Eric Wisotzky

Poster 155: Unilateral Upper Extremity Lymphedema Secondary to Subcutaneous Hemorrhage in the Setting of ACP-196 Treatment: A Case Report

Disclosures: Michael Wroten: I Have No Relevant Financial Relationships To Disclose Case/Program Description: We report a novel case of unilateral upper extremity lymphedema in a 75-year-old woman with a past medical history of Stage-IV chronic lymphocytic leukemia, thrombocytopenia and hypogammaglobulinemia. She reports taking ACP-196 (Acalabrutinib) a novel Btk-inhibitor as part of a study, starting in July 2015. She experienced hemorrhaging and edema of the left arm starting in December 2015. The edema started in the hand and migrated proximally. The medication was held in May 2016. The left arm returned to normal within 5 weeks and the medication was resumed. Hemorrhaging and edema returned, however, the medication was continued as it was deemed life-saving therapy. Setting: Outpatient Cancer Rehabilitation Clinic Results: Lymphoscintigraphy showed slowing proximal to the elbow and absence of lymphatics in the left axilla with collateral circulation. The lymphedema was attributed to chronic ecchymosis causing damage to the lymphatics and known enlargement of axillary and supraclavicular lymph nodes. The lymphedema improved with complete decongestive therapy of the left arm and diligent use of compressive garments and pneumatic compression pump. She also experienced abdominal lymphedema secondary to intra-abdominal and left axillary lymphadenopathy. This improved with manual lymphatic drainage and use of an abdominal attachment for her pneumatic compression pump. Discussion: Lymphedema is a common presenting complaint in cancer rehabilitation. Most commonly lymphedema results from trauma (i.e. surgery, radiation) or obstruction (i.e. tumor invasion) of the lymphatic system in affected patients. However, this case presents a scenario in which chronic ecchymosis likely led to damage to the lymphatic system, causing lymphedema. Conclusions: The rise of biologic therapies in the treatment of hematologic and oncologic conditions has resulted in a rapidly evolving pharmaceutical landscape. With a large number of new and experimental medications on the market, the cancer rehabilitation specialist should have a working knowledge of their side effects and impact on function and quality of life. Level of Evidence: Level V

Poster 170: Novel Approach to Ultrasound-Guided Botulinum Toxin Injection of the Medial Pterygoid for Trismus

Case/Program Description: A previously healthy 19-year-old man with severe hypoxic-ischemic brain injury secondary to acute respiratory distress syndrome requiring prolonged extracorporeal membrane oxygenation was initially admitted to our inpatient brain injury service with profound cognitive deficits, diffuse weakness, and bilateral knee flexion contractures. Throughout his rehab course, he made improvements in his cognitive and linguistic abilities and motor strength, however his ambulatory ability was markedly hindered by knee flexion contractures despite standard stretching exercises. He was unable to tolerate serial casting due to behavioral difficulties. Setting: Acute rehabilitation hospital Results: A continuous passive motion (CPM) machine was trialed for treatment of the patient’s bilateral knee flexion contractures. Initial measurements were -22 and -15 to neutral extension on the left and right knee, respectively. CPM was applied for 2 hours to each leg every night for 30 days. The CPM machine was initially set to medium speed with 45 flexion and extension to end range with 3 second extension rest. Degree of extension was increased every 2-3 days. Measurements of knee extension were obtained every 7 days. Patient continued with conventional inpatient therapies. By 30 days, the patient had knee extension of -5 and 0 to neutral on the left and right knees, respectively. He also demonstrated functional improvements including in limb advancement during gait, step length, and static standing. No adverse effects were noted. Discussion: Knee flexion contractures have major implications on functional gait impairment especially in patients with concomitant cognitive and motor deficits. Traditional interventions including serial casting, range of motional exercises aided by therapists, or surgery may be ineffective or poorly tolerated by certain patient populations. Here we describe an unconventional yet effective treatment for knee flexion contractures using the CPM machine. Conclusions: CPM may act as a simple, non-operative, cost-effective, and low risk treatment for knee flexion contractures. Level of Evidence: Level V

Poster 268: Metastatic and Radiation Brachial Plexopathy Masquerading as Carpal Tunnel Syndrome: A Case Report

upper extremities consistent with neuralgic amyotrophy also known as Parsonage-Turner syndrome. Setting: Tertiary care hospital outpatient clinic. Results: At 4 months after the onset of symptoms the patient regained significant amount of strength and function in bilateral upper extremities. He has continued with his prescribed physical therapy and home exercise program. Discussion: Neuralgic amyotrophy is a rare condition presenting usually unilaterally. It is thought tobecausedby immune-mediatedprocessesbut exact cause is unknown. As per previous studies, the recovery usually takes few years and is associated with residual weakness. This is the first reported case, to my knowledge, of significant recovery in bilateral neuralgic amyotrophy before 6 months after the onset of disease. Conclusions: Recovery of strength and function in bilateral neuralgic amyotrophy may occur earlier in the course of the disease than previously thought. Level of Evidence: Level V

Poster 278 Axillary Vein Compression Masquerading as Lymphedema: A Case Report

Disclosures: C. Cunningham: I Have No Relevant Financial Relationships To Disclose. Objective: To determine the prevalence and functional impact of Critical Illness Polyneuromyopathy (CIPNM) on inpatient rehabilitation. Design: Prospective observational study. Setting: Inpatient rehabilitation. Participants: Participants had ICU admission 72 hours, were admitted to inpatient rehabilitation from 2013-2014, were 19 years old, had no contraindications to electromyography or nerve conduction studies (EMG/NCS), and had no known history of neuropathy, myopathy, neuromuscular junction disorder or diabetes. Interventions: EMG/NCS to evaluate for axonal neuropathy and/or myopathy in at least one upper and one lower limb. Main Outcome Measures: Primary outcome measure was prevalence of CIPNM. Secondary outcome measures were Functional Independence Measure (FIM) scores at admission and discharge, FIM gain, FIM efficiency, rehabilitation length of stay and discharge disposition. Results or Clinical Course: 33 participants were enrolled. 23 (69.7%) had evidence of CIPNM. Average admission FIM score, discharge FIM and FIM gain were 60.0, 97.5 and 30.2 in those with CIPNM versus 74.8, 102.8 and 15.5 in those without. FIM efficiency was 0.37 in both groups. Average rehabilitation length of stay was 117 days versus 63 days and discharge to home was 43% versus 80% in the CIPNM and nonCIPNM groups, respectively. Conclusion: Our results suggest that CIPNM is very common in rehabilitation inpatients with a history of ICU admission. CIPNM is associated with lower admission FIM scores. Discharge FIM scores were similar between groups, but those with CIPNM had longer lengths of stay and were less likely to be discharged home. Our results will enable design of appropriately powered future studies to further determine the impact of CIPNM on rehabilitation outcomes.

Botulinum A Toxin Injections For Right Upper Extremity Spastic Hemiparesis in a Patient With Right Arm Lymphedema: A Case Report

groups. Although patients with more severe CVD presented lower flow volume augmentation during call-up (r1⁄4-0.64; P1⁄4.003) and during reabsorption maneuver (r1⁄4-0.52; P1⁄4.031), respectively in FV and GSV. Conclusions: Manual lymphatic drainage increases venous flow in lower extremity with a magnitude that is independent of the specific technique employed or the presence of CVD. Therefore, MLD may be an alternative strategy for treatment and prevention of venous stasis complications in CVD.

Ultrasound-Guided Intercostobrachial Nerve Block for Post Mastectomy Pain: A Case Series

Disclosures: R. A. Dutton, No Disclosures: I Have Nothing To Disclose. Case Description: The patient presented with chronic posterolateral hip pain for 15 years. He recalled a remote history of hip hyperextension during boot camp training. He described right hip pain, as well as a vibrating sensation (pallesthesia) and weakness involving the right lower extremity. On exam, internal and external right hip rotation elicited severe pain in the posterior hip. Straight leg raise test was unremarkable. There was no palpable bony lesion. Strength of right hip abduction was mildly decreased. Setting: Tertiary care outpatient clinic. Results or Clinical Course: EMG showed no evidence of neuropathy or myopathy. Pelvic X-ray revealed an accessory bone between the ischium and femur. MRI demonstrated a digit-like, non-fractured, non-inflammatory mature bone formation with pseudoarthrosis at the ischium. Oral analgesics and physical therapy failed to control symptoms. Trochanteric bursa steroid injection yielded temporary relief at the lateral hip, but pallesthesia and pain with hip rotation and extension persisted. The patient was referred for surgical resection of the pelvic digit. Discussion: Pelvic digit is a rare, congenital anomaly in which bone develops in soft tissue adjacent to normal skeletal bone. Often, the phenomenon is an incidental finding that does not require intervention. It is important to distinguish from other conditions such as avulsion fracture, myositis ossificans, or heterotopic ossification. To our knowledge, less than fifty cases have been reported, of which only two have been associated with symptoms. Both cases were managed surgically. Here, we report a third case of suspected symptomatic pelvic digit, which failed to respond to conservative measures. Conclusions: Pelvic digit is a rare and mostly asymptomatic developmental anomaly. However, pelvic digit can cause pain. An algorithm for management of symptomatic cases has not been established. Surgical resection may be a viable option for refractory symptoms.

An Unusual Presentation of Femoroacetabular Impingement: A Case Report

Disclosures: N. Muraoka, No Disclosures: I Have Nothing To Disclose. Case Description: A 57-year-old man with history of Hodgkin’s lymphoma treatedwith radiation 20þ years ago presented to our clinic for evaluation of intractable left hip pain that started a week prior without inciting event and is made worse with activity. It did not radiate and no associated numbness or tingling. Exam revealed mildly painful and reduced range of motion of the left hip (30 internal and 40 external) and tenderness over the left greater trochanter and left gluteal muscles. Sensation and reflexes intact. There is reduced bulk of the trunk and gluteal muscles without weakness on manual muscle testing. He walks with a Trendelenburg gait. Setting: Tertiary care hospital outpatient clinic. Results or Clinical Course: Left hip MRI showed a partial tear of the left quadratus femoris muscle with 9 x 9 x 3 cm hematoma and full thickness tear of the left quadratus femoris tendon, iliopsoas bursitis, atrophy and fatty infiltration of gluteus maximus, medius, and minimus muscles and hamstrings and edema in left adductor compartment. Patient was referred for aquatic therapy. Follow-up visit was 6 weeks later and in the interim, he developed similar atraumatic right-sided hip pain. Second MRI showed new right quadratus femoris tear with hematoma (7 x 3 x 5 cm), edema in the right adductor compartment, interval improvement of the left hematoma (3 x 2 cm). Discussion: Radiation fibrosis is a pathologic change in any tissue that can result as a late complication of radiation therapy. Radiation exposure can affect the vas vasorum and cause infarction of nerve, with atrophy of the innervated. The muscle fibers themselves can undergo fibrotic changes, leading to structural failure under tension. This patient had spontaneous bilateral quadratus femoris tears inside of six weeks without risk factors like steroids or fluoroquinolones and highlights the significant morbidity that can be a late consequence of radiation therapy. The quadratus femoris muscle acts as an adductor and external rotator of the hip and its failure likely contributed to the adductor strains seen on MRI imaging. Conclusions: Radiation fibrosis can be an early or late consequence of radiation therapy that can result in significant morbidity and functional impairment.

Poster 73 Suspected Parsonage-Turner Syndrome After Head and Neck Radiation Therapy: A Case Report

with right stage IIIA breast cancer and underwent bilateral mastectomies followed by chemotherapy with cyclophosphamide, doxorubicin, and docetaxel. She was radiated to the right subclavian lymph nodes with 4500cGy in 25 fractions and to the right chest wall with 5040cGy in 28 fractions. Within weeks of radiation she developed insidiously progressive right upper extremity weakness worse in the hand as well as worsening weakness of neck extension, and gait dysfunction. These symptoms significantly affected her function, ADLs and quality of life. Setting: Tertiary Cancer Center. Results or Clinical Course: The patient’s history, physical exam, MRI and EMG were all consistent with a severe right-sided RIBP as well as radiation-induced radiculo-plexo-neuro-myopathy consistent with radiation-fibrosis syndrome explaining her neck extensor weakness. A lumbar polyradiculopathy unrelated to radiation but consistent with her known history of spinal stenosis explained her gait dysfunction. The patient began physical and occupational therapy, was given a Headmaster cervical collar and bilateral posterior leaf spring orthosis, and appropriate nerve stabilizing medication. Discussion: While the diagnosis of RIBP carries a poor prognosis, providing patients with an accurate diagnosis and therapy aimed at increasing function can significantly improve quality of life. Conclusions: Mantle field radiation in addition to standard radiation can lead to severe brachial plexopathy. This possible sequela should be taken into consideration before treatment. The rehabilitation of cancer survivors suffering the late effects of radiation is a major challenge for physiatrists.