Francis Lopez

Poster 182: Brachial Plexopathy in Electrical Burn, A Collaborative Team Approach for Functional Planning: A Case Report

diagnosed with rhabdomyolysis and myonecrosis, suspected secondary to nutritional supplement use. He was admitted to inpatient rehabilitation to improve ambulation and overall strength and endurance, as well as activities of daily living. Setting: Inpatient Rehabilitation of Academic Medical Center. Results: Thepatient initially had significantbackpain and spasms,which limitedhis function. Bothof these symptoms improvedwhile in rehab. His CPKs trended down toward a normal range after intensive IV and oral hydration. At discharge, he was independent with transfers and ambulation, and was able to ambulate >500 feet with no assistive device. Discussion: Rhabdomyolysis can be caused by traumatic events (crush injuries) or non-traumatic events such as supplements, drugs, infections or overtraining. Over the counter nutritional supplements are used frequently by athletes, many times in combination with other supplements as well as prescription medications. The FDA does not evaluate these supplements and great caution must be taken when considering using these products. Patients should consult with a physician to fully review all current medications as well as herbal and nutritional supplements they are taking prior to beginning any new supplements. Conclusions: Nutritional supplements can be a possible cause of rhabdomyolysis. Level of Evidence: Level V

Poster 309: A Rare Cause of Ischemic Stroke in the Absence of Classical Risk Factors in an Otherwise Healthy 34-Year Old: A Case Report

Disclosures: Justin Raper: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 34-year-old Asian woman presented to the emergency department after an acute episode of confusion and speech difficulty. On initial evaluation she was disoriented, aphasic, had left-sided facial asymmetry, right-sided extremity weakness, and numbness. Urinary toxicology was negative. Computed tomography (CT), magnetic resonance imaging/angiogram (MRI/MRA), and carotid ultrasound were performed which confirmed an ischemic stroke. She was started on Aspirin, Plavix, and Lipitor, and transferred to acute inpatient rehab for further diagnostic investigation and functional optimization. Hematology recommended a hypercoagulable work-up. In collaboration with Neurology, advanced imaging was integrated with the entire clinical picture, resulting in a diagnosis of Moyamoya disease. Setting: Community Hospital. Results: MRI/MRA showed acute infarcts in the left anterior and left middle cerebral arteries with corresponding flow restriction. Carotid Ultrasound was negative for stenosis. Hypercoagulable work-up including Factor 5 Leiden, Protein C/S, Anti-Cardiolipin, Sickle Cell, Janus Kinase 2, Beta 2 glycoprotein were negative. Discussion: Moyamoya disease is a rare progressive cerebrovascular condition with an incidence of less than 1 in 100,000 in the United States. It most often occurs in children, but can also affect young adults in their thirties. Its etiology is believed to involve a genetic component which causes cerebrovascular stenosis and abnormal collateral blood vessels. These collaterals are fragile and may lead to hemorrhagic stroke. Prognosis depends on age and extent of ischemia; but the patient’s neurological status at the time of treatment is the most important prognostic factor. Medical management thus far has proven ineffective. Treatment is primarily surgical using encephaloduroarteriosynangiosis or encephalomyosynangiosis with the goal of revascularization across the blockage. Conclusions: Although rare in the United States, Moyamoya disease should be considered as a possible differential in young patients lacking classical risk factors for stroke. Since medical management has proven ineffective, a correct diagnosis is critical so patients may undergo revascularization surgery. Level of Evidence: Level V

Poster 64 Ischemic Stroke after Routine Cardiac Catheterization: A Case Report.

attempted. During the procedure, he became diaphoretic and complained of left-sided numbness and weakness. Immediate CT head revealed no hemorrhage or acute infarct, and tPAwas administered. CT Angiogram revealed an occluded left posterior inferior cerebellar artery (PICA) and a thrombus in the distal left vertebral artery. Cervical MRI revealed acute left PICA territory and posterolateral upper cord infarctions. It was later discovered that he had underlying fibromuscular dysplasia, a rare medical condition whereby patients have abnormal cellular growth (beading) in thewalls of their mediumand large arteries making them narrow and stenotic. After the patient was stabilized, he was transferred to acute inpatient rehabilitation. On arrival, he complained of intractable hiccups and vertical diplopia. Functionally, he required maximum assistance with ADLs and was non-ambulatory. Examination revealed left hemiplegia and impaired sensation on the left. Setting: Acute Inpatient Rehabilitation. Results: After comprehensive rehabilitation, he was ambulatory with contact-guard assistance using a quad cane and was discharged at a wheelchair level. Discussion: Vertebral artery dissection leading to stroke after chiropractic manipulation is rare, reported to occur in 0.5-16.7 in 100,000 cases; however, exact incidence is unknown. Fewer men than women suffer from fibromuscular dysplasia, but men have a higher incidence of dissections and aneurysms. Conclusions: It is important for physiatrists to investigate a history of fibromuscular dysplasia in patients presenting with cerebellar CVA secondary to vertebral artery dissection. Moreover, physiatrists with osteopathic training who routinely perform cervical manipulation should screen for fibromuscular dysplasia. Level of Evidence: Level V

Poster 43 Massive Mortality Risk Not a Barrier to Acute Rehabilitation: A Case Report

Objective: To investigate the association between seat elevator (SE) procurement and changes in functional mobility for clients recommended new equipment with SEs. Design: A retrospective analysis was conducted on clients recommended new equipment with SEs. Demographics, procurement data, and Functional Mobility Assessment (FMA) scores were obtained. Clients were divided into 4 groups, based on SE status before and after receiving new equipment: SE to SE (clients with prior SEs who received new SEs); no SE (NSE) to SE; SE to NSE; and NSE to NSE. Analysis was performed on 3 groups (NSE to NSE group was excluded due to insufficient sample). Setting: Assistive Technology clinic. Participants: 83 clients had data from both time points. Age range was 13 to 88 years. Participants were 41.0% female and 59.0% male. Interventions: Procuring new equipment with or without SEs. Main Outcome Measures: Groups were compared with regard to baseline demographics using ANOVA, Chi-square, and Fishers Exact tests. Within each group, Wilcoxon Rank Sum Analyses were used to compare two time points with respect to FMA individual items (on reach and transfer) and total FMA scores. Results: The 3 groups were not significantly different with regard to age, gender, or diagnosis. In the SE to NSE group, a significant decrease in FMA reach score was seen (P 1⁄4 .026). In the SE to SE group, a significant increase in FMA reach score, FMA transfer score, and total FMA was seen (P 1⁄4 .001, P 1⁄4 .002, P 1⁄4 .001, respectively). In the NSE to SE group, a significant increase in FMA reach score and total FMA was seen (P 1⁄4 .041, P 1⁄4 .049, respectively). Conclusions: Because SEs are often denied by insurance, more research is needed on SEs. This is one of the first studies to show that SEs may have a beneficial effect on reach, transfers, and overall functional mobility. Level of Evidence: Level III

Poster 397 Noninvasive Treatment of Cervical Muscle Spasm After Cervical Laminectomy and Fusion: Osteopathic Manipulative Therapy in Acute Rehab: A Case Report

Case/Program Description: A 69-year-old woman with past medical history of lymphosarcoma and status post revision of a T9-pelvic posterior instrumentation and fusion was admitted to an inpatient rehabilitation facility. She presented with weakness in bilateral lower extremities as a result of her non-traumatic spinal cord injury. She also complained of severe neuropathic pain of bilateral lower extremities and was treated with low-dose gabapentin which was titrated up to 3,200 mg/day. However, in the following days, she began to develop sudden, intermittent jerking of bilateral upper extremities. Setting: Acute Inpatient Rehabilitation Facility. Results: On further examination, she was noted to have intermittent myoclonic jerking of bilateral upper extremities. Her mental status and the remainder of her neuromuscular examination were unchanged from earlier in her admission. Due to the onset of myoclonus and recently increased dose of gabapentin, she was titrated off of gabapentin and her myoclonus resolved. In addition, a blood level of gabapentin was found to be supra-therapeutic confirming the suspicion of gabapentin-induced myoclonus. Discussion: Myoclonus is a brief, involuntary twitching of a group of muscles. Although rare, gabapentin toxicity can alone cause myoclonus. Gabapentin is a first-line medication in treating neuropathic pain. It should be used with discretion at high doses, particularly in patients with renal impairment. When there is concern for gabapentin-induced myoclonus, the patient should be titrated off of the medication and monitored for the resolution of symptoms. Conclusions: Gabapentin is a commonly used medication in the management of neuropathic pain. The clinical diagnosis of gabapentin-induced myoclonus should be considered when there is an acute onset of myoclonic jerking in a patient taking gabapentin. The physiatrist must maintain a high level of clinical suspicion when evaluating patients with neuropathic pain who develop new neurological symptoms. The clinician must identify early signs of gabapentin-induced myoclonus and act promptly to wean patients off of the offending agent. Level of Evidence: Level V

Poster 220 Metronidazole Induced Encephalopathy with Cerebellar and Magnetic Resonance Imaging Findings: A Case Report

Disclosures: O. Kim: I Have No Relevant Financial Relationships To Disclose. Objective: To investigate the effect of treadmill walking exercise as a treatment method for the improvement of gait efficiency in adults with CP and to clarify the gait efficiency during overground walking after the treadmill walking exercise. Design: The study collected oxygen consumption data for 21 adults with CP. Setting: The study was conducted in outpatient and inpatient settings. Participants: Fourteen adults with CP were recruited for treadmill walking exercise as an experimental group. A control group of seven adults with CP, who attended conventional physical therapy, were also recruited. Interventions: Not applicable Main Outcome Measures: The treadmill walking exercise protocol consisted of 3w5 training sessions per week for 1w2 months (total 20 sessions). Gait velocity, VO2, VCO2, O2 rate and O2 cost were assessed at the beginning and at the end of the treadmill walking exercise. The parameters were measured by KB1-C oxymeter. Results or Clinical Course: After the treadmill walking exercise, gait distance during overground walking up to six minute significantly increased from 151.29 24.53 m to 193.93 21.12 m, and gait velocity increased from 28.09 3.82 m/min to 33.49 3.40 m/min (P<.05). Energy efficiency evaluated by O2 cost during overground walking also significantly improved from 0.56 0.10 ml/kg/m to 0.41 0.05 ml/kg/m (P<.05), whereas O2 rate did not improve significantly after the treadmill walking exercise. On the other hand, gait velocity and O2 cost during the overground walking were not significantly changed in the control group. Conclusion: Treadmill walking exercise improved the gait efficiency showing decreased energy expenditure during overground walking in adults with CP. The treadmill walking exercise can be an important method for gait training in adults with CP who have higher energy expenditure.

Poster 73 A Rare Case of an Isolated Median Motor Neuropathy With Sensory Sparing Caused By A Palmar Ganglion Cyst: A Case Report

plegia and neurogenic bladder. Setting: Acute inpatient rehabilitation setting. Results: Physical examination at postoperative day 40 showed areflexia and impaired light touch sensation and weakness of the lower extremities. The second electrodiagnostic study showed remarkably diminished compound muscle action potentials with normal distal latencies and conduction velocities of the bilateral peroneal nerves but less severe in bilateral tibial nerves. Sensory conduction was normal. Late responses (H and F) were absent or delayed. Copious abnormal spontaneous activities were demonstrated in the left lower extremity. Discussion: Postoperative acute inflammatory demyelinating polyradiculoneuropathy was occasionally reported after cardiac surgery. However, no case reported of acute motor axonal neuropathy after cardiac surgery. Because electrodiagnostic findings change as the natural history of acute inflammatory demyelinating polyradiculoneuropathy, if early electrodiagnostic study is not confirmative for a diagnosis of acute inflammatory demyelinating polyradiculoneuropathy or acute motor axonal neuropathy, then sequential electrodiagnostic study is useful to confirm diagnosis. Conclusions: This is a report of the first case of acute motor axonal neuropathy developed after cardiac surgery by sequential electrodiagnostic studies.

Poster 34: Ventricular Assist Devices in Acute Rehabilitation: A Case Report

Disclosures: Y. Houshyar, None. Objective: Assessment of erectile dysfunction in coronary artery diseases. Design: Cardiac rehabilitation ward of Shahid Madani Hospital. Setting: Original. Participants: 12 men with coronary artery disease and erectile dysfunction. Interventions: EECP therapy was conducted in 20 sessions. Every session lasted 1 hour. Results: Mean BMI was 28.76 5.6, mean ejection fraction was 50.36 8.78 and mean VAS before and after EECP were 3 2.48 and 4.66 3.10, respectively, and the difference between them was significant (P .05). Conclusions: Our study showed that EECP can be significantly effective for ED in CAD patients, but further study is warranted to evaluate our results.