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discussion and approval of the patient’s mother, our team made a plan
to start a trial of low-dose Levodopa-Carbidopa for improvement of
her movement disorder. Patient was initially started on 10-100 mg one
hour prior to starting therapies.
Setting:
Acute Inpatient Rehabilitation Center.
Results:
After close monitoring with PT/OT/SLP it was noted that the
patient had significant improvement of her dystonic movements in all
four extremities. The next day we increased the dose to 10-100 mg
dosing one prior to morning therapies and one prior to afternoon
therapies. Our therapy team observed that the patient had a smoother
gait pattern, reduction in adventitious movements, and an easier time
initiating speech with the medication. These improvements were
sustained during her inpatient stay.
Discussion:
Conventionally, Levodopa-Carbidopa is FDA approved
for the treatment of Parkinson’s disease. Movement disorders can
stem from abnormalities in neurotransmitter levels after brain
injury. Although formal studies are lacking, we hypothesized that
the off-label use of Levodopa-Carbidopa may increase neuro-
transmitters in the brain to improve dystonic movements that were
limiting her during acute rehabilitation. Levodopa-Carbidopa can
be monitored after a one-time dose to determine any changes in
movement. In our patient it was adventitious to trial a dose during
an inpatient stay because we were able to closely monitor for
adverse effects.
Conclusions:
Consider off-label use of Levodopa-Carbidopa in pa-
tients with dystonic movements during rehabilitation. Levodopa-Car-
bidopa may provide noticeable improvements. Future studies of
pharmaceuticals are indicated to determine their role for manage-
ment of dystonia.
Level of Evidence:
Level V
Poster 455:
Functional Electrical Stimulation for Acute Flaccid Myelitis:
A Case Report
Xiaoning Yuan, MD, PhD (NY Presby Hosp/Columbia/Cornell, New
York, New York, United States), Hannah A. Shoval, MD, Xiaofang Wei,
MD, Ruth E. Alejandro, MD
Disclosures:
Xiaoning Yuan: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 4-year-old boy with autism presented
with onset of bilateral lower extremity (BLE) acute flaccid paralysis
over 2 days. Lumbar puncture was notable for pleocytosis and
elevated protein consistent with inflammation. Infectious work-up
was negative including enteroviruses. Imaging revealed enhance-
ment of the anterior spinal cord and cauda equina nerve roots.
Electrodiagnostics demonstrated normal sensory but absent motor LE
responses. He received intravenous steroids, intravenous immuno-
globulin, and plasmapharesis with no improvement. He was dis-
charged to acute rehabilitation with a diagnosis of acute flaccid
myelitis (AFM). Physical exam was notable for full bilateral upper
extremity strength and reflexes, and BLE flaccid paralysis, absent
reflexes, decreased tone, but intact sensation. Functional electrical
stimulation (FES) with a LE cycle was initiated 1 month into his
rehabilitation course, starting with daily 30-minute sessions of pul-
satile direct current stimulation (2 mA current, 30 Hz frequency,
125
m
s pulse duration). Surface electrodes were placed on the
quadriceps and tibialis anterior muscles.
Setting:
Inpatient rehabilitation unit.
Results:
The patient tolerated FES sessions with passive LE cycling for
2 weeks with no adverse effects. FES frequency was increased to 50 Hz
in order to recruit more individual motor units. However, after 4 more
weeks, his exam remained unchanged.
Discussion:
FES has wide application in upper motor neuron
diseases, but use in lower motor neuron diseases is controversial.
Our hypothesis is that FES provides orthodromic stimulation of
musculature to prevent atrophy, and antidromic stimulation at the
anterior horn, potentially leading to re-connectivity. However,
motor recovery was not demonstrated in our patient after 6 weeks
of FES.
Conclusions:
FES should be considered in AFM for prevention of
denervation atrophy. Muscle cross-sectional area may be a useful
parameter to measure in future FES studies to monitor for atrophy.
Antidromic stimulation may promote re-connectivity at the anterior
horn, but further investigation is necessary to establish this
relationship.
Level of Evidence:
Level V
Poster 456:
Pediatric Synovial Chondromatosis of the Hip: A Case
Report
Jared R. Levin, MD (Albert Einstein Col of Med, Bronx, New York,
United States), Yuxi Chen, MD, FAAPMR
Disclosures:
Jared Levin: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 16-year-old female with hip pain. The
patient had experienced 4 years of right hip pain after falling from a
jump in basketball, landing with the hip hyper flexed. The patient was
worked up in the ED, and subsequently by Rheumatology and Ortho-
pedics. Initial and 6 month followup MRI failed to reveal any bony or
soft tissue injury. She was eventually diagnosed with Juvenile Idio-
pathic Arthritis, despite negative serology, and treated with NSAIDs
without improvement. She was unable to walk greater than a block
due to pain.
Setting:
Pediatric Rehabilitation Clinic.
Results:
Recent MRI revealed a large right hip effusion with innu-
merable loose bodies, suggestive of Synovial chondromatosis. She
underwent Orthopedic surgery. Intraoperative biopsy confirmed the
diagnosis. Despite surgical intervention, she continued to have range
of motion limitations and pain, and was thus referred to Rehab where
she was started on physical therapy.
Discussion:
Synovial chondromatosis is a rare condition of a single
joint, in which niduses of cartilage form in the synovial membrane.
It is a benign form of connective tissue metaplasia. While it is
considered rare, it is most common in middle aged adults, and
about twice as common in men. Synovial chondromatosis can be of
primary or secondary etiology. The secondary form is associated
with a preexisting bony injury or arthritis. Our patient developed
synovial chondromatosis at a relatively young age. While cases of
Pediatric synovial chondromatosis have been reported, they are
very rare. We suggest this case to be of primary origin. In literature
review, we found no evidence of association between synovial
chondromatosis and juvenile Idiopathic Arthritis. Primary synovial
chondromatosis has previously been misdiagnosed as a
monoarthritis.
Conclusions:
This is unique case of synovial chondromatosis.
We suggest that Synovial chondromatosis is a worthwile differential
diagnosis to consider in a patient with unresponsive monoarthritis.
Level of Evidence:
Level V
Poster 457:
Improvement in Post-Traumatic Elbow Flexion
Contracture After Botulinum Toxin Type A Injection
Followed By Serial Casting of Active Female
Teenager: A Case Report
Shean Huey Ng (Rutgers University Medical School-Kessler
Rehabilitation Institute), Katherine S. Bentley, MD
Disclosures:
Shean Huey Ng: I Have No Relevant Financial Relation-
ships To Disclose
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Abstracts / PM R 9 (2017) S131-S290