AIM

To facilitate opportunities for interdisciplinary learning and aligning the missions of the two organizations, we organized an educational program for current and future healthcare professionals focused on the relationship between quality and cost using the Top 5 lists to promote good stewardship in clinical practice, initially developed by the NPA, as a tool to initiate collaboration.

Patient: 37-year-old male with diabetic myonecrosis.

Case Description: The patient had a long-standing history of uncontrolled diabetes mellitus with multiple comorbidities, including end-stage renal disease on dialysis and diabetic myonecrosis of the left biceps femoris diagnosed by biopsy and magnetic resonance imaging (MRI.) On this admission, he presented with right leg pain and swelling, found to be a reoccurrence of diabetic myonecrosis in the vastus lateralis, medialis, and intermedius, diagnosed by MRI only. Prior to admission, he lived alone in a wheelchair inaccessible duplex and required minimal assistance with housekeeping.

Assessment/Results: Upon initial consultation, he ambulated 25-50 feet at a minimum assistance level with a single point cane. As he was unsafe to return home alone, he was transferred to inpatient rehabilitation after a two week acute hospitalization. During his rehabilitation stay, he increasingly was unable to tolerate standing secondary to pain, and at discharge, he was non-ambulatory despite many attempts at pain control and assistive devices for ambulation. His right leg swelling persisted throughout his stay. After five weeks on our unit, he was discharged to a long-term care facility at a wheelchair independent level. One year later he still was not ambulating, and still lived in the long-term care facility.

Discussion: Diabetic myonecrosis is an uncommon complication of both insulin-dependent and non-insulin dependent diabetics. Symptoms usually resolve on their own with rest and analgesics within weeks to several months. There are reports of physical therapy prolonging the recovery period and exacerbating symptoms, which may have happened with our patient.

Conclusions: Download poster.

Patient: 65-year-old female status-post liver transplant secondary to cirrhosis.

Case Description: Prior to the rehabilitation consult on post-operative day 42, she had an episode of acute rejection requiring rapid escalation of cyclosporine dosage, later changed to high dose tacrolimus for immunosuppression, resulting in high blood levels of both calcineurin inhibitors. She then complained of paroxysms of 10/10 pain over her entire body not relieved by opioids despite escalation in medication by the acute pain service. She was not participating in a rehabilitation program because of pain. Examination revealed an anxious woman for whom any tactile stimulation caused profound pain, precluding a thorough neuromuscular examination. She demonstrated spontaneous movement in all four limbs with akathesias.

Assessment/Results: After a literature search and discussion with the transplant team to determine if calcineurin-inhibitor induced pain syndrome (CIPS) was a likely cause for her pain, the patient’s immunosuppressive regimen was adjusted, as she was no longer in acute rejection. Tacrolimus was stopped, and cyclosporine dosage was gradually increased over several weeks. After her calcineurin inhibitor levels dropped, she had relief of pain such that she no longer required opioids, and could participate fully in an inpatient rehabilitation program. After less than two weeks on our inpatient service, she was discharged at a supervision level for household ambulation with a rolling walker.

Discussion: CIPS has been described as a cause of disabling pain after organ transplantation. In our patient, treatment of CIPS resulted in improved function. Reducing the blood levels of calcineurin inhibitor is the preferred treatment in the literature, as with our patient. In cases where this is not possible, calcium channel blockers have been used for pain relief.

Conclusions: Download Poster

Program Description: Patient presented initially to neurology service with chronic right hand flexion contracture in the context of 3 days of weakness and numbness in lower extremities after exertion. MRI/MRA Brain, Head CT, CT of entire spine were all unrevealing. Patient was transferred to the rehabilitation unit 8 days after initial admission. On rehabilitation admission patient exam was noted to have right hand markedly flexed with pain to passive ranging out of extreme flexion, chronic in nature. Patient initially had her hand ranged in the context of traditional therapy with limited success; however with use of EMG biofeedback patient was able to move all five metacarpophalangel joints on rehabilitation day 4, patient remarking that she was right handed again. Her pain level also dramatically decreased. Her overall functional status improved markedly by discharge and though she remained with decreased active range-of-motion in her right-hand, it did not detract from her overall functional status.

Setting: Rehabilitation Unit, University Hospital.

Results and Conclusions: Download poster.

Setting: Acute Inpatient Rehabilitation Unit, University Hospital.

Participant: 36 year old Caucasian woman at 18 weeks gestation.

Interventions: Provided education and training on basic childcare tasks at a wheelchair level, and on how to obtain wheelchair accessible baby furniture. Provided availability of a peer who sustained a spinal cord injury prior to pregnancy. Maintained a close working relationship with maternal fetal health department regarding management of nausea and pain management, and educated team members about the possibility of autonomic dysfunction. Physical and occupational therapies geared toward spinal cord patients in addition in psychological counseling to address the anxiety related to evolving neurological status in setting of her first pregnancy.

Results: Download poster.

Patient: 75-year-old woman with Stiff-Person Syndrome (SPS) with a recent fall and Colles fracture.

Case Description: Four months prior to admission, the patient was diagnosed with SPS, negative for anti-GAD antibodies. Diagnosis was based on a 3-year history of progressive rigidity leading to frequent falls and fractures. Anxiety and fear of falling limited her mobility, and she sustained a sacral pressure ulcer during acute hospitalization. On admission, history was remarkable for unsteady gait and muscle cramps exacerbated when startled or excited. Examination was remarkable for rigidity in her axial and limb muscles. She presented at the maximal assist level for transfers and toileting and moderate assist level for grooming and ambulation using a platform walker (right arm in cast). She was unable to tolerate titration of diazepam due to sedation, or baclofen due to hypotension.

Results: During acute rehabilitation, rigidity was treated with titration of dantrolene (from 25 to 50 mg four times daily) in addition to maximal tolerated doses of diazepam (1 mg qAM/2 mg qPM) and baclofen (20mg TID). The addition of dantrolene reduced rigidity and improved range of motion, both subjectively per patient and objectively by exam. Functional gains stalled with dose decrease and resumed with dose increase. She had pronounced gains in grooming to the supervision level, modest gains in transfers and toileting to the moderate assist level, but remained at the moderate assist level for ambulation. Progress was limited due to a change to non-weight bearing status of her right arm. Anxiety and depression were improved with buspirone, paroxetine, and psychological counseling.

Discussion: SPS results in significant activity of daily life and ambulatory dysfunction as exemplified by her pressure ulcer and multiple falls. Although GABA agonists are the preferred treatment for SPS, the adverse effects of high doses can increase the risk of falls. Dantrolene reduced muscle rigidity and improved function without sedative or hypotensive effects.

Conclusion: Dantrolene is a useful additional treatment for SPS rigidity.

Atlantoaxial instability results from cartilaginous destruction, periarticular erosions, and ligament and tendon attenuation. Instability affects 19%-70% of patients, and basilar invagination from vertical odontoid subluxation through the foramen magnum occurs in 38% of patients. This phenomenon occurs twice as often in women than men, whose age at diagnosis typically ranges from 30-50 years. Along with bony compression, the pannus further decreases the space available for the cord by 3mmor more in approximately 66% of patients (Figures 1-7). The earliest and most common symptom of cervical subluxation is pain radiating up into the occiput with associated headaches. Episodes of medullary dysfunction that represent severe but less common patterns of progressive myelopathic symptoms provide an even more grim prognosis. When cervical myelopathy is established, 50% of these patients die within 1 year.

Our data is consistent with prior studies in demonstrating that the incidence of dural puncture and CSF leak with SCS procedures is rare. Based on our experiences, performing an epidural blood patch intra-operatively on the contra-lateral side under fluoroscopy could prevent PDPH. This treatment should especially be considered in patients undergoing SCS trials in order to accurately assess the level of pain reduction. Patients with prior spine surgeries might pose higher risks for dural puncture and more extensive pre-operative assessment could be beneficial.

In our case series, percutaneous aspiration has been successfully used for 3 of 4 PTs with marked decrease in size of cyst on imaging and clinical improvement.

Obstructing pathology and ultimately the location of the cyst can be major factors in determining the success of the procedure.

Our study demonstrated that a minimally invasive aspiration of a ZP SC can often achieve clinical improvement.

This may save the PT from undergoing an invasive surgical decompression.

As part of a program of research on attention in TBI, we administered the SART and the CFQ to a sample of 34 survivors of moderate to severe TBI and to 35 control participants. CFQ scores reported by significant others showed clear group differences in everyday lapses of attention. Despite this, group differences in SART errors of commission were small and non-significant, and the correlations between SART errors and CFQ scores were small within both groups. Further analyses excluding participants with invalid score profiles, or restricting the analysis to the first performance of the SART failed to alter the results.

These findings suggest that more research is needed to establish the validity of the SART as a measure of sustained attention after TBI, and to determine under what circumstances the original findings hold.