulette Niewczyk, MPH, PhD; Lewis Kazis, ScD; Ross D. Zafonte, DO; Jeffrey C. Schneider, MD. Disclosures: S. Shih, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To study functional status as a predictor of hospital readmissions in medically complex patients. Design: Retrospective database study. Setting: Inpatient rehabilitation facilities. Participants: A total of 120,957 (2.7%) patients in the Uniform Data System for Medical Rehabilitation who were admitted to inpatient rehabilitation facilities under the “Medically Complex” impairment code between 2002 and 2011. Interventions: Using logistic regression, we developed a Basic Model with the variables gender and functional status to predict the odds of 3-day, 7-day, and 30-day readmission from inpatient rehabilitation facilities to acute care hospitals. The FIM(R) motor score was used as a measure of functional status. We compared this model with six other models: three that added a comorbidity measure to the Basic Model and three that contained only gender and comorbidities. The comorbidity measures used were the Elixhauser index, the Deyo-Charlson index, and the Medicare comorbidity tier system. The c-statistic, or area under the receiver
spontaneous movements and responded to painful stimuli. On the third day, she was more awake and alert and was transferred to the general medical floor and was eventually discharged home upon resolution of symptoms. Discussion: Patients undergoing rehabilitation tend to be on several serotonergic agents. This case study highlights the importance of considering the possibility serotonin syndrome when patients are on serotonergic agents especially if they have chronic kidney disease. Conclusions: One dose of duloxetine in a chronic kidney disease patient while on trazodone may cause serotonin syndrome. Poster 92 Persistent Fainting with Nausea and Vomiting: A Case Report. Don Mathew (Marianjoy Rehabilitation Hospital, Wheaton, IL, United States); Padma Srigiriraju, MD. Disclosures: D. Mathew, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 40-year-old woman with depression and anxiety who worked as an accountant, presented with several episodes of fainting lasting less than a minute, along with bouts of nausea and vomiting for over 1 week’s duration. The patient described these episodes as sporadic and sometimes without preceding symptoms. Other times, she reported feeling light headed. These would occur with positional changes, typically from supine to sit or sit to stand. She also experienced nausea and vomiting upon eating, which eventually led to unintentional weight loss and deconditioning. She presented to a University Medical Center, where she was extensively worked up without any promising leads. Subsequently, the patient was seen by neurology and evaluated in an autonomic laboratory. The patient’s findings appeared to be consistent with seronegative autoimmune subacute autonomic neuropathy with severe orthostatic hypotension. It described the process to be at the level of the cardiac vasomotor and pseudo motor fibers, more so than cardiac vagal fibers. Patient was then placed on midodrine and fludrocortisone to help alleviate the orthostatic hypotension along with nutritional supplementation and Marinol to aid with appetite. She also received a plasma exchange, with only moderate relief. The patients symptoms persisted and led to difficulty in ambulating, balance issues, and difficulty transferring. In addition to medical therapy, the patient was sent to acute inpatient rehabilation. Setting: Acute Inpatient Rehabilitation Hospital, Results or Clinical Course: Since her admission in rehabiliation, the patient’s hospital course continued to be complicated; however, there were significant gains acheieved that medical management alone could not provide. The patient demonstrated improvements in all aspects of rehab, including strength and functional mobility. Moreover, she achieved more endurance, better balance, and independence in managing her own symptoms. Conclusions: Innovative techniques, such isometric exercises to help improve orthostasis and cardiovascular retraining to help stabilize autonomic dysfunction, in addition to balance and strength training, are all essential rehabilitation components which complement medical managment when treating the complexities of seronegative autoimmune subacute autonomic neuropathy.
Vol. 6, Iss. 9S, 2014
S215
Poster 93 Lipedema, Lymphedema and Lipolymphedema: A Case Report. Abir Naguib (Montefiore, Bronx, NY, United States); Anna M. Lasak, MD. Disclosures: A. Naguib, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 34-year-old woman presented with bilateral lower extremity (BLE) swelling and pain for 3 years. She had been seen by various practitioners; extensive workup had been done and she was diagnosed with primary lymphedema. She had been on diuretics but did not show any improvement. On examination, there was BLE swelling and erythema of the legs with skin induration. The swelling was especially prominent from the mid leg to the ankles. There was non-pitting edema on the dorsum of both feet. Stemmer’s sign was positive and there was tenderness to palpation. Limb circumference measurements were done at the metatarsophalangeal joint, heel, 10cm proximal to the lateral malleolus and at 10 cm increments up to 70 cm from the lateral malleolus. Body mass index was 55.7 kg/m2 and so weight loss was encouraged. Setting: Outpatient rehab clinic. Results or Clinical Course: Based on the clinical findings, the patient was diagnosed as lipolymphedema. She underwent complete decongestive therapy (CDT) which included manual lymphatic drainage, compression bandaging and compression stockings. Sessions were 2-3 times a week and each session lasted 90 minutes and so it was decided to initiate therapy on one extremity at a time. A home exercise program was taught. After 3 months of therapy, there was a significant improvement in the left LE swelling and pain compared to before and compared to the right LE. Discussion: Lipedema is the bilateral symmetrical deposition of fatty tissues in the lower extremities, extending from the hips to the ankles, sparing the feet. It is believed to be genetic and hormonal in origin being almost exclusively limited to females. It is an underdiagnosed condition as it is commonly mistaken for lymphedema or obesity and so diagnosis is usually late. It results in decreased mobility and disfigurement leading to depression and eating disorders. Lipolymphedema is a complication of lipedema which involves secondary lymphedema. Thus, early diagnosis and management of lipedema with CDT is important to prevent complications. Conclusions: Although there is no definitive treatment for lipedema, patients may benefit from CDT, diet and exercise. It is a chronic condition, therefore physiatrists must educate patients on maintenance therapy and self management in order to prevent progression. Poster 94 Bilateral Hip Pain and Limited Functional Recovery in Guillain Barre Syndrome: A Case Report. Abir Naguib, (Montefiore, Bronx, NY, United States); Huma H. Naqvi, MD. Disclosures: A. Naguib, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 47-year-old man presented with acute onset of bilateral upper and lower extremity numbness and weakness. He reported viral illness a week prior. Muscle strength was 1/5
S216
throughout, deep tendon reflexes were unobtainable and cranial nerves were intact. Suspicion was high for Guillain Barre Syndrome (GBS) and the patient was transferred to the ICU and started on a high dose of IVIG for 2 days. He was intubated for respiratory compromise. CSF and electrodiagnostic studies suggested Acute Inflammatory Demyelinating Polyneuropathy. During his ICU course he had failed an extubation and remained intubated for 3 weeks. Despite a second course of IVIG infusion no significant improvement was noted in his condition. Setting: Hospital in-patient and subacute rehabilitation. Results or Clinical Course: Repeat EMG was performed which was consistent with the diagnosis of acute motor axonal neuropathy (AMAN) variant of GBS. This explained why the patient was making very slow progress in rehabilitation. Also contributing to this was bilateral hip pain and stiffness which had gradually developed despite no history of trauma. Initial radiographs of the hips were negative for pathology. On follow up radiographs and CT scan of the hips there was evidence of bilateral heterotopic ossification (HO) of the hips. Bisphosphonates were offered to the patient but he declined. The patient continued intensive therapy and has currently regained near normal strength in the upper extremities. Recovery has been slow in the lower extremities; he is able to stand supported but unable to walk due to pain and stiffness in the hips. Discussion: HO is usually seen in the context of central nervous system disorders as traumatic brain injuries or spinal cord injuries. To date, there have been very few case reports of HO in GBS. Previous studies have found the incidence of HO to be higher in cases of GBS who have been in the ICU and on mechanical ventilation as well as immobilization for prolonged periods; this usually occurs in the AMAN variant of GBS. Conclusions: Physicians should be aware of the possibility of HO in GBS. Joint pain and limited ROM is an important indicator of underlying pathology. A high index of suspicion is required to detect HO early in the course of GBS to prevent further progression as it may have a significant impact on functional recovery. Poster 95 SAPHO Syndrome, a Rare Spondyloarthropathy: A Case Report. Manish Mammen, MD (SUNY Downstate Medical Center, Brooklyn, NY, United States); Anatoly Shnayder, MD; Raj Raval, MD; Sanjeev Agarwal, MD. Disclosures: M. Mammen, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: Patient presented to outpatient clinic with complaints of neck pain and decreased range of motion of her neck in all planes. She noticed these symptoms approximately 8 years ago after giving birth. After having a caesarean section, her incision did not heal for two years due to skin pustules. Over the next 6 years she developed decreased range of motion in her neck and paraspinal muscle cramps. She also developed alopecia. Imaging of her spine showed paravertebral hyperostosis. She had full range of motion in her neck without any significant muscle or joint complaints prior to getting pregnant. She was later diagnosed with SAPHO syndrome. Program Description: A 34-year-old woman. Setting: Outpatient clinic.
PRESENTATIONS
Results or Clinical Course: The patient was prescribed a nonsteroidal anti-inflammatory drug (NSAID), physical therapy and was advised to follow up in 6 weeks for re-evaluation. Discussion: SAPHO syndrome is a rare autoimmune disease. The acronym SAPHO represents Synovitis, Acne, Pustolosis, Hyperostosis, and Osteitis that are clinical features of the syndrome. It is a type of spondyloarthropathy, with an obscure pathogenesis, similar to psoriatic arthritis. Unlike Diffuse Idiopathic Skeletal Hyperostosis (DISH) which affects mostly men over 50, SAPHO affects mostly women between the ages of 10 and 50. Early recognition of SAPHO syndrome can be challenging as it can present in many different ways. The mainstay of treatment is symptomatic relief as there is currently no cure. The most common initial presentations include osteitis and palmoplantar pustulosis and first line treatments are with NSAIDs and antibiotics. The long term prognosis is usually good however symptoms may recur. Rehabilitation may play a role in improving range of motion from paravertebral hyperostosis by frequent stretching and isometric exercises to preserve strength. Conclusions: SAPHO syndrome may present with a combination of various musculoskeletal syndromes along with cutaneous involvement. SAPHO syndrome should be considered as a differential diagnosis in young female patients presenting with paravertebral hyperostosis. It is important to recognize and begin appropriate treatment early to control pain and avoid unnecessary and invasive treatments. Poster 96 Functional Status as a Better Predictor of Acute Care Readmissions as Compared to Comorbidities in Medically Complex Inpatient Rehabilitation Patients. Shirley Shih, MD (Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States); Paul Gerrard, MD; Richard Goldstein, PhD; Margaret A. DiVita, MS, PhD; Colleen M. Ryan, M.D; Jacqueline M. Mix, MPH; Paulette Niewczyk, MPH, PhD; Lewis Kazis, ScD; Ross D. Zafonte, DO; Jeffrey C. Schneider, MD. Disclosures: S. Shih, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To study functional status as a predictor of hospital readmissions in medically complex patients. Design: Retrospective database study. Setting: Inpatient rehabilitation facilities. Participants: A total of 120,957 (2.7%) patients in the Uniform Data System for Medical Rehabilitation who were admitted to inpatient rehabilitation facilities under the “Medically Complex” impairment code between 2002 and 2011. Interventions: Using logistic regression, we developed a Basic Model with the variables gender and functional status to predict the odds of 3-day, 7-day, and 30-day readmission from inpatient rehabilitation facilities to acute care hospitals. The FIM(R) motor score was used as a measure of functional status. We compared this model with six other models: three that added a comorbidity measure to the Basic Model and three that contained only gender and comorbidities. The comorbidity measures used were the Elixhauser index, the Deyo-Charlson index, and the Medicare comorbidity tier system. The c-statistic, or area under the receiver