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diagnosed with rhabdomyolysis and myonecrosis, suspected secondary
to nutritional supplement use. He was admitted to inpatient rehabil-
itation to improve ambulation and overall strength and endurance, as
well as activities of daily living.
Setting:
Inpatient Rehabilitation of Academic Medical Center.
Results:
The patient initially had significant back pain and spasms, which
limited his function. Both of 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 ambu-
lation, 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 supple-
ments 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 sup-
plements 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 181:
When Falling Is No Accident: A Rare Case of Distal
Acquired Demyelinating Symmetrical Neuropathy
Lisanne C. Cruz, MD (Icahn School of Medicine at Mount Sinai,
Brooklyn, New York, United States), Dara Jones, MD
Disclosures:
Lisanne Cruz: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 79-year-old man presented to the
emergency room after a fall and reported progressive lower extremity
numbness and “poor balance”. We review how our rehabilitation team
diagnosed this patient with distal acquired demyelinating symmetric
(DADS) neuropathy and worked to improve the patient’s function while
addressing the underlying cause of his dysfunction.
Setting:
Community Hospital.
Results:
The patient was admitted to Acute Inpatient Rehabilitation
for gait instability after undergoing evacuation for the subdural he-
matomas that resulted after his fall. While on the rehab service, pa-
tient was noted to have an ataxic gait, decreased sensation in the
distal extremities and significant distal atrophy. Electrodiagnosis was
performed and showed markedly prolonged latencies, reduced CMAP
amplitudes and very slow conduction velocities. SNAPs could not be
elicited in the lower extremities and there was evidence of denerva-
tion. The electrodiagnostic findings were consistent with a bilateral,
predominantly distal, sensorimotor polyneuropathy with both demy-
elinating and axonal features in distal upper and lower extremities.
Extensive laboratory work-up was negative, and immunoglobulin
testing was normal. These findings are most supportive of a diagnosis
of idiopathic chronic acquired inflammatory demyelinating (CIDP)
polyneuropathy with the DADS phenotype.
Discussion:
DADS is a progressive disorder that is typically sensory. It
varies from CIDP in that symptoms are only distal and weakness is
often absent. The majority of patients will have a monoclonal
gammopathy or it can be idiopathic without this finding. Immuno-
modulatory therapy is the treatment of choice. Hundreds of patients
are hospitalized annually for recurrent falls of unclear etiology, and
rarely is an underlying neuropathy diagnosed or considered. Physiat-
rists can uniquely offer both a diagnosis with implementation of
thorough neurological examination and electromyography, as well as
treatment through intensive rehabilitation.
Conclusions:
Experienced interdisciplinary Rehabilitation teams are
well prepared to assist patients with rare pathology, by not only
improving function but also treating the underlying etiology.
Level of Evidence:
Level V
Poster 182:
Brachial Plexopathy in Electrical Burn, A
Collaborative Team Approach for Functional
Planning: A Case Report
Yuriy O. Ivanov, MD (Montefiore Medical Center Albert Einstein
College of Medicine), Francis J. Lopez, MD, Michelle Stern, MD
Disclosures:
Yuriy Ivanov: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
Electrical injuries frequently cause burns,
blast injuries, life-threatening arrhythmias, trauma from falls and
neurological damage. Here we describe a 58-year-old woman who fell
on the electrical rail in the subway and sustained severe burns.
Setting:
Teaching Hospital.
Results:
She sustained bilateral axillae electric-current exit trauma
resulting in exposed neurovascular structures. The left upper limb
demonstrated a completely detached triceps muscle. Patient had se-
vere edema of the left arm and no volitional movement. There was
patchy distribution of sensory preservation in the left hand and
shoulder. On the right side patient had some motor movement with
preserved elbow and hand flexion but intact sensation. Rehab was
asked to join a collaborative team to determine optimal level of
amputation for the left upper extremity to salvage maximum function.
An attempt to perform an electrodiagnostic (EDX) study on the left
upper extremity was not successful due to edema. EDX on the right
upper limb demonstrated a severe brachial plexopathy.
Discussion:
According to an article by Wilbourn, the decision to salvage
an electrically injured extremity should be carefully weighed against
the potential for significant morbidity and mortality, especially when a
cold insensate, stiff extremity will be less useful to a patient than a
functional prosthesis. Literature search showed that accurate and
thorough EDX studies are important in aiding surgical planning when
deciding on the level of amputation as there are possibilities of recovery
in the future. After a collaborative multidisciplinary effort, rehab
recommended above elbow amputation vs shoulder disarticulation due
to infection risk combined with negligible functional benefits. This was
based on the severe and extensive damage to the left axilla, arm and
elbow.
Conclusions:
Collaborative team approach is essential in planning
amputations to maximize future functional recovery of patients.
Although EDX studies are important in aiding surgical preparation,
clinical judgement takes priority when evaluating electrical injury.
Level of Evidence:
Level V
Poster 183:
From Knee X-ray to Lymphoma Diagnosis: A Case Report
Rishi Vora (MedStar Georgetown/National Rehabilitation Hospital,
Washington, DC, USA), Thomas Heckman, DO
Disclosures:
Rishi Vora: I Have No Relevant Financial Relationships To
Disclose
Case/Program Description:
A knee x-ray revealed findings that lead
to a diagnosis of recurrent lymphoma.
Setting:
Outpatient Pain Management.
Results:
A 72-year-old man with an extensive medical history,
including treatment of B cell lymphoma, presented with left knee
pain. An x-ray of his left knee revealed cortical thickening of the
proximal tibia and fibular metadiaphysis. With a lack of trauma to the
knee, this finding became suspicious for hypertrophic osteo-
arthropathy (HOA) with a likely primary malignancy or pulmonary
etiology. PET scan confirmed an oncologic source with cervical
lymphadenopathy that demonstrated a recurrence of his lymphoma.
Discussion:
An interesting finding on a knee x-ray led to detecting the
recurrence of the patient’s lymphoma. Given a lack of trauma to the
knee and the location of hypertrophy, an intrathoracic or malignant
etiology could be suspected. While there are many causes of HOA, his
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Abstracts / PM R 9 (2017) S131-S290