Padma Srigiriraju

The Effects of Two Different Ankle-Foot Orthoses on Gait of Patients with Acute Hemiparetic Cerebrovascular Accident

Objective. To compare the effects of two types of ankle-foot orthoses on gait of patients with cerebrovascular accident (CVA) and to evaluate their preference in using each AFO type. Design. Thirty individuals with acute hemiparetic CVA were tested without an AFO, with an off-the-shelf carbon AFO (C-AFO), and with a custom plastic AFO (P-AFO) in random order at the time of initial orthotic fitting. Gait velocity, cadence, stride length, and step length were collected using an electronic walkway and the subjects were surveyed about their perceptions of each device. Results. Subjects walked significantly faster, with a higher cadence, longer stride, and step lengths, when using either the P-AFO or the C-AFO as compared to no AFO (P < 0.05). No significant difference was observed between gait parameters of the two AFOs. However, the subjects demonstrated a statistically significant preference of using P-AFO in relation to their balance, confidence, and sense of safety during ambulation (P < 0.05). Moreover, if they had a choice, 50.87 ± 14.7% of the participants preferred the P-AFO and 23.56 ± 9.70% preferred the C-AFO. Conclusions. AFO use significantly improved gait in patients with acute CVA. The majority of users preferred the P-AFO over the Cf-AFO especially when asked about balance and sense of safety.

Poster 216: Left Ventricular Assistive Device (LVAD) Placement as Bridge to Transplant for Patients with Chronic Inflammatory Viral Myocarditis: A Case Report

Disclosures: Evangeline Koutalianos: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 59-year-old woman with bilateral below elbow and below knee amputations (BKA); 30-year-old woman with bilateral BKA and partial hand amputations; 60-year-old man with bilateral BKA and transradial amputations. These patients all sustained QA secondary to sepsis. All participated in an acute inpatient rehabilitation program. One year postoperatively, two patients received pin-locking lower extremity (LE) prosthetics, one patient did not receive prosthetics secondary to infection. Myoelectric upper extremity (UE) prostheses enabled performance of fine motor tasks and increased independence with activities of daily living (ADLs). Upper limb hypersensitivity was treated with desensitization. Phantom limb pain varied in onset and management in all patients, majority reported acute onset pain persisting beyond the acute rehabilitation period. Residual limb and low back pain (LBP) seen in overweight patients was treated with aquatic therapy, core strengthening and stretching program. Setting: University Hospital. Results: On average, patients with QA achieved acute phantom limb pain control; received their prosthetics 1 year postoperatively; became independent with ADLs using myoelectric prostheses and with ambulation using LE prosthetics 1-2 years postoperatively. Barriers to receiving LE prosthetic sockets after 1 year included: poor healing, infections, weight bearing restrictions, insurance authorization. Overweight body habitus and poor activity participation were associated with pain and poorly fitting sockets. Discussion: More patients are surviving septic shock and sustain QA as a result. To date there is a paucity of literature on long-term rehabilitation management and expectations in these patients. Due to this growing population, it is vital to discuss cases such as these to determine functional expectations and achievable goals for our patients. Conclusions: This case series demonstrates long-term rehabilitation management in patients with QA. Awareness of such cases will improve rehabilitation management by optimizing pain control, carefully considering prostheses options, and providing realistic goals to improve functional independence. Level of Evidence: Level V

Poster 307: Non-Rhythmic Recurrent Shaking After Right Basal Ganglia Stroke: A Case Report

Disclosures: Austin Myers: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Three patients presented for evaluation of wrist drop. Patient 1 was a 15-year-old boy who awoke with a wrist drop and numbness following surgical repair of a humerus fracture. Patient 2 was a 58-year-old woman who awoke with wrist drop associated with a bruise on her triceps and no history of trauma. Patient 3 was a 61-year-old man who awoke with a wrist drop following crutch use and recent weight loss. Setting: Outpatient EMG Clinic. Results: Patient 1 had reduced radial motor and sensory amplitudes on nerve conduction studies (NCS); Neuromuscular ultrasound (NMUS) revealed a surgical screw impinging on the nerve at the spiral groove. Patient 2 had normal radial NCS and reduced recruitment in the extensor digitorum communis; NMUS revealed increased hypoechogenicity and caliber of the radial nerve at the exit of the spiral groove in direct contact with a hematoma. Patient 3 had reduced amplitude of the radial motor response with a normal radial sensory response, NMUS showed increased nerve swelling at the spiral groove on ultrasound. Discussion: Radial neuropathy at the spiral groove (Saturday Night Palsy) can be a challenging diagnosis based on electrodiagnosis alone because mild lesions can result in normal nerve conduction studies and severe lesions result in non-localizing axon loss pathology. Additionally, fascicular sparing can lead to erroneous localization (such as in case 3 where the lesion is at the spiral groove, but sensory fibers were spared). NMUS also revealed radial nerve pathology in this case series that has not been described previously in the literature (non-traumatic hematoma in case 2). Conclusions: Neuromuscular ultrasound can be a powerful compliment to electrodiagnosis in localizing radial neuropathies and determining etiology. Level of Evidence: Level V

Poster 378 Transverse Myelitis Secondary to Infectious Mononucleosis: A Case Report.

Disclosures: Michelle Chi: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 61-year-old woman was referred to the rehabilitation clinic for management of a 7-year history of refractory left foot pain and swelling, starting in 2009. She has a history of stage 4-endometrial cancer status post debulking with total abdominal hysterectomy, bilateral salpingo-oophorectomy, and retroperitoneal lymph node dissection in 2008 with recurrence in 2009. Recently, she was diagnosed with Lynch Syndrome, with a medullary carcinoma of the left transverse colon, and underwent total colectomy in 2015. Her left foot pain had been refractory to various prior treatments, including oral analgesics and physical therapy. Upon re-evaluation, the patient reported extreme left foot pain associated with increased edema since her recent surgery. Examination was notable for a mottled, erythematous appearing left foot associated with pitting edema from her ankles to toes. The diagnosis of CRPS in the context of lymphedema secondary to lymph node dissection was made. Treatment included lymphedema therapy, consisting of manual therapy and compression, with a 1-year history of pain relief. Due to recurrence, she was ultimately referred to pain management for further evaluation and subsequently underwent a lumbar sympathetic block. Setting: Outpatient cancer rehabilitation clinic. Results: Following sympathetic block, the patient reported no relief of pain. Treatment options for refractory CRPS were reassessed and she ultimately opted for a spinal cord stimulator (SCS) trial. After good pain relief from the trial, the patient is currently in the process of arranging implantation of a SCS. Discussion: This is a unique case, to our knowledge, of a patient with refractory lower extremity CRPS in the setting of lymphedema, originally stemming from multiple oncologic comorbidities. Additionally, this case highlights the unique position of the physiatrist in diagnosing and treating CRPS. Conclusions: CRPS is a serious and functionally limiting condition that may be especially difficult to treat in cancer patients who have undergone multiple extensive surgeries, resulting in lower extremity lymphedema. Level of Evidence: Level V

Poster 288 35-year-old Woman with Acute Inflammatory Demyelinating Disease (AIDP) after Laparoscopic Roux-en-Y Gastric Bypass: A Case Report

participate in the study (mean number of visits 1⁄4 2). Inclusion criteria: less than one year of age and no previous exposure to plagiocephaly cranial remolding therapy or surgical intervention. Interventions: Not applicable Main Outcome Measures: Reported measures include patient demographics and birth history (delivery type, presentation, induction of labor, birth aid, shoulder dystocia and torticollis); NBPP factors include palsy side, Narakas score and range of motion (shoulder flexion in adduction and elbow flexions in abduction). Cranial diagonal difference and cephalic index were measured to determine plagiocephaly factors. Results or Clinical Course: There were a total of twenty babies (71%) observed with plagiocephaly throughout the study (eight resolved). Shoulder dystocia was found to be prevalent among the group (46%) and was more common along the resolved group (88%, P1⁄4.02). Babies in the non-plagio group generally exhibited more active range of motion in shoulder flexion, elbow flexion abduction and adduction than babies with plagio. All other factors had no significant correlations. Conclusion: High prevalence of plagiocephaly exists among the NBPP population examined. Shoulder dystocia may be an important feature that can be used as a predictive quality in the future. In summary, parents and physicians should encourage infants to use their upper extremity to change position; for example, tummy time, could be introduced in order to strength the muscle and potentially reduce chance of cranial asymmetry.

Poster 256 Wegener’s Granulomatosis and the Rehabilitation Challenges in the Setting of Steroid Induced Myopathy: A Case Report

forty-two patients (12%) were re-admitted to acute rehabilitation for a second hospitalization. For this small subset of patients (n1⁄45), their admission FIM (70.8) and discharge FIM (86.5) had a paired t-test value with P 1⁄4 .078 showing a trend towards significance. Conclusion: Patients with chronic GVHD show significant improvement in physical functioning from acute inpatient rehabilitation as measured by FIM scores. Furthermore, in a small subset of patients readmitted for acute rehabilitation, they also show functional gains despite previous medical decline.

Poster 202 Recurrent Pneumonia Complicated by Sepsis Secondary to Silent Aspiration from Zenker's Diverticulum: A Case Report

Disclosures: A. Navarasala: I Have No Relevant Financial Relationships To Disclose. Case Description: A 73-year-old man with history of recurrent pneumonia complicated by sepsis presented with fevers, chills, and cough to the acute care setting. Chest x ray showed basilar infiltrates in ED suggestive of pneumonia. Following admission ID was consulted and merrem, vancomycin, and micafungin were started. During the hospital course blood cultures were positive for E. coli. On transfer to the rehabilitation hospital the patient was on chopped diet with thin liquids due to dysphagia. Video-fluoroscopic swallow study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) were performed and a Zenker’s diverticulum was discovered. Studies demonstrated penetration and aspiration on initial swallow worse with nectar thick than thin liquid from the diverticulum. Setting: Acute inpatient rehabilitation hospital. Results or Clinical Course: The FEES showed residuals in the valleculae, throughout the pharynx, A-E fold, and the intraarytenoid space. Swallowing strategies including chin tuck and multiple swallow cues improved clearance, but residual penetration and aspiration did not trigger cough. Aspiration occurred silently with nectar thick liquids vs. thin liquids, likely due to inadequate clearing. Follow up with a barium esophogram for more detailed assessment was recommended. The patient worked with speech therapy and strategies learned included alternating liquid/solid, throat clearing, controlling rate, and amount. Discussion: Zenker’s diverticulum is a rare complication in the elderly population that has a prevalence of 0.01 e 0.11% in the population. It is common in the male population during the 7th to 9th decades. Symptoms include dysphagia, sensation of food or medications sticking in the throat, unexplained weight loss, and chronic halitosis. This patient presented with complications of recurrent pneumonia with sepsis and a long history of pill dysphagia. Conclusion: In the elderly population with chronic dysphagia and the sensation of food sticking in the throat, a Zenker’s diverticulum must be ruled out. VFSS and FEES are screening methods that can be done in the rehabilitation setting to rule out mechanical causes of dysphagia which can prompt additional studies and surgical necessity. This patient was subsequently scheduled for barium swallow and surgical evaluation by an ENT specialist.

Poster 45 Postural Tachycardia Syndrome After Concussion: A Case Report

Disclosures: N. H. Gerber, No Disclosures. Objective: Determine the utility of a force feedback robot and virtual reality interface in assessed upper extremity activities in subjects with chronic traumatic brain injury (TBI). Design: Prospective cohort study. Setting: Biomedical research facility. Participants: 19 adults with TBI (7 mild, 3 moderate, 9 severe), 11 male / 8 female, mean age 50.4 years (SD 7.1), mean years from injury 10 year (SD 6.4). 3 were employed, 1 full time student; 9 received inpatient neurorehabilitation. Seven injuries resulted from MVA, 9 from falls, 2 from IED and 1 sports. Interventions: Stylus-driven haptic device navigating virtual scenes in 3D space. Subjects performed three repetitions of virtual tasks: 1. remove tools from a workbench (TOOL), 2. compose three-letter words (SPELL), 3. manipulate utensils to prepare a sandwich (SAND). Main Outcome Measures: Self-report of engagement in the activities (boredom), time to completion or number of words completed, neuropsychological symptom inventory (NSI), Purdue Peg Motor Test (PPT). Results: All 19 reported high engagement; 6 reported high level of frustration, but completed tasks with short breaks. Mean boredom score: 108 (SD 17.7) (normal range 81-117); mean PPT 54 (SD 15), (normal range for assembly line workers 67); mean NSI: 33 (SD 26). Change in three trials: best improvement in TOOL time decreased by (mean) 48 secs (SD 56.9); best improvement in SPELL was (mean) 2.8 words (SD 2.6), and best improvement in SANDprep time decreased by (mean) 19.7 sec(SD 32). PPT correlated with baseline SAND (r-.61, P .008) and SAND improvement time (r.60, P .02). NSI correlated with improvement in TOOL time (r-.45, P .09). Conclusions: All subjects were highly engaged, despite some subjects having difficulty with the task. Almost all subjects improved their performance suggesting significant practice effects that will require further study before this tool can be deployed as an assessment measure. The significant correlations between the PPT, NSI and haptic outcomes suggest a promising level of external validity.

Poster 13: Early surgery for heterotopic ossification in traumatic brain injury with 10-year follow-up: a report of 2 cases1

Abstract Setting: Freestanding rehabilitation hospital. Patients: A 54-year-old man and a 48-year-old woman. Case Description: We studied the cases of 2 patients who were admitted in 1987 (patient A) and 1990 (patient B) to our institution for traumatic brain injury rehabilitation. Both patients had heterotopic ossification (HO) of the hip. Patient B could achieve a maximum hip flexion of 20° to 30° before surgery with intensive physical therapy (PT) during inpatient rehabilitation. Patient As right hip range of motion (ROM) was 65° of flexion during inpatient rehabilitation. Over next 6 to 8 months, during outpatient treatment, patient As ROM decreased to 50° of flexion at hip. Both underwent early surgical excision of immature HO (patient B at 7mo; patient A at 12mo after injury) secondary to severe limitation in ROM at the hip leading to pain and dysfunction. Assessment/Results: After resection of HO, patient As right hip ROM increased to 90° and patient Bs left hip ROM increased to 55°. With intensive PT over the next 3 months, hip flexion improved to 85° for patient B. Both patients were independent community ambulators with a straight cane at the time of discharge from outpatient rehabilitation. Discussion: At 10-year follow-up, functional and ROM gains were maintained in both patients without any recurrence after surgery. Conclusions: Early surgical intervention is beneficial in patients with HO, which causes severe limitation in ROM and functional loss. The benefits far outweigh the risks of recurrence and are long lasting.