The Journal of the International Society of Physical and Rehabilitation Medicine

ABSTRACTS
Year
: 2020  |  Volume : 3  |  Issue : 5  |  Page : 1--488

Abstracts of scientific papers and posters presented at the ISPRM world congress and annual meeting of the association of academic physiatrists Orlando, Florida march 4–9, 2020


 

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How to cite this article:
. Abstracts of scientific papers and posters presented at the ISPRM world congress and annual meeting of the association of academic physiatrists Orlando, Florida march 4–9, 2020.J Int Soc Phys Rehabil Med 2020;3:1-488


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. Abstracts of scientific papers and posters presented at the ISPRM world congress and annual meeting of the association of academic physiatrists Orlando, Florida march 4–9, 2020. J Int Soc Phys Rehabil Med [serial online] 2020 [cited 2021 May 12 ];3:1-488
Available from: https://www.jisprm.org/text.asp?2020/3/5/1/283766


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 BEST PAPER PRESENTATIONS



 Faculty Category Award Winner



 Mild traumatic brain injury is associated with increased dual task cost during ambulation



Shanti Pinto, Mark A. Newman, Michael S. Runyon, Michael Gibbs, Lori M. Grafton, Mark A. Hirsch

Objectives: To determine the impact of dual task conditions on mobility following mild traumatic brain injury (mTBI). Design: Eleven individuals with mTBI (age 37.6 + 12.1 years; 6 female) within 1 week of injury and 10 age and sex matched healthy controls (age 38.9 + 11.6 years; 5 female) completed gait trials with a single task condition (baseline) and 3 separate dual task conditions: counting by 1 (low cognitive load), serial subtraction by 3 (medium cognitive load), and alternating sequence of letters and numbers (high cognitive load). Gait speed was measured using the GaitRite walkway. Dual task cost (DTC) refers to the percent decline in performance with addition of a simultaneous task and was calculated for each dual task condition. Repeated measures ANOVA was used to determine differences in gait speed or DTC by group and dual task condition. Results: There were significant differences in gait speed based on group and dual task condition (p-value 0.006) with significant main effect for group (p-value < 0.001). Participants with mTBI ambulated slower than control subjects with significant differences only in the medium and high cognitive loads (p-value < 0.05). Only 1/11 individuals with mTBI and 1/10 controls demonstrated gait speed < 0.8 m/s, which is predictive of community mobility, during any dual task condition. Significant differences were noted in DTC based on group and dual task condition (p-value < 0.001) with significant differences noted for group (p-value < 0.001) and dual task condition (p-value 0.005). DTC was greater for those with mTBI compared with controls with significant group differences for the low and high cognitive loads (p-value < 0.05). DTC exceeded 11.9%, previously determined to be the minimal detectable change in healthy adults, for 9/11 individuals with mTBI compared with 3/10 controls. Conclusions: DTC may be a more sensitive measure for impairment during dual task conditions than gait speed following mTBI.

 Fellow Category Award Winner



 Perceived benefits with the implementation of a cadaver-based ultrasound procedure workshop curriculum in physical medicine and rehabilitation (PM&R) resident and fellow trainees



Sharon Bushi, Rex T. Ma, Tiffany Ezepue

Objectives: Assessment of resident and fellow perceived benefits with a cadaver-based workshop to enhance their training for ultrasound-guided procedural skills. Design: 28 PM&R trainees in a single institution participated in a hands-on cadaver-based workshop with focus on ultrasound guided musculoskeletal and spasticity procedures. Five hours were Designated for the workshop with the first hour consisting of practice using tofu to visualize needles under ultrasound. This was followed by four hours of hands-on rotations through six stations, four for musculoskeletal and two for spasticity procedures, using cadavers and supervised by faculty with musculoskeletal ultrasound experience. The trainees were asked to fill out surveys before and after the workshop to assess self-perceived benefits. Results: The trainees were divided into the following post-graduate year (PGY) levels: 8 PGY-2, 8 PGY-3, 8 PGY-4 and 4 fellows. Everyone completed the surveys except one resident was excluded because she helped create the workshop. Among the trainees, 81.4% planned to incorporate musculoskeletal procedures in their practice while 74.1% planned to incorporate spasticity procedures. Most trainees felt clinical rotations to be most valuable in learning these types of procedures (77.7%) compared to independent study (48.1%) and formal didactics (44.4%). 40.7% of the trainees attended outside courses related to procedural training. Following the workshop, 92.6% of the trainees felt improvement in their overall knowledge of ultrasound guided musculoskeletal procedures with 77.8% increasing their knowledge of ultrasound guided spasticity procedures. In addition, 70.4% improved their level of comfort in planning procedures independently while 59.3% improved their level of comfort performing the procedures independently after this workshop. Conclusions: The use of a cadaver-based workshop demonstrated benefits in self-perceived knowledge, as well as comfort with independent planning and performing of ultrasound-guided musculoskeletal and spasticity procedures in PM&R trainees. This is especially important as most trainees plan to incorporate these procedures into their future practice.

 Resident Category Award Winner



 Prevalence of obesity and cardiometabolic syndrome in SCI patients in an Academic University Hospital System



Natasha Bhatia, Joshua L. Elkin

Objectives: Obesity prevalence increases annually in the United States. In the SCI population, the development of obesity, subsequent cardiometabolic syndrome, and further sequelae occurs at earlier ages and with increased prevalence compared to the able-bodied population. However, the diagnosis of obesity after SCI is complicated by a rapid loss of muscle mass and accumulation of visceral adipose tissue which artificially lowers BMI, and thus comorbid risk factor likelihoods have been significantly underappreciated in this population. Studies have shown that using the SCI-specific BMI cut-off of 22 (as opposed to the cut-off of 30 in the able-bodied population) results in obesity prevalence of up to 70-80% in the SCI population. This study was created as a quality improvement project to determine the prevalence of obesity and cardiometabolic syndrome in traumatic spinal cord injured patients within an academic hospital system in order to better understand our population's need for screening and intervention. Design: A retrospective observational study was condu7cted of patients with traumatic SCI within an academic hospital system from available electronic medical records. Collected information included age, SCI level/classification, mechanism of and time from injury, BMI, lipid levels, blood pressures, and fasting glucose levels. Obesity prevalence was determined by using the adjusted and unadjusted BMI measures (22 and 30 respectively). Metabolic syndrome prevalence was determined by IDF criteria. This is defined as obesity in addition to two of the following: serum triglycerides ≥150 mg dL-1 or drug treatment for elevated triglycerides, serum high-density lipoprotein HDL cholesterol < 40 mg dL-1 in men or < 50 mg dL-1 in women or drug treatment for low HDL cholesterol, blood pressure ≥130/85 mmHg or drug treatment for elevated blood pressure, fasting plasma glucose ≥100 mg dL-1 or drug treatment for elevated blood glucose) with adjusted BMI. Results: The sample consisted of 113 patients. 54 patients (48%) experienced a traumatic spinal cord injury and were included in the analysis. The average time since onset of SCI was 13 years, and 91% of the patients included were more than 1 year out from their initial injury. Time from injury ranged from 1 month to 43 years. 37% of the patients had a cervical injury, 26% thoracic, 9% lumbar, and 28% did not have a documented level of injury. Of the 52 patients with an available measured BMI, 45 (87%) met the criteria for obesity using the SCI-adjusted BMI cutoff of greater than 22. Only 22 (42%) of these would meet criteria for obesity when the unadjusted BMI >30 cutoff is used. Of the patients who had available metabolic laboratory values (n=23), 10 of them (43%) met criteria for metabolic syndrome, while the remaining 13 patients (57%) did not. Conclusions: Previous studies have shown that using the SCI-specific BMI cut-off of 22 Results in obesity prevalence of up to 70-80% in the SCI population. In our retrospective observational study, we found an obesity prevalence of 87%, though 45% of these patients would not have been categorized as such had the able-bodied BMI criteria been used. Patients with SCI are at increased risk of developing poor cardiovascular outcomes, but this risk may be under-recognized. In patients with traumatic SCI, both obesity and cardiometabolic syndrome are common and lead to a myriad of chronic inflammatory diseases. Our study shows, however, that many SCI patients may not be receiving rigorous screening given the high rate of incomplete data found in our cohort. More stringent guidelines for screening and treating these conditions must be implemented for primary and secondary prevention in this patient population.

 Medical Student Category Award Winner



 The acute impact of lower body positive pressure treadmill walking on biological markers of joint disease and joint pain in individuals with knee osteoarthritis



Sarah Libfraind, Chad M. Hanaoka, Avraham B. Eisenstein, Irmina J. Swiostek, Prakash Jayabalan

Objectives: The lower body positive pressure (LBPP) treadmill has potential in allowing individuals with knee osteoarthritis (OA) to obtain the cardiovascular benefits of exercise without risking potentially adverse articular cartilage loading by controlling the magnitude of biomechanical stress at the knee joint. The goal of this study was to investigate the biological and symptomatic effects of varying the percentage of joint loading imposed on the lower extremity during LBPP treadmill walking in individuals with knee OA. Design: Participants with knee OA (n=13) underwent two 45-minute walking sessions at least 72 hours apart. In each session, individuals walked on the LBPP treadmill at 100% and 50% body weight (BW), respectively. Every 15 minutes while walking, subjects were asked their pain score using the numeric pain rating scale (NPRS) and also had blood/serum drawn which was tested for a biological marker of cartilage turnover (cartilage oligomeric matrix protein, COMP), degradative enzyme (MMP-3) and inhibitor of degradation (TIMP-1). Results: The mean age of participants was 66.0+/-9.0 years, with a BMI of 29.0+/-4.0. At 45 minutes of 50% BW walking, subjects had a significant reduction in knee pain (NPRS) compared to the 100% BW condition (mean difference 2.39 +/1.59, p< 0.001). Biomarker analyses revealed that 100% BW walking was associated with a significant increase in COMP at 45 minutes of walking compared to baseline, not observed with the 50% BW condition (p=0.02). In addition, 50% BW walking was associated with a trend in increase of TIMP-1 (an inhibitor of cartilage degradative enzymes, 11% increase) that was not observed with 100% BW condition. There was no significant change in MMP-3 pre-and post-walking in each loading condition. Conclusions: Controlled knee joint off-loading using the LBPP treadmill, may limit the biomechanical and subsequent biological stress on the knee joint, improving symptoms, and has the potential to improve the catabolic state of the osteoarthritic knee joint.

 SCIENTIFIC PAPER PRESENTATIONS



 A protocol aimed to optimize bacteriuria management in patients with spinal cord injury



Felicia Skelton-Dudley, Lindsey Martin, Larissa Grigoryan, Sarah May, Casey Hines-Munson, S. Ann Holmes, Ivy Poon, Charlesnika Evans, Barbara Trautner

Objectives: Bacteriuria, either asymptomatic (ASB) or symptomatic urinary tract infection (UTI), is common in persons with spinal cord injury (SCI). Current Veterans Health Administration (VHA) guidelines recommend a screening urinalysis and urine culture for every Veteran with SCI during annual evaluation, even when asymptomatic, which is contrary to other national guidelines, such as those from the Infectious Diseases Society of America (IDSA). Through a series of innovative studies we will gain an in-depth understanding about the knowledge, attitudes and behaviors driving current UTI and ASB testing and treatment practices during the Veterans Health Administration (VHA) SCI annual exam (AE), as well as quantitative data on the clinical outcomes of these practices. Design: Prospective qualitative interviews and quantitative surveys; retrospective database analysis. Results: 12 SCI providers (SCI attending and resident physicians, physician assistants and nurse practioners) were interviewed. Thematic analysis of the interviews identified lack of awareness of the IDSA guidelines for ASB and UTI among SCI providers as a potential barrier to their use, but agreement that the guidelines are applicable to their patient population once informed. 24% of provider participants responded to a survey querying knowledge of the IDSA guidelines for treatment of UTI/ASB; 30% of all participants endorsed incorrect triggers for obtaining a urine culture (change in urine color, cloudiness or odor). 10 SCI patients were interviewed; thematic analysis revealed a good understanding of the importance of taking antibiotics for UTI as prescribed, as well as the possible consequences of antibiotic overuse. Analysis of the 9,880 unique AEs completed during 2018 and 2019 revealed that 29% had a screening urine culture obtained. Conclusions: The negative consequences of bacteriuria over-testing, subsequent antibiotic overuse and antibiotic resistance are well documented, and have national and even global implications. We have identified actionable gaps in SCI provider knowledge and behaviors towards ASB/UTI treatment. This study will inform an intervention aimed to educate stakeholders on evidence-based management of ASB and UTI, and guide antibiotic stewardship in the high-risk SCI population.

 A retrospective review of chemoprophylaxis for deep venous thrombosis in postoperative hip fracture patients during acute inpatient rehabilitation



Ameer S. Ali, Corey Johnson, Brian Mavretich, Perry Stein, Ann Erlanger

Objectives: Compare the incidence of DVT in hip fracture patients on various chemoprophylactic agents. The goal of this study would be to determine if Aspirin is sufficient for preventing a DVT. Design: This was a retrospective study. Included all patients (N=157) with hip fractures status-post operative repair admitted to acute inpatient rehabilitation between the dates July 2017 to July 2019. Patients with a prior history of DVT, pulmonary embolism, metastatic cancer or inherited Pro-thrombotic coagulopathies were excluded from this study. The study was conducted at Mercy Medical Center Acute Inpatient Rehabilitation Facility in Rockville Centre, New York. Data points gathered included age, gender, type of hip fracture, method of hip fracture repair, anticoagulant agent used and comorbidities. To adequate power, the anticoagulants were classified into three main groups. Aspirin (Group 1), Heparins (Group 2), and Novel Oral anticoagulants (NOAC) or Coumadin (Group 3). Patients on aspirin were examined with a weekly scheduled lower extremity venous ultrasound during the rehabilitation course. Results: 25.7% of patients in Group 1 developed a DVT. This is compared to 6% of patients in Group 2, and 2.6% of patients in Group 3. Hence, the incidence of patients developing a DVT on aspirin is significantly higher compared to heparin or NOAC's/coumadin. Conclusions: Based on these Results, patients treated with aspirin for chemoprophylaxis have a higher incidence of DVT. Our Results revealed, 25.7% of patients on Aspirin developed a DVT, compared to 6% on heparin, and 2.6% on NOAC/coumadin. We refute the recommendations by various orthopedic articles (2, 3, 4) claiming aspirin as one of the most effective, inexpensive and safest methods for DVT prophylaxis in these patients. These findings represent the importance of sufficient chemoprophylaxis to prevent potentially fatal pulmonary emboli. Hence, adequate anticoagulation with heparin or NOAC is imperative for good patient outcomes status post-surgical hip fracture repair. To adequate power, the anticoagulation medications were separated into three primary groups, irrespective of the dose of anticoagulation. For this reason, we recommend further research into analysis with account of the dosages of medications.

 Augmented reality treadmill training as a modality to improve gait rehabilitation poststroke



Nabela Enam, Oluwaseun Ibironke, Brandon Ross, Karen J. Nolan, Rakesh Pilkar

Objectives: Gait impairment following stroke often limits a patient's ability to achieve functional independence. The objective of this study is to develop an augmented reality-based treadmill program and evaluate its efficacy as a rehabilitation modality in improving dynamic gait and balance in individuals with post-stroke hemiparesis by targeting gait symmetry. Design: This is a randomized, control study. We include a healthy control to validate the equipment and six post-stroke patients with hemiparetic gait (3 stroke control, 3 stroke intervention). Both stroke groups undergo a treadmill intervention three days per week for a total of four weeks. The stroke control group performs standard treadmill training without augmented reality. The stroke intervention group goes through treadmill training with augmented reality in the form of projected stepping stones to guide step length. The outcome measures include pre and post intervention data collection of the six-minute walk test, ten-meter walk test, dynamic gait index, berg balance scale, and timed up and go. The physical activity enjoyment scale (PACES) is implemented as a post-intervention assessment tool. Results: Data interpretation from the healthy control showed that with feedback from augmented reality during treadmill training, the participant's center of pressure and loading force profiles could be manipulated towards by adjusting step length. With this rationale, we propose to implement augmented reality based guidance to specifically train the paretic-side stepping mechanisms during gait. Data collection for the stroke control and intervention groups is ongoing. Conclusions: Augmented reality treadmill training is a novel approach with the potential to impact and improve post-stroke gait training by providing patient-specific and interactive training in a safe environment.

 Cachexia syndrome is associated with the functional recovery of cancer patients in inpatient rehabilitation



Ishan Roy, Kevin Huang, Akash Bhakta, Jacqueline Spangenberg, Prakash Jayabalan

Objectives: The primary goal of this study was to investigate the association of cachexia with inpatient cancer rehabilitation through the following objectives: characterize the incidence of cachexia syndrome using weight- and lab-based criteria; identify factors associated with incidence of cachexia prior to rehabilitation; and determine if cachexia impacts functional recovery. Design: Retrospective cohort study of 330 admissions to Shirley Ryan Ability Lab (SRAlab). Included – subjects aged ≥ 18 years with diagnosis of cancer admitted to Northwestern Memorial Hospital (NMH) for acute care preceding rehabilitation. Data regarding oncologic care, acute care, and inpatient rehabilitation were acquired via medical charts at NMH and SRAlab. Four non-exclusive cohorts for cachexia syndrome were identified: chronic weight loss (5% body weight loss (BWL)/2% BWL with BMI< 20 in 2-6 months), rapid weight loss (5% BWL/2% BWL with BMI< 20 during acute care), serum creatinine< 0.60 mg/dL, and serum albumin< 3.5 g/dL. Results: On admission to inpatient cancer rehabilitation, the incidence of chronic weight loss was 58%, rapid weight loss was 25%, low creatinine was 35%, and low albumin was 69%. Chronic weight loss was associated with hematologic cancer (OR=2.1, p=0.02), recurrent cancer (OR=3.8, p< 0.0001), and infection (OR=2.9, p=0.01). Rapid weight loss was associated with GI cancers (OR=3.4, p=0.008), infection (OR=2.4, p=0.02), increased acute care length of stay (LOS) (OR=3.0, p< 0.0001), ICU stay (OR=3.7, p=0.003), and need for supplemental nutrition (OR=3.9, p=0.007). Low creatinine was associated with supplemental nutrition (OR=2.6, p=0.017), while low albumin was associated with increased acute care LOS and ICU stay (OR=7.8, p=0.0025; OR=7.5, p=0.031). Multivariate analysis then showed that low creatinine was independently associated with negative motor Functional Independence Measure gains during rehabilitation (p=0.021). Conclusions: This is the first study to characterize the incidence of cachexia syndrome in cancer patients requiring rehabilitation. While a diversity of factors were associated with cachexia, low creatinine was independently associated with poor functional prognosis, suggesting that this population may require more tailored rehabilitation.

 Development of a novel task-oriented rehabilitation program using a rehabilitation robot



Yi Mei Chen, Szu Shen Lai, Yu Cheng Pei, Jian Jia Huang, Chia Ju Hsieh, Wei Han Chang

Objectives: Hand function is essential for activities of daily living. Task-oriented rehabilitation is an individualized training program that involves multiple sensory feedbacks and facilitates neuroplasticity to recover from upper limb dysfunction caused by neurological disorders. However, it is usually difficult for a stroke patient to move his paralyzed fingers during hand function training in task-oriented rehabilitation. We then developed a new task-oriented training program using a novel robotic system that assists the movement of paretic fingers during robot-assisted rehabilitation and showed its effectiveness in patients with stroke. Design: The case series study consists of two steps: first, three healthy adults were recruited for investigating the usability and safety of training program; second, three stroke patients were recruited (age: 20-60 years-old, unilateral stroke, MAS≦2, BRS-A≦2, and MMSE≧24) for investigating the utility of training program. The robotic hand system (Mirror Hand) consists of an exoskeletal hand for affected hand, a sensor glove for non-affected hand and a control box. For the robot-assisted task-oriented training program, five types of objects were Designed to fit patient's hand function with different BRS, including: peg, rectangular cube, cube, ball, and cylindrical bar. Training program: firstly, a 5 mins of PROM and a 5 mins of robotic hand assisted bimanual movement applied as the preparation stage, and then applied task-oriented training using 5 objects for 20 times each object as the manipulation stage. The program was conducted for consecutive 3 days. Results: In the first step, the subjects in the healthy group perfectly manipulated all the objects both with and without the robotic hand. The average of successful rates in 3 days with or without robotic hand were 100±0%. The Results support the usability of the training program. In second step, subjects in the patient group had poor motor abilities and were unable to manipulate the objects without the use of robot. However, their successful rates dramatically increased after the application of the robotic hand (successful rate: peg= 98.89±1.92%, rectangular cube= 97.78±3.84%, cube= 97.78±2.55%, ball= 99.44±0.96% and cylindrical bar=100±0%) and thus showed no statistical significance as compared with the healthy subjects, indicating that the training program improved stroke patients' motor activities. Besides, the results revealed no significant difference between days in each subject with assistance by the robotic hand, again supporting the utility of our robot-assisted, task-oriented rehabilitation program for stroke patients. Conclusions: The objects can be successfully grasped by both healthy or stroke subjects, indicating the sufficient feasibility, stability and elasticity of the grasping objects we chosen. Also, the training program can be fruitfully performed in stroke patients, which indicates its utility in hand function rehabilitation. In the future, our team will perform a randomized controlled trial to evaluate the therapeutic effect of the training program.

 Diagnostic utility of electromyography to assess consciousness in patients with disorders of consciousness: A literature review



Nathan Darji

Objectives: There is a growing interest in diagnostic tools for the assessment of consciousness in patients with a disorder of consciousness (DoC). Currently, the gold standard for assessment of consciousness is the Coma Recovery Scale-Revised (CRS-R), a behavioral assessment that often relies on examiner experience and observed behaviors. Amongst the available diagnostic tools to assess consciousness, electromyography is underreported in current literature reviews. Given the significant ethical and rehabilitation implications of an accurate diagnosis of consciousness in patients with DoC, there is a necessity to review the effectiveness and potential clinical use of electromyography in the assessment of consciousness in patients with DoC, which is the objective of this literature review. Design: A comprehensive review of the literature was performed. Multiple databases including PubMed, MEDLINE, Embase, Cochrane, and CINAHL were searched with no timeframe restrictions. Search terms included “electromyography” and “disorders of consciousness” in all fields. Inclusion criteria included human subject patients with a diagnosis on the DoC spectrum, comparison of EMG to CRS-R (gold standard), and electromyography response as an outcome measure. Exclusion criteria included non-human studies, editorial commentaries, and literature reviews. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) was used to assess the quality of the reviewed literature. Results: A total of 183 studies were identified from the initial literature search, 72 of which studied human subject DoC patients. 19 articles remained after duplicates removed and 6 articles used EMG response as an outcome measure. 5 articles compared EMG to CRS-S. 1 article was excluded as it was an editorial commentary. A total of 4 studies examining the use of electromyography as a diagnostic tool to assess consciousness were included in this review. Conclusions: There is great variability in the methods of assessing EMG response in the reviewed studies. All 4 of these studies identified patients who were behaviorally non-responsive on CRS-R but demonstrated a significant clinical EMG response to either command or to a joke. All 4 studies demonstrated a high risk of bias on the QUADAS-2. Given that electromyography can potentially identify subclinical behaviors, there are significant diagnostic implications for the use of electromyography in the assessment of consciousness, but further studies with Designs that limit the risk of bias are needed. While there are limitations to using EMG as an assessment tool, it can potentially be utilized by the interdisciplinary team concurrently with standard rehabilitation treatments and assessments such as the CRS-R to enhance the diagnostic accuracy of patients on the DoC spectrum.

 Early amputation versus limb salvation – Comparing the impact on quality of life



Ramesh Munjal, Han Yin, Lisa G. Grandidge

Objectives: To compare patients' quality of life before and after amputation. Design: 27 patients who had an amputation following three or more limb salvage surgeries or ankle/knee replacements, who attended The Mobility and Specialised Rehabilitation Centre, Sheffield, between 01.02.16 and 31.07.16 and between 01.02.19 and 28.02.19 were included. A questionnaire was created using a visual analogue scale (VAS) and relevant factors from the EQ5D and then re-designed following a pilot on 4 patients. One to one interview was conducted following amputation and the questionnaire completed. Results: 66% (17) were transtibial amputees. 70.4% (19) had previous trauma followed by multiple reconstruction surgeries (range 3-28 operations). 11% (3) had infected knee replacements. The interval between the initial aetiology and amputation ranged from 1-29 years. Prior to amputation, 77.8% (21) patients scored their pain 10/10 (VAS). Post amputation pain improved significantly; 33.3% (9) reported they were pain free (p=0.00), with 92.6% (25) scoring less than 6/10. Pre amputation 59.3% (16) were SIGAM grade C. Pre-amputation only 11.1% (3) were at grade D or above compared to 81.5% (22) following amputation. There was an improvement in mood; prior to amputation 66.7% (18) reported depression compared to 37% (10) following amputation. 11.1% (3) could walk without aids prior amputation compared to 51.6% (14) post amputation. Conclusions: All in the infected knee group recommended early amputation as it had a positive effect on their quality of life. All except one patient in the traumatic group confirmed they would recommend early amputation or would have liked early amputation if they could turn the clock back. Repeated limb salvage surgery resulted in prolonged suffering, infections, several admissions, low mood and a high cost to the NHS. This is a small retrospective study but we feel a larger study will reveal similar findings and would recommend consideration of amputation at an early stage.

 Effect of independent versus common goal task condition on paretic arm movement performance



Gordon A. Ridgeway, Shailesh Kantak

Objectives: Individuals with unilateral stroke resulting from cerebrovascular accident (CVA) demonstrate substantial motor performance deficits in the contralesional paretic arm. While rehabilitation interventions involve task practice, characteristics of task conditions that augment paretic arm performance are highly debatable. In particular, the extent to which paretic arm performance is modified when a stroke survivor uses it to accomplish bimanual tasks with independent goals or a common goal is not known. The main purpose of this study was to compare motor performance of the paretic arm during bimanual common goal, bimanual independent goals and unimanual performance. A secondary aim was to determine if the effect of task conditions on motor performance differed between those with left and right CVA. Design: 17 individuals with LCVA, 16 individuals with RCVA and 10 neurotypical age-matched controls reached to grasp a dowel under three task conditions: unimanual, bimanual with independent goals and bimanual with common goal. Total movement time, peak velocity for reaching actions, grasp aperture, time to peak grip aperture and time from peak velocity to object grasp were extracted from position data acquired using electromagnetic sensors donned to the tip of index finger, thumb and wrist. Results: Compared to unimanual and independent bimanual conditions, common goal bimanual actions led to faster movements, higher peak reach velocity, smaller peak grasp aperture, and shorter time from peak reach velocity to object grasp in stroke survivors. Particularly, common goal bimanual task led to greater performance benefits in the LCVA group compared to the RCVA group. There were minimal effects of task conditions on motor performance in neurotypical adults. Conclusions: Our results indicate that task goals during bimanual actions significantly influence the kinematics of the paretic arm during reach-to-grasp actions. Common-goal bimanual actions need to be incorporated in therapeutic practice for arm rehabilitation after stroke, particularly for those with left CVAs.

 Factors associated with ambulatory and transfer ability: A study from the national spina bifida patient registry



Nicholas L. Benjamin, Gina McKernan, Sara Izzo, Theresa M. Crytzer, Gerald Clayton, Pamela Wilson, Amy Houtrow, Brad Dicianno

Objectives: This study used a Spina Bifida (SB) Electronic Medical Record (EMR) and the National Spina Bifida Patient Registry (NSBPR) to explore the effects of surgical history and other defined variables on ambulatory and transfer status over time in individuals with SB. Design: This study was an analysis of longitudinal data collected within the NSBPR. Demographics, motor level, ambulation ability, and transfer ability were collected. Ambulation and transfer ability were treated as binary outcomes. The SB EMR was used to collect additional variables at three sites (i.e. full orthopedic and neurosurgical history). Separate logistic regression models were created for ambulation ability and transfer ability for both myelomeningocele (MMC) and non-MMC subtypes. Results: In total, 643 individuals with MMC and 163 individuals with non-MMC had complete records and were included in the analysis. For ambulation in the MMC group, higher motor level, tethered cord releases, spinal correctional surgeries, hip orthopedic surgeries, and having supplemental insurance with or without public insurance were associated with decreased independent ambulation ability over time. Tibial torsion surgeries, being female, being non-Hispanic/Latino, and having public-only insurance were associated with increased independent ambulation ability over time while age, number of shunt revisions, and number of annual visits had weak associations. In the MMC group, higher motor level was associated with decreased independent transfer ability over time. Age, number of shunt revisions, and number of annual visits had weak associations. No significant associations were detected for ambulation or transfer ability in the non-MMC group. Conclusions: In addition to using the NSBPR, collecting a full neurosurgical and orthopedic surgery history within the SB EMR provides information useful for modeling ambulation and transfer ability over time. These results can help clinicians inform patients and families about functional prognosis and the effect of surgical interventions on ambulation ability and the ability to transfer.

 Functional changes after multilevel surgery in children with cerebral palsy



Javier R. Delgado Martinez, Diana Soto, Fernando Ortiz Corredor

Objectives: The goal of orthopaedic surgery in children with Cerebral Palsy is to improve the functionality in ambulation in those patients with the potential to perform this activity or correct and prevent deformities. To analyze postoperative functional changes in children with CP after multilevel surgery, measured with the GMFM-66 scale on each level of GMFCS. Design: Retrospective study, to compare GMFM-66 scores before and after multilevel surgery in patients under 18 years old with CP evaluated at one third level Hospital since 2004 until 2018. We excluded cases with unilateral CP, those operated before the first functional assessment with the GMFM-66 scale and those with other orthopaedic surgeries. The Wilcoxon signed-rank test was used for statistical analysis. Results: A sample of 103 patients was obtained, from 5 to 17 years old (mean 8.03); 58 boys. GMFCS: 4 patients in Level I (3.8%), 11 in Level II (10.5%), 18 in Level III (17.1%), 39 in level IV (37.1%) and 33 in level V (31.4%) of GMFCS. Type of CP: 77.1% spastic, 19.1% dyskinetic and 3.8% mixed. 56 of 103 patients showed a higher postoperative score of GMFM-66, 42 a lower score and 7 draws (Wilcoxon signed-rank test, p=0.41). With the analysis by functional level groups, it was found that there were no significant changes for levels I-II (p=0.33), Level III (p=0.24) or levels IV-V (p=0.92). Conclusions: It is controversial that the multilevel surgery results in a shift towards improvement in the functionality of patients with CP. However, studies of better methodological Design are required to clarify these Conclusions. It should be noted that patients with functional levels III, IV and V did not show a deterioration of their functional level measured with the GMFM-66 scale after multilevel surgery.

 Functional restoration in burns: A comparison between enzymatic escharlysis and surgery



Davide Dalla Costa, Patrizia Sgabussi, Vincenzo Morello, Michele Nichelatti, Antonella Citterio

Objectives: Acute phase of wound care in burns is crucial for the outcomes. The aim of the study is to analyze the impact of enzymatic debridement (ED) using Nexobrid (NXB) on rehabilitation, functional restoration and scarring outcome, compared to escharectomy (standard of care SOC). Design: 74 patients (aged 18-88) were enrolled consecutively in this retrospective study, divided in two arms (ED & SOC) according to depth of burn, total body surface area (TBSA), anatomical regions. Inclusion criteria: age > 18 years; deep dermal/full thickness burns of upper/lower limb, trunk, neck; caused by fire, flame, contact; requirement of surgical escharectomy, event occurred < 72 hours, wound area >0.5% TBSA. Burn Specific Health Scale-Brief (BSHS-B), Michigan Hand Questionnaire – Brief (Brief MHQ) were applied for Quality of Life (QoL) and functional recovery. Vancouver Scar Scale (VSS), Patient and Observer Scar Assessment Scale (POSAS) judged the scars. The same rehabilitation program was used. Measurements were recorded at discharge and follow-up (3-6-12 months). The primary objective was analyzed by means of Wald's test after logistic regression. Analysis of differences between arms included Mann-Whitney U test (Fisher's exact test). ANOVA was applied for VSS, POSAS, Brief-MHQ, BSHS-B. Results: The groups were similar respect to TBSA (NXB 16%, SOC 17%, p=0.038). The odds of needing rehabilitation was reduced by 81,2% (CI95%) (p=0.001) using NXB. About scar assessment (VSS, p=0.969; POSAS patient p=0.159, observer p=0.192), functional recovery and Qol, any significant differences were observed. Within each group, QoL was improved for BSHS-B and MHQ-B (p< 0.001). Conclusions: ED may reduce the need and length of rehabilitation after discharge in comparison with SOC for deep partial and full thickness burns. A larger cohort study should be done in order to corroborate these findings.

 High prevalence of disability in children aged 2–17 years old in Honduras, Central America, 2017



Gabriela M. Galdamez, Norma M. Castellanos, Ismary S. Rodríguez, José E. Sierra, Jackeline Alger, Rene M. Gonzales, Leonardo R. Sierra, Sonia Flores, Edna J. Maradiaga

Objectives: To determine disability prevalence in children aged 2-17 years old, Honduras, 2017, with the purpose to contribute with information for public policies to prevent and treat disabilities in this age group. Design: Cross-sectional descriptive study. Honduras National University (UNAH) last-year medical students trained in disability/rehabilitation visited 50 houses in their designated geographical area across the country and according to a multi-staged randomized sample methodology. Previous informed consent/assent, data was registered using two forms: one registered cases/population, and the other disability characteristics (Washington Group Instrument) and related factors (perinatal, congenital, genetics and acquired). Results: 271 last-year medical students were distributed nation-wide, covering 310 communities, 180 (58.1%) urban and 130 (41.9%) rural. They visited 16,676 houses of which 13,854 (83.1%) were inhabited with 15,511 children aged 2-17 years old, 4,852 (31.3%) aged 2-4 and 10,659 (68.7%) aged 5-17, 7,662 (49.4%) males and 7,849 (50.6%) females. The disability prevalence was 1,390 (9.0%, CI95%=8.52-9.41), 805 males, prevalence 10.5% (CI 95% 9.8-11.2), 585 females, prevalence 7.5% (CI95%=6.9-8.1). Prevalence by age in children aged 2-4 was 4.8% (CI95%=4.3-5.5), and children aged 5-17 was 10.8% (CI95%=10.3-11.4). Provinces with most disability prevalence were in the country central corridor: El Paraíso (13.7%), Francisco Morazán (12.4%), Santa Bárbara (11.5%), Cortés (10.2%). The structures and functions most affected were the ones related to the Central Nervous System, 62.2% (CI95%=59.6-64.7) and 67.5% (CI95%=64.9-69.9), respectively. The most affected ambits were behavior 4.3% (CI95%=3.8-4.6) and learning 3.1% (CI95%=2.6-3.4). Conclusions: Childhood disability prevalence identified was 9.0%, 7.5 times higher than the previously registered for Honduras by INE 2002. It is necessary to review perinatal policies to reduce preventable factors associated to childhood disability in Honduras.

 High rates of Vitamin D deficiency in acute inpatient rehabilitation



Jennifer Wu, Jay Han, Bi-Ying Yeh

Objectives: Vitamin D deficiency has wide ranging implications for the rehabilitation patient, including muscle strength, risk of falls, and osteopenia. The objective of the current study was to determine contemporary rates of vitamin D insufficiency and deficiency in an acute inpatient rehabilitation setting. Design: Retrospective cohort study of vitamin D levels in patients admitted to a university-affiliated inpatient rehabilitation facility (IRF). Secondary analyses examined demographic and clinical variables, including age, ethnicity, pre-IRF length of acute hospitalization, admitting diagnosis, and concurrent treatment with antiepileptics and systemic steroids and their association with vitamin D status. Results: In 100 patients admitted to a university-affiliated IRF, 76% of patients demonstrated low vitamin D level (serum 25(OH)D < 30ng/mL), with 47% vitamin D deficiency (< 20ng/mL) and 29% vitamin D insufficiency (20-29.9ng/mL). Increasing age was associated with lower rates of vitamin D deficiency and low vitamin D level (p< 0.0001). Conclusions: Vitamin D deficiency is common in patients admitted to an acute inpatient rehabilitation facility, particularly in younger individuals. The current results lend support to routine vitamin D deficiency screening in the inpatient rehabilitation setting.

 Ipsilesional intracortical excitability and hand recovery after stroke: An integrative neuroimaging approach



Carmen M. Cirstea, In-Young Choi, Phil Lee, Andrew Apostol, Shawn Yoo

Objectives: Hand recovery after stroke is in part dependent on neuroplasticity. By neuroplasticity, which can take many forms, we mean here changes in intracortical excitability. For instance, an increase of excitability augments plastic properties of the neural circuits resulting in creation of newly available networks and strengthening the existing ones, all to generate a new motor output to the impaired hand. In-vivo evaluation of intracortical excitability, especially at the molecular level, is lacking in humans and thus, it remains difficult to discern whether such changes are functionally relevant. We tested whether intracortical excitability (MR Spectroscopy-measured marker of excitability, Glx) in the motor and premotor representations of the impaired hand, defined functionally (functional MRI), is altered and plays a role in the trajectory of hand recovery after stroke. Design: Six subacute (age: mean±SD, 65.5±9.3 years, 50% males) and 10 chronic (58.7±6.8 years, 50% males) survivors of a subcortical ischemic stroke underwent Glx and clinical (Fugl-Meyer, FM) assessments. In chronic stroke survivors, FM was repeated after a four-week motor training and clinical gain was defined as positive values of FM changes (ΔFM). Glx levels in stroke were compared to those in 16 age/sex/handedness-matched controls. Correlations between Glx levels and FM or ΔFM were also evaluated. Results: Glx in subacute stroke survivors was significantly lower compared to both controls and chronic stroke survivors (motor: by 29%, p=0.02 and by 27%, p=0.03 respectively; premotor: 28%, p=0.04; 27%, p=0.04). Glx in chronic stroke survivors was not significantly different from controls (motor: p=0.2; premotor: p=0.4) but significantly correlated with ΔFM (motor: r=0.77, p=0.01; premotor: r=0.78, p=0.008). Conclusions: An increase in Glx with time implies that lower intracortical excitability early after stroke “recovers” later on. Strong correlations between Glx and subsequent clinical gain suggest that higher intracortical excitability in ipsilesional motor areas induces a suitable environment for hand motor improvement. This knowledge helps developing new or modify current treatments to maximize hand recovery after stroke.

 Knowledge, attitudes and practices of health personnel regarding rehabilitation in inpatients, Honduras 2019



Maria F. Calderon, Karla Funes, Jessica Galeas, Erika Calderon, Yanitza Hernandez, Jackeline Alger, Elpidio Sierra, Edna J. Maradiaga, Claudia Martinez, Mauricio Gonzales

Objectives: One out of ten patients suffer an adverse event during their hospital stay, deserving interdisciplinary collaboration. Knowledge, Attitudes and Practices (KAP) studies provide information to organizations responsible for the creation and execution of rehabilitation programs. It is imperative that health personnel master basic knowledge to perform rehabilitation practices to enhance the recovery and functionality of patients. The objective of the study was to determine the KAP of health personnel in relation to rehabilitation of inpatients in four hospitals, Honduras, in order to provide information that contributes to the design of strategies that favor the integral management of patients. Design: Descriptive cross-sectional study in health personnel, Medical Surgical wards, sample size n=162. Non-probabilistic and intentional sampling; self-administered questionnaire previous written informed consent. Univariate analysis with frequencies, percentages and measures of central tendency/dispersion. Results: Average age 39 years, women 74.7% (121), auxiliary nurses 37.0% (60) and specialized physician 22.8% (37); average years of training 6.4. About 90% (147) reported working in the hospital environment for more than 1 year (average 11.5 years). Overall, 51.2% (83) of the global staff had poor knowledge, with greater deficit in detecting the appropriate moment for the initiation of rehabilitation (78.4%); nonetheless the attitude towards the importance in rehabilitation of the inpatient was positive. Most performed practices: request rehabilitation intervention (88.3%), education to family members about risk of falls (81.5%) and water mattress installation (80.9%). Less performed practices: cough stimulation (28.4%) and bedside sitting (28.4%). Conclusions: The overall knowledge of health personnel regarding rehabilitation of hospitalized patients is poor; however, a positive attitude towards the importance and impact of rehabilitation in the prevention of complications and recovery of the hospitalized patient, is reflected in some practices they said to perform. Therefore, it is essential the continuous training of health personnel and protocolize rehabilitation care in the different hospitals.

 Microprocessor knee technology reduces odds of incurring an injurious fall for diabetic/dysvascular amputees



Shane R. Wurdeman, Taavy Miller, Phillip Stevens, James H. Campbell

Objectives: Microprocessor Knees (MPKs) represent a now established technological advancement in the field of external limb prostheses. MPKs have been identified with a number of clinical benefits including reductions in stumbles and falls. However, these observations are largely derived from smaller studies in which amputations due to trauma were common. The impact of MPKs on stumbles and falls in general, and injurious falls in particular, in patients with amputation due to diabetes and/or vascular disease has not been specifically studied. Given the roll of diabetes/vascular disease as a known risk factor for falls, the purpose of this analysis was to determine the impact of MPK technology on injurious falls in a large cohort of patients with amputation due to diabetes/vascular disease. Design: Subjects: From a multi-center outcomes database of patients with lower limb amputation, 881 individuals were identified. Inclusion criteria included amputation due to diabetes/vascular disease, unilateral above-knee or knee disarticulation amputation, and K3 ambulation status. PLUS-M® mobility scores and comorbid health status were also required (age: 61.7±11.1y, male: 636, BMI: 31.1±7.0, PLUS-M®: 44.3±9.7). Instruments: A binary fall question was administered during outcomes assessment asking patients whether they had incurred a fall within the previous 6 months which subsequently resulted in the need for medical attention. The fall question was anchored to a medical event for improved recall memory by patients. Procedures and Analysis: Summary and descriptive statistics were calculated among the sample population. Next, univariate logistic regression was used to model the association between falls and MPK utilization. Each independent variable was subsequently analyzed. Lastly, multivariate logistic regression was used to calculate adjusted odds ratios and 95% confidence intervals. Results: The results of this study showed that compared with those individual utilizing an MPK, individuals without an MPK had 3.38 increased odds of having an injurious fall within a 6-month time frame (Odds Ratio=3.38; 95% CI=1.44-7.94; P=0.005). By contrast, the additional variables of BMI (Body Mass Index adjusted for limb loss), Gender, Age and Time Since Amputation had no significant influence on the rates of reported injurious falls within this population. Conclusions: Individuals with unilateral transfemoral amputation who were not fit with an MPK were more than 3 times as likely to report an injurious fall than their peers fit with this prosthetic technology. These results were specifically found in a large population comprised only of individuals with amputation due to diabetes and/or vascular disease that were classified for functional level (i.e. K3). Importantly, age, time since amputation, gender, and BMI were all controlled for within the statistical model. Combined with previous evidence, the current findings would suggest for a patient classified as functional level K3, with an above-knee amputation due to diabetes/vascular disease, a MPK should be considered for reducing the likelihood of the patient incurring an injurious fall.

 Modulating spinal reflex pathway for treatment of detrusor overactivity in patients with spinal cord injury by stimulating sacral afferents at sole of foot



Abhinav Singh, Jacob George, Rajdeep Ojha

Objectives: Study therapeutic effect of electrical stimulation at sole of foot in modulating spinal-reflex pathways by reducing detrusor overactivity in patients with spinal cord injury (SCI). Design: Fifteen patients, meeting key inclusion/exclusion criteria, on self intermittent clean catheterization having Cystometrogram (CMG) proven detrusor overactivity, having ankle-jerk and at least one leak per day consented for the study. Patients were asked to maintain voiding chart one week prior to the treatment and two weeks during the study period. Cystometrogram was done on day 1 and 15. The in-house developed stimulator costing less than INR 2000 (30$), was used. Parameters for electrical stimulation were Freq 20 Hz, Amplitude 10 mA – 80 mA, pulse width 200 μs and was given half an hour every day for 14 days . Stimulation was given half-an-hour daily for two weeks. Anode and cathode were placed at metatarsal and arch of the foot respectively. Satisfaction questionnaire were taken on day 15. The study was approved by Institutional review board and ethics committee. Results: Data analysis showed trends in improvement in fourteen patients as reported by voiding chart while no trend was seen in CMG data. All patients were satisfied by this treatment. Conclusions: Neuromodulation by surface electrical stimulation at sole of foot is simple, non-pharmacological, non-invasive, inexpensive, promising alternative treatment modality for reducing detrusor overactivity.

 Preliminary effect of three dimensional printing dynamic ankle foot orthosis on plantar pressure distribution in stroke patients



Jimmy, Chun Ming Fu, Yi-Pei Chen, Liang-Ying Ke, Yi-Jen Chen, Chia-Hsin Chen

Objectives: To compare the plantar pressure distribution during wearing 3 dimensional printing dynamic ankle foot orthosis (3DP-DAFO) with wearing anterior ankle foot support (A-AFO) in post-stroke hemiplegic patients. Design: Total 8 stroke patients were enrolled in this study. Selection criteria including at least 3 months after stroke or patient reach motor improvement plateau, Unilateral hemiplegia with brunnstrom stage of lower extremity III-IV, and patient can walk independently without using the aids. Exclusion criteria including poor standing balance, postural hypotension and other diseases involving leg. All the patients performed 10 meters walk in 3 different circumstances of affected leg. (1) Wearing 3DP-DAFO (2) Wearing a-AFO (3) Bare foot. The contact area, peak contact pressure, maximal contact force, mean contact area and mean contact force were collected by using pedar X insole system. The cadence and walking speed were also recorded during walking. Quebec User Evaluation of Satisfaction with Assistive Technology scale test (QUEST-T) were used for evaluation of patient's satisfaction. Results: Effect of plantar parameters change in affected leg using different AFO. The contact area of medial midfoot on the affected leg was significantly increased (P=0.03), while the contact area of forefoot was significantly decreased (P=0.02 ) in 3DP-DAFO walking. 3DP-DAFO walking also showed the trend of decrease maximal force of forefoot (P=0.08), decrease peak pressure of lateral midfoot (P=0.08) and increase peak pressure of medial midfoot (P=0.08). Effect of plantar parameters change in sound side leg using different AFO. The contact area and peak pressure of medial midfoot of unaffected leg are significantly increased in 3DP-DAFO walking. (P=0.008 and 0.04) However, there is no difference in walking speed and cadence between 3DP-DAFO, A-AFO and bare foot walking. In QUEST survey, patient has better satisfaction with wearing 3DP-DAFO in aspect of safety, durability, adjustment, effectiveness, comfort and feasibility, but inferior in aspect of weight. Conclusions: 3DP-DAFO has better effect to reduce the degree of ankle inversion and plantar flexion of affected leg during walking in post stoke patient. 3DP-DAFO has good subjective satisfaction. Overall, 3DP-DAFO is a reasonable choice for hemiplegic patient to improve ankle control and ambulation satisfication.

 Prevalence of lateral epicondylosis in manual wheelchair users participating in adaptive sports



Andrea Cyr, Michael J. Uihlein, Berdale Colorado, Kristin Garlanger, Kenneth K. Lee

Objectives: The objective of this study was to determine the prevalence of LE in the dominant elbow in manual wheelchair-users who participate in adaptive sports. We hypothesized that the prevalence of LE would be higher in the wheelchair athletes than reported norms in able-bodied individuals. Design: This was a prospective, cross-sectional study conducted at the 2018 and 2019 National Veteran Wheelchair Games. Participants completed a questionnaire then the dominant arm of each participant was examined by a board-certified, ultrasound-trained physician to evaluate tendon thickening, increased vascularity and hypoechogenicity and a standard physical exam was performed using palpation, the Cozens and Mills test. Results: 87 participants (78 male, 9 female) were recruited. Average age of the individuals was 56.3±12.3 years. Injuries included spinal cord injuries (n=56; 64%), amputation (n=19; 28%) and “other” (n=9; 10%), and the average time using a manual wheelchair was 16±13 years. Self-reported elbow pain was reported in 25% of participants (n=22). The prevalence of LE in manual wheelchair-users was dramatically higher than published norms for able-bodied individuals, with 46% (n=40) of participants meeting the diagnostic criteria for LE by ultrasound assessment and 17% (n=15) meeting the criteria based on physical exam alone. Conclusions: Compared to previously published meta-analysis with able-bodied individuals, there is approximately a 35-fold increase in the prevalence of LE in manual wheelchair users who participate in adaptive sports based on ultrasound examination, and a 13-fold increase based on physical examination. Wheelchair-users depend upon increased use of their upper extremities for mobility, thus they are predisposed to significant chronic joint pathology of the upper extremity. Ultrasound evaluation of the lateral epicondyle in manual wheelchair-users in the context of adaptive sport can be used to better assess the population most at risk to develop symptomatic LE.

 Salbutamol improves fidelity of neuromuscular junction transmission and physical function in aged mice



Elizabeth A. Page, W. David Arnold, Deepti Chugh

Objectives: Sarcopenia is a geriatric syndrome associated with pathological loss of muscle mass and strength that is associated with increased morbidity and mortality. Our recent studies in aged mice suggest that NMJ transmission may be a rational therapeutic target. We hypothesized that salbutamol, a treatment that is effective in a primary NMJ disorder, would improve NMJ transmission in aged mice. Design: Two experiments were Designed to investigate salbutamol as a method to improve NMJ transmission and physical function in aged wildtype mice (C57BL/6J, 25-27 months). Raters were blinded to treatment and groups were balanced for age/sex. Experiment 1 assessed repetitive nerve stimulation decrement (RNS) 25 minutes after a single intravenous salbutamol dose (8mg/kg). Experiment 2 assessed the effect of repetitive salbutamol dosing (intraperitoneal 8 mg/kg, once per day for 3 days) on motor function (grip strength, rotarod) and NMJ transmission (single fiber electromyography (SFEMG)). Results: A single salbutamol dose reduced decrement on RNS (Salbutamol: 33±29% of baseline decrement versus Vehicle: 91±3% of baseline decrement, p=0.027). Repeated salbutamol dosing reduced rotarod fatigability ratio by 65% (0.1260±0.0780 vs 0.3464±0.2707, p=0.0456) and improved grip strength by ~10% (Salbutamol= 6.928 g/g; Vehicle: 6.303 g/g, p=0.0738), but only rotarod reached significance. SFEMG was significantly improved following salbutamol treatment for both jitter (Salbutamol=16 ±17us versus Vehicle=35 ± 25us, p< 0.0001) and blocking (Salbutamol=26% blocking versus Vehicle=74% blocking, p=0.0003). Conclusions: Salbutamol has a marked effect on NMJ transmission and motor function in aged mice. This warrants future investigation regarding NMJ transmission in older adults as a potential contributor to sarcopenia and whether treatments that modulate NMJ transmission may be therapeutic for sarcopenia. Future studies are needed to understand how salbutamol increases NMJ transmission fidelity, to assess the long-term effects of salbutamol on muscle and NMJ function, and to explore relationships between different dosages of salbutamol and response.

 Teaching rehabilitation in low resources countries



Germano Pestelli

Case Diagnosis: The world needs more rehabilitation systems for disable people. In low resources countries there are a lot of disable people without rehabilitation services except in in the main tows. Territories and villages are completely lack of rehabilitation both medical and social. Case Description: More is the poverty of people and more you can meet disability. The situation in low resources countries and also in some countries in economic problems is dramatic. If people have money, they can have health care and rehabilitation if people have' no money are in very problematic situation of health and for participation to a good quality of life. Where is poverty you meet surely disability. Discussions: From 1999 we start, as association as SIMFER as volunteers, to teach rehabilitation to volunteers and workers of ONG in al lot of countries all over the world: Albania, Macedonia, Moldova, Ethiopia, Guatemala, Romania, Ukraine, Djbuti, Jordan, Peru, Montenegro, and in the next time in Mozambico, Madagascar and Kazhakistan. We start to teach to volunteers and workers to improve activities on Community based Inclusive development and in some country, so as Albania, we start after a few years with a regular university course of rehabilitation for therapists. Volunteers began to do reeducation and rehabilitation activities in the compounds of humanitarian associations and in the villages .They are also today, giving help to a lot of disable and forgotten people. Conclusions: We believe that to teach rehabilitation, everywhere disability and social problems are daily a big problem for the quality of life of people, may be a good way to propose rehabilitation all over the world and to arrive with medical and social rehabilitation must arrive: in the last village of the poorest countries. This is a simple way to have less poverty and disability. #rehabilitationforall#.

 The effect of paraspinal muscles on the improvement of patients with degenerative spondylolisthesis after surgery



Emel Ece Özcan-Ekşi, Faisal Bawahab, Sibel Demir-Deviren, Hemra Cil, Sigurd Berven, Shane Burch, Bobby Tay

Objectives: Currently, no validated predictive algorithms for surgical vs non-surgical treatments exist in patients with degenerative spondylolisthesis (DS). Since lumbar instability is a major indication for surgery, understanding the role of the active stabilizers (paraspinal muscles) on clinical outcomes after surgery is important. The aim of this study is to identify lumbar paraspinal muscles (multifidus, erector spinae, and psoas) association with pain and disability improvement in patients with DS after posterior lumbar laminectomy and fusion (PLIF). Design: We used our prospective spine database and identified 35 patients with DS who underwent PLIF, had complete sets of lumbar spine MRIs, and clinical outcome data (female: 24, male: 1, mean age: 66.57±9.90 years). Paraspinal muscle quality was evaluated pre-surgically using functional cross-sectional area (fCSA), percentage atrophy, and fatty infiltration. Facet joint widening (FJW) was used as a measurement of instability at the level of DS on pre-surgical MRIs. Visual Analog Scales (VAS) and Oswestry disability index (ODI) were measured at baseline, 6-weeks, 3, 6 and 12 months. Association between paraspinal muscle quality and FJW with postsurgical clinical outcomes was evaluated. Reults: Paraspinal muscles quality below the level of DS predicted short-term improvement in post-surgical disability. Patients with less fatty infiltration in paraspinal muscles below the level of DS had better improvement in VAS post-surgically at 6-weeks, 3 and 6 months. Bigger multifidus and psoas muscles pre-surgically had better improvement in pain and disability 12-months post-surgically. Conclusions: Pre-surgical instability didn't predict subjects' baseline pain and disability, nor its improvement post-surgically. Even though with the limited sample size, the data consistently showed that paraspinal muscles' quality predicted improvement in pain and disability post-surgically in DS. Pre-surgical evaluation of paraspinal muscles' quality in clinical outcome studies is recommended; however, further prospective studies are required to evaluate the effect of paraspinal muscles on patient outcomes.

 The effects of a very common brain derived neurotrophic factor gene variant on motor neurons derived from human induced pluripotent stem cells



Joseph A. Ruiz, Claire McGregor, Colin K. Franz

Objectives: The goal of this study is to test the hypothesis that human neurons derived from human induced pluripotent stem cells (hiPSCs) that carry the highly prevalent Brain Derived Neurotrophic Factor (BDNF) Val66Met single nucleotide polymorphism (SNP) will have greater intrinsic growth capacity than non-carriers. This SNP is carried by 1/3rd of the US population. Design: Using the Crisper/Cas9 gene editing system 3 lines of hiPSCs were generated from a single patient that differ only by their BDNF Val66Met genotype: i.e. Val/Val, Val/Met and Met/Met. This isogenic strategy enables us to definitively isolate the impact of this SNP on experimental outcomes. Isogenic sets of motor neurons were differentiated over 2 weeks, using our well-established protocol, and then the hiPSC-neurons were seeded and grown in culture for 48 hours. The primary outcome measurement was the length of the longest neurite per cell, which was measured after immunofluorescent staining and imaging on a Leica CTR 6500 upright microscope. Results: The hiPSC-neurons expressing the val/met genotype had significantly longer neurites as compared to the val/val genotype (p< 0.005), but the met/met genotype was not significantly different from either group. Conclusions: This data suggests that patients who carry the common BDNF Val66Met SNP may have increased intrinsic capacity for motor axon growth and regeneration. Ongoing studies include testing hiPSC axon regrowth using a microfluidic chamber device, testing activity-based interventions on hiPSC-neurons, as well as clinical correlations between outcomes after nerve repair surgery and patient genotype. In the longer term, we hope to use this approach to achieve precision rehabilitation strategies based on genotype.

 The human preference for symmetric gait disappears when one leg is constrained



Cam S. Smock, Ryan Roemmich

Objectives: Humans have an innate preference for a symmetric gait pattern with a natural step length that minimizes total energy expenditure. The objectives of this study were to determine the metabolic cost associated with a variety of step length constraints imposed on the preferred gait pattern and to assess whether the preference for gait symmetry was conserved when subjects were tasked with a unilateral constraint. Design: Fourteen healthy participants performed one baseline walking trial to determine preferred step length, six trials with bilateral step length constraints, and one trial with a unilateral step length constraint. Subjects utilized visual step length feedback to produce the gait pattern specified in each trial. Oxygen consumption was collected during each trial to calculate metabolic power as the metabolic rate normalized to body mass. Results: For all participants, the trial involving bilateral step length constraints approximating subjects' preferred gait pattern was associated with the lowest metabolic power. All trials with constraints requiring subjects to deviate from their preferred step length with one or both legs resulted in a significant increase in metabolic power. Walking with symmetric, short steps showed higher metabolic power than walking with one short step and one step of preferred baseline step length. When confronted with a unilateral constraint of a shortened right step, subjects did not choose a symmetrically shortened left step but rather opted for an asymmetric gait pattern. Conclusions: The results suggest that gait asymmetry involving a unilateral deviation from baseline is associated with lower metabolic power than a symmetric, bilateral deviation of a comparable magnitude. Furthermore, when confronted with a unilateral constraint, healthy participants opt for asymmetry rather than conserving the human preference for symmetric gait.

 The impact of CMS' mandatory bundled payment model on postacute care discharge disposition of patients with lower joint replacements: A national study



Liliana E. Pezzin, Eric Hume, Emily McGinley, Daniel Polsky, Roy Schwartz, Mitra McLarney, Timothy Dillingham

Objectives: Prompted by the growth in Medicare spending and uncertainty about the effectiveness of post-acute care provided at alternative settings (e.g., inpatient rehabilitation facilities, IRF; skilled nursing facilities, SNF), CMS established a mandatory, episode-based, prospective bundling payment model for persons undergoing elective joint arthroplasties (CJR 2016). In this paper, we examine the impact of CJR on the composition of patients undergoing joint replacements and their post-acute care disposition. Design: Difference-in-difference techniques applied to serial cohorts of elderly Medicare beneficiaries undergoing joint replacement before (2013-2014) and after (2017-2018) CJR in geographic areas subjected to or exempted from the policy. All analyses were adjusted for patients' age, gender, race/ethnicity, poverty status, comorbidities, surgery site, and region. Results: A total 1,131,453 elderly Medicare beneficiaries underwent total hip (44.8%) or knee (55.2%) replacement during the study period. Multivariate results indicate that, regardless of bundling area, more recent/post- bundling cohorts were less likely to be discharged to an IRF (-0.79, p< 0.0001) or to an SNF (-0.73, p< 0.0001), suggesting a nationwide trend towards reduced post-acute care discharge of joint replacement patients to institutional settings. Difference-in-difference estimates, however, reveal that while only 6.7% of the drop in discharges to SNF in bundling areas can be attributed to CJR, 26% of the decline in IRF discharges in bundling areas is attributable directly and solely to the new bundling policy. Thus, our results indicate that bundling had a much more dramatic impact on discharges to IRFs than to SNFs. Conclusions: Our results indicate that most of the reduction in institutional post-acute care in bundling areas was borne by IRFs as opposed to SNFs. These findings are especially relevant in the current healthcare reform environment, which is expected to tighten access to and reimbursement for IRF care provided to patients with these and other medical conditions.

 The implementation process of disability evaluation system based on the ICF in Taiwan, 10-year experience



Tsan-Hon Liou, Kwang-Hwa Chang

Objectives: Since 1980, the Taiwanese government enacted certain legislative procedures to create and revise categories regarding disabilities. However, the criteria for disability evaluation mainly based on the medical model that considered disability as a physical and mental impairment. Thus, physicians identified candidates for disability benefits mainly based on their severity of body impairment, but without a sufficient evaluation of their daily activity, participation, and environmental factors. In 2007, Taiwan legislated a law known as the “People with Disabilities Rights Protection Act”. This act mandated that the assessment of individual eligibility for disability benefits should base on the ICF framework. The purpose of this study is to report the implementation process and major outcome of the new national-level, biopsychosocial model based on the ICF. Design: During the preparation period (2007~2012), there were eight steps of implementation process. Step 1: taskforce building and meeting, step 2: developing assessment tools for medical and functional assessments, step 3: developing measurement tools for needs assessment, step 4: a small-scale field trial, step 5: refine evaluation tools, step 6: a nationwide study, step 7: verify the evaluation procedure, step 8: collaboration and monitor the new system. We formulated a core set of disability evaluation and carried out several field and nationwide trials. This new system has been implemented successfully in July 2012. We monitored the data and reported to our government monthly for quality control since then. We also assessed the applicants' perceptions and attitudes toward the system and identified those factors associated with the applicants' satisfaction with the system. Results: We developed a core set of disability evaluation which included components of body function/ structure (43 categories), activity & participation (36 items of WHODAS 2.0, test–retest reliability r= 0.83-0.89), personal and environmental factors. We trained 11,417 certified testers for the purpose of functioning assessment. By august, 2018, we have accepted 1,089,955 application cases. Among them, 44% were from mental and cognitive dysfunction, 24% neuromusculoskeletal dysfunction, and 16% sensory dysfunction. From a nationwide questionnaire survey, most participants were satisfied with the new system overall (58.7%) and persons with disabilities and their primary caregivers have positive attitudes towards the ICF-based new system. Conclusions: To our knowledge, Taiwan is the pioneer to implement disability evaluation system based on the ICF. Our experience demonstrated that disability evaluation system based on this biopsychosocial model could provide a common language between disability eligibility, needs assessment and welfare services. Policy makers could have a better understanding of persons' needs and make a good allocation of resources. Persons with disabilities and their stakeholders have positive attitudes toward the ICF-based system after implementation.

 The phantom limb in upper extremity limb loss: Identifying barriers to prosthetic limb utilization



Kyle Ryan, David R. Del Toro

Objectives: Many individuals with upper extremity (UE) limb loss experience phantom limb pain (PLP), which may affect the use of prosthetic devices. The objective of this study was to determine if there is a link between PLP and prosthesis wear, and to better understand barriers to using prosthetic devices in the UE amputee population. Design: This was a descriptive, cross-sectional, survey-based study conducted in adults with UE limb loss located at, or proximal to, the wrist. Participants completed a web-based survey to evaluate the history of PLP and barriers to prosthesis usage. Quantitative tools included the use of a numeric pain scale to assess pain severity and the TAPES-R, a questionnaire related to psychosocial adjustment, activity restriction, and prosthetic satisfaction domains. Results: 101 individuals completed the survey. 85% of respondents had previously been fitted with a prosthesis and 88% had experienced PLP. There was a positive correlation between PLP intensity and hours/day prosthesis wear (r=0.43, p< 0.001), but no significant correlation between PLP intensity and days/month prosthesis wear time (r=0.08, p=0.49). 70% of prosthesis users with PLP indicated that the presence of PLP encouraged prosthesis use. Negative correlations existed between PLP intensity within the past week and general (r=-0.47, p< 0.001) and social adjustment (r=-0.61, p< 0.001) subscores of the TAPES-R. No correlation was seen between PLP intensity and adjustment to functional limitation (r=0.03, p=0.77) or prosthesis satisfaction subscores (r=0.05, p=0.63). Finally, a positive correlation existed between prosthesis wear time and the general adjustment (r=0.48, p< 0.001) and functional satisfaction (r=0.47, p< 0.001) subscores. Conclusions: PLP does not appear to be a barrier to UE prosthesis use. Conversely, most respondents indicated that PLP encourages prosthesis use, and that prosthesis wear leads to less overall PLP. Higher levels of PLP do portend lower psychosocial adjustment scores, emphasizing the importance of PLP management in this population.

 The quality of rehabilitation clinical practice guidelines: An overview study



Thiru M. Annaswamy, Devin Dedrick, Jennifer L. Moore, Andrew Moul, Irene Ward, Marcel P. Dijkers

Objectives: Clinical practice guidelines (CPGs) provide evidence-based recommendations to improve quality of care, and decrease variability in practices and costs. However, CPGs have been criticized for being not very applicable clinically. Our objective was to review existing papers that used Appraisal of Guidelines for Research & Evaluation version II (AGREE II) to evaluate rehabilitation CPGs, especially in the Applicability domain. Design: MEDLINE, Cochrane, PsycINFO, Embase, CINAHL and Web of Science were searched from 1/2017-8/2019. 449 abstracts resulted; 47 papers that used AGREE II to evaluate the quality of rehabilitation CPGs were reviewed in full text, using these criteria: the 6 AGREE II domain scores and/or 23 item scores were reported for each CPG; the CPGs rated involved rehabilitation; primary target of the CPG was a rehabilitation clinician or other health care provider. Relevant data on the CPGs evaluated were extracted, and the 6 domain percent scores calculated from the 23 item scores if needed. Results: We found 41 papers that provided AGREE II ratings on a total of 591 CPGs (Median=10 CPGs/paper). The average global quality rating was 5.6 (1-7 scale; SD=1.4). Summary CPG recommendations included: 18% “not recommended”; 44% “recommended with modifications” and 38% “recommended”. The average Applicability domain score was 34% (SD=25%)., The 4 Applicability Domain item scores averaged from 2.4 to 3.5. CPGs' quality improved over time, but slightly so. Conclusions: These findings suggest that rehabilitation CPGs have poor quality, especially in the applicability domain, and cannot be recommended, even with modifications, in 18-38% of cases. Lack of consideration of facilitators and barriers to application, advice and tools for putting recommendations into practice, resource implications and monitoring and auditing criteria are some of the key problems. CPGs need to be improved to become more likely to be implemented in practice.

 The relationship between gait complexity and decline in physical function



Neil A. Segal, Irina Tolstykh, David Felson, Jeffrey Hausdorff, Cora E. Lewis, Eran Gazit, Michael Nevitt

Objectives: Stable gait relies on neuromuscular adaptability. A loss of physiological complexity is a characteristic of many pathological conditions as well as decreased ability to compensate for limitations with senescence. Compensation for impairments that accompany lower-limb osteoarthritis (OA) often. Results in repetition of specific motion patterns, i.e., a loss of complexity, recognized as a limp, for example. The objective of this study was to test the hypothesis that lower gait complexity predicts worsening physical function and physical performance (increase in: WOMAC-PF, walk and chair stand times) over 24-month follow-up. Design: Participants in the Multicenter Osteoarthritis Study (MOST) who completed the 144-month baseline and 24-month follow-up visits were recruited. Gait complexity was assessed by measuring Sample entropy (SampEn) during a 6-minute walk test. Motion patterns were assessed using the vertical acceleration signal from triaxial accelerometers attached to posterior pelvis, using a subseries of 5-second epochs. Self-reported physical function was assessed with the WOMAC-PF (0-68 scale). Physical performance was assessed as the time to stand from a chair five times and the time to walk 20 meters. Change scores were calculated between baseline and 24-month follow-up and correlation coefficients and linear models were constructed for the continuous worsening of physical performance. Minimal clinically important worsening (MCIW) on the WOMAC-PF was defined by worsening of ≥8 points by 8-, 16-or 24-month follow-up, using cumulative logistic regression models adjusted for age, sex, race, clinic site, BMI and pain severity in the worse knee (NRS). Results: 1,128 participants had baseline and follow-up measurments for gait complexity, outcomes and covariates. Less gait complexity correlated with worse baseline WOMAC-PF score (r=-0.35), greater age (r=-0.39) and greater BMI (r=-0.21) (all p< .0001). Less complexity was associated with MCIW of WOMAC-PF {OR=.65 (0.43, 0.98) per unit of Samp (En) (p=0.038)}, even after adjustment for maximal knee pain, sub-cohort characteristics, radiographic knee OA, clinic, race, sex, BMI and age {OR=0.63 (0.42, 0.95)}. In unadjusted analyses, greater complexity was associated with smaller increases in chair stand time over 24-months (p=0.002). However, this association between lower complexity and chair stand time worsening was attenuated by additional adjustment for site, race, sex, BMI, age and baseline maximal knee pain (p=0.357). Entropy was not associated with worsening walk time (p=0.345). Conclusions: In this cohort of people with or at risk for symptomatic knee OA, less restricted motion (greater gait complexity) appears to confer lower risk for worsening of self-reported physical function over 24-month follow-up. Gait complexity was not significantly associated with worsening of chair stand or walk times after considering other potential contributors to worsening physical performance.

 Treatment of spastic hemiparesis with guided self-rehabilitation contracts combined with simultaneous injections of abobotulinumtoxina in upper and lower limbs: Results from the ENGAGE study



Jean-Michel Gracies, Gerard E. Francisco, Robert Jech, Svetlana Khatkova, Carl Rios, Pascal Maisonobe

Objectives: ENGAGE, an international phase 3b/4, prospective, single-arm, open-label study (NCT02969356), assessed effects of Guided Self-rehabilitation Contracts (GSC) combined with concomitant abobotulinumtoxinA (aboBoNT-A; Dysport®) injections into the upper (UL) and lower limbs (LL) on active movements, in patients with spastic hemiparesis. Here we report baseline and primary outcomes from ENGAGE. Results: Patients with spasticity resulting from acquired brain injury, stratified with UL or LL as primary treatment target (PTT), received 2 consecutive injections of aboBoNT-A 1,500 U across PTT and non-PTT limbs, together with personalized GSC. Primary efficacy endpoint was the proportion of responders in the PTT (improvement in composite active range of motion [CXA], a novel composite endpoint, of ≥35° or 5° in UL or LL, respectively) at Cycle 2 Week 6. Design: Of 160 patients enrolled, 153 were included in the intention-to-treat (ITT) population (mean [SD] age, 52.9 [12.6] years; etiology, 90.8% stroke). Proportion of patients split by PTT was 52.3% vs 47.7% for UL and LL, respectively; median baseline aboBoNT-A dose administered was 1,000 U (for each PTT). Mean (SD) overall compliance to GSC was 92.8% (9.9) and 98 patients (72.1% [95% CI: 64.0, 78.9]) achieved the primary efficacy endpoint (modified ITT population [n=136]). Greater responder rate was observed in patients with LL as PTT versus UL (83.1% [95% CI: 72.0, 90.5] vs 62.0% [95% CI: 50.3, 72.4], respectively; ITT). Mean (SD) CXA increased from 141.6° (33.7) at baseline to 162.6° (28.1) at last study visit in LL, and from 318.8° (118.3) to 368.0° (112.8) in UL (mITT). Safety data were in line with the known profile of aboBoNT-A; 78 (49.7%) patients reported treatment-emergent adverse events. Conclusions: In this single-arm, open-label study in patients with spastic hemiparesis, the combination of GSC with aboBoNT-A simultaneously injected into UL and LL was associated with improvement of composite active range of motion (CXA).

 Friday, March 6, 2020 POSTERS: Forty year old male with stroke-like migraine after radiation syndrome after receiving radiation for medulloblastoma in childhood



Joshua Levin, Brian McDonald

Case Diagnosis: SMART (Stroke-like Migraine After Radiation) Syndrome. Case Description: 40 year old with history of childhood medulloblastoma (1983) with resection, whole brain radiation and chemotherapy. He developed a headache with emesis and was taken to the hospital after being confused and answering questions inappropriately. He was aphasic with left sided weakness and a left field cut. Stroke alert was called, but imaging did not show evidence of CVA. It did reveal asymmetric right convexity in the right cerebral hemisphere with dural thickening and leptomeningeal enhancement with small areas of restricted diffusion in several right frontal and occipital sulci. LP showed WBC 31. He developed fevers and was started on antibiotics and acyclovir for presumed meningoencephalitis, however infectious workup was negative. Long term monitoring showed multifocal slowing but no seizures. Based on his remote history of radiation and negative infectious workup he was eventually diagnosed with SMART Syndrome. Discussions: Patient had a rare complication from radiation therapy years prior. As treatments for brain tumors have improved leading to greater life expectancy, the odds of developing late complications increase. Initially the patient was extremely weak and aphasic. Fortunately this condition usually spontaneously resolves and he made good progress after being transferred to inpatient rehabilitation going from min-mod assist for most ADLs and transfers to overall supervision level. Conclusions: Given the length of time between his radiation treatments (1983) and the development of SMART Syndrome (2019), the diagnosis could have easily been overlooked. This case highlights the importance of taking a good history as SMART Syndrome may not have been considered if his remote radiation exposure was unknown. Although uncommon, for patients with a known radiation exposure history who develop new neurologic deficits, SMART Syndrome should be considered after ruling out more serious pathology.

 830 nm light-emitting diode therapy reduces persistent inflammatory pain: Analysis of the mechanism of action



Bruna L. Turnes, Bruna Hoffmann de Oliveira, Franciane Bobinski, Ralph F. Rosas, Lucinéia G. Danielski, Fabrícia Petronilho, Francisco J. Cidral Filho, Adair R. S. Santos, Daniel Fernandes Martins

Objectives: The use of light emitting diode (LEDT) therapy in the 830 nm wavelength has increased significantly in recent years. However, our understanding of the systems involved in the therapeutic effect of LEDT is still limited. This study investigated the antihyperalgesic, anti-inflammatory and anti-oxidative effect of LEDT in a mouse model of inflammatory hyperalgesia, as well as examined some of the possible mechanisms involved in LEDT effects. Design: Mice subjected to intraplantar (i.pl.) injection of Freund's Complete Adjuvant (CFA) were evaluated: mechanical and thermal hyperalgesia, paw edema, paw tissue levels of tumor necrosis factor (TNF), interleukin-1 beta (IL -1β), insulin-like growth factor-1 (IGF-1), thiobarbituric acid reactive species (TBARS), catalase (CAT) and superoxide dismutase (SOD). Mechanical hyperalgesia was also assessed following pre-administration of Naloxone, fucoidin, histamine, IGF-1 and compound 48/80. Results: LEDT inhibited mechanical and thermal (chronically) hyperalgesia; reduced paw edema; decreased paw tissue levels of TNF, IL1-β and IGF-1; as well as carbonyl protein levels. Pre-administration of naloxone (opioid antagonist), fucoidine (selectin binder), histamine, IGF-1 and compound 48/80 (induces mast cell depletion) prevented the analgesic effect of LEDT. Conclusions: These results contribute to the understanding of the neurobiological mechanism involved in the therapeutic effect of 830nm LEDT, in addition to providing evidence supporting its use for the treatment of painful conditions of inflammatory etiology.

 A 4-case series to assess effectiveness of an orthotic design (Judy Colditz design) for thumb CMC OA pain reduction during pinch activity



Jyotsna R. Supnekar

Case Diagnosis: Effectiveness of an orthotic Design for immediate pain reduction during pinch for patients with thumb CMC OA. Case Description: A 4 case series of thumb CMC OA cases was performed. Each patient was issued a custom fabricated thumb CMC joint support orthotic. Pain and pinch strength with and without the orthotic were measured. The goal was to determine if the orthotic served its intended purpose of immediate pain reduction when custom molded per Design specifications. Discussions: With thumb CMC joint OA there is an attenuation of the supportive ligaments at the CMC joint along with a strong pull/ tilt of the distal end of the metacarpal into flexion during pinch caused by the four strong intrinsic thenar muscles. The extrinsic thumb extensors are relatively weak and with the CMC beak ligament laxity in CMC OA, a dorsal subluxation effect at the base of the fist metacarpal at the CMC joint occurs thus causing pain during pinch. This custom molded orthotic Design utilizes the stability of the II and III metacarpals to anchor the first MC during thumb adduction/ flexion and pinch. The orthosis is molded with the thumb in a functional palmar abduction. The palmar molding creates a strut that prevents the distal metacarpal volar tilting during pinch. The wrist and thumb IP joint is free so allows function with decreased pain. Conclusions: The orthosis when fabricated based on the author's specifications, guidelines and rationale was noted to serve its intended purpose of pain reduction during pinch. The orthosis Design is Designed to prevent CMC motion during pinch thus reducing pain. The 4 cases that were issued the orthotic reported an immediate reduction of pain during pinch upon wear of the orthotic. Measurements for pain (VAS), pinch strength (pinch meter) and functional outcomes scores using Quick Dash was utilized.

 A bridge between the mind and the body: The interoceptive awareness in the rehabilitation of multiple sclerosis



Teresa Paolucci, Andrea Bernetti, Marco Paoloni, Marta Altieri, Angela Salomè, Chiara Larussa, Silvia Sbardella, Vittorio Di Piero, Valter Santilli, Francesco Agostini, Massimiliano Mangone

Objectives: The aim of the study was to evaluate the efficacy of an “embodied” rehabilitation treatment that integrates exercises respect to body awareness and self-correction of postural spine assessment to improve balance and motor performance in multiple sclerosis patients. Design: The research was designed as a single-blind, randomized, controlled trial. The inclusion criteria were: age between 18 and 60 years, clinically definite MS-RR diagnosis, EDSS scores between 0 and 2, 5, body mass index (BMI) < 30. Sixty-three (N=63) patients were enrolled and randomized into two groups : Group Embodied (TG) (N = 31) and Waiting List (WL) (N = 32). The Tinetti Mobility Test and Stabilometry test for balance, the Short Form Health Survey ( SF-12) for quality of life, the Trunk Appearance Perception Scale (TAPS) and the Multidimensional Assessment of Interoceptive Awareness ( MAIA) was performed at the three evaluation times ( T0= baseline), at the end of 2 months of treatment , after 2 months follow up (T2-fup). Results: For Tinetti Scale in the TG a statistically significant improvement was highlighted after rehabilitative treatment with good follow-up ( at T0= 24,3 ± 3,17; at T1= 26,7 ± 2,1; at T2= 26,23 ± 2,4, p < 0,001) instead in the waiting list there was a worsening. The MAIA scale showed, in the treatment group, a statistically significant improvement for the total value (MAIA TOT) and in 5 of the 8 sub-scales (Noticing, NotWorring, Emotional Awareness, Self Regulation, Body Listening) , while there were no significant variations in the WL. Conclusions: Enhancing interoceptive awareness, patients could improve residual capacities, motor and psychic performance. Thanks to a specific embodied physiotherapy, patients could find the balance between body and mind, a safe body able to express their emotions and free their mind.

 A case of a posterior fossa atypical teratoid rhabdoid tumor in an adult female



Michael V. Lin, Laura Prince, Courtney Hogendorn, Benjamin T. Gillespie

Case Diagnosis: Atypical teratoid rhabdoid tumor of the central nervous system. Case Description: A 39-year old female was diagnosed with a fourth ventricular mass after presenting with severe nystagmus and ataxia. Treatment included gross total microsurgical resection of the tumor with pathology revealing WHO grade IV atypical teratoid rhabdoid tumor (AT/RT). Rehabilitation course was complicated by poor appetite, which improved on dronabinol and mirtazapine; significant nausea/emesis, which responded to prochlorperazine; and symptomatic orthostatic hypotension that responded to fludrocortisone and midodrine. She made functional gains while in acute inpatient rehabilitation and was safely discharged home. Patient then underwent adjuvant craniospinal radiotherapy without significant clinical toxicity. Rehab medicine assisted with weaning patient off of appetite stimulants and BP supportive medications in preparation to begin multi-agent systemic chemotherapy. Discussions: AT/RT of the central nervous system are rare and extremely aggressive tumors that primarily affect children younger than 3 years old, with very rare adult cases reported in the literature. Of adult cases reported, the most common tumor locations are sellar and hemispheric. Treatment in adults with AT/RT is typically extrapolated from protocols developed for pediatric patients. Given such limited cases reported in adults, overall prognosis and impact of resection and adjuvant therapy remains unclear. Conclusions: AT/RT is a rare, potentially devastating diagnosis which can produce an array of neurologic and functional deficits. These patients would benefit from early access to a multidisciplinary team including oncology, neurosurgery and rehabilitation medicine to assist with ongoing care.

 A case of catatonia in a patient with severe traumatic brain injury



Nathan Darji, Sunil Kothari

Case Diagnosis: Catatonia Diagnosed with Lorazepam Trial in a Patient with Severe Traumatic Brain Injury. Case Description: Following a severe traumatic brain injury, a 46-year-old caucasian female was admitted to a freestanding rehabilitation institution in a minimally conscious state. Initial head imaging showed intraparenchymal hemorrhage in the left midbrain, thalamus, and temporal lobe. On admission to the rehabilitation facility, the patient demonstrated spontaneous eye-opening, visual tracking, and reflexive movements but no command following. With continued rehabilitation, the patient began demonstrating inconsistent command following with behaviors consistent with expressive and receptive aphasia, left gaze preference, and non-purposeful use of the left upper extremity. Catatonia was suspected as a diagnosis and a trial of 2 mg lorazepam tablet was administered. One hour after medication administration, the patient spoke a full intelligible sentence and demonstrated functional object use. With twice daily lorazepam scheduled, therapists noted more consistent and accurate command following, more purposeful use of the left upper extremity, decreased right inattention, intelligible verbal expression, and increased affect display. Discussions: Catatonia has been described as a syndrome of motor abnormalities accompanied by mood and behavioral disorders that is effectively treated with benzodiazepines. This case demonstrates that although a patient with traumatic brain injury may appear to have a particular neurologic deficit, such as global aphasia, a differential diagnosis of catatonia must be considered. Treatment of catatonia with a benzodiazepine can result in dramatic improvements of the perceived neurologic deficits that ultimately translate to meaningful functional progress. Conclusions: Catatonia is an uncommonly, and likely under-diagnosed sequela of traumatic brain injury that can easily be misdiagnosed as other common neurological deficits, such as aphasia. Recognition of catatonia in a patient after traumatic brain injury and the use of a benzodiazepine both diagnostically and therapeutically is critical in allowing for the patients' maximal functional recovery.

 A case of diffuse large B cell lymphoma leading to increased morbidity



Adam Michalik, Ramzi A. El-Hassan

Case Diagnosis: Diffuse Large B cell Lymphoma /Conus Medullaris Syndrome (DLBCL) has been previously demonstrated to affect the spinal cord through extramedullary (extradural and intradural) and rarely as intramedullary lesions (1). However, the evaluation of patients with spinal disorders can be complex and fraught with diagnostic pitfalls and astute clinical nous is necessary to identify lesions that masquerade as mechanical spine disease (2). Case Description: 63 year old female with no past medical history presented with progressive bilateral lower extremity weakness, urine incontinence, and saddle anesthesia. Pre-operative lumbar magnetic resonance imaging (MRI) demonstrated degenerative lumbar scoliosis, increased T2 signal in the conus medullaris with only mild central stenosis at L4-5. Patient was incorrectly presumed to have cauda equina syndrome and underwent L3-L5 laminectomy. Post-operative course complicated by continued neurological decline prompting transfer to an academic medical center for further evaluation. Initial exam was notable for diffuse weakness in bilateral lower extremities, impaired lumbosacral sensation and partial surgical incision dehiscence. Repeat MRI of the lumbar spine demonstrated enlarging, heterogeneous T2 lesion involving the lower thoracic cord and conus medullaris and expected post-surgical changes. Given enlarging lesion in the conus, concern for malignancy prompted further diagnostic studies and confirmed metastatic DLBCL. Additionally, patient developed an enterococcus surgical site infection requiring transfer to a higher level of care. Discussions: Unfortunately, the lack of accurate and timely diagnosis resulted in increased morbidity for this patient. Poor interpretation of advanced neuroimaging in conjunction with poor clinical judgment led to inaccurate diagnosis and unwarranted surgical treatment, respectively (3). This case demonstrates an unusual presentation of DLBCL. Conclusions: It is important for interventional spine physicians to be aware of this clinical entity, diagnostic testing, and treatment in order to prevent increased morbidity.

 A case of elderly hip joint transection acquiring prosthetic gait from acute stage



Saya Iwasa, Yuki Uchiyama, Yasunari Hashimoto, Jun Aoyagi, Toshiki Yasukawa, Kazuko Takahashi, Norihiko Kodama, Kazuhisa Domen

Case Diagnosis: In 2010, a 78-year-old woman underwent extensive resection and chemotherapy for left thigh liposarcoma at our hospital. In October 2018, she had a pathological fracture due to tumor infiltration into the femur. Radical treatment was initiated, and hip disarticulation was planned. Rehabilitation treatment was initiated 5 days before the surgery. Case Description: Because the patient's cognitive function was normal and the muscle strength of both the upper and right lower limbs were maintained, she was successfully able to adapt to the hip prosthesis. Three days after the operation, she started walking on parallel bars, and19 days later, she started wearing the hip prosthesis and began training to walk. Eleven days later, she could walk with a fixed walker. Her FIM score increased from 66 on the first day of hospitalization to 108 on the 30thpostoperative day. Discussions: To our knowledge, this is the first case in which an elderly patient with hip disarticulation began using prosthesis during the acute phase after surgery. Compared with patients with other lower limb amputations, those with hip disarticulation need compensatory exercises using the pelvis to align the artificial leg and for special selection of knee/foot joints; therefore, patients often take time to be able to walk. Conclusions: Even elderly people should consider the use of hip prosthesis. Like this case, it is thought that there are not a few cases that eventually lead to practical walking.

 A case of isolated left foot cuboid fracture resulting in left foot chronic regional pain syndrome type II



Aaron Krueger, Lindsay Wilkinson

Case Diagnosis: We present here the case of a 32 year old male who sustained an isolated left foot cuboid fracture at the age of 27 from a hyperextension injury. The patient had immediate pain and swelling at the top of his foot and was misdiagnosed with an ankle sprain for 3 months until his fracture was identified on xray. The patient subsequently developed Chronic Regional Pain Syndrome (CRPS) II approximately 2 years after the initial injury. Case Description: 32 year old male who sustained a left foot non displaced cuboid fracture misdiagnosed with an ankle sprain after an injury in the ocean where his foot was hyperextended under the sand. He was treated with conservative measures for 3 months leading to improper bone healing, being allowed to bear weight through the foot, ultimately leading to chronic pain and swelling which developed into CRPS II with confirmed nerve damage 2 years later. Discussions: CRPS type II is hallmarked by chronic flares of swelling, erythema, and burning pain following a traumatic injury with confirmed nerve damage in the nerve distribution of the initial injury. The patient's treatment included neuropathic pain medications, sympathetic blocks, and PT. The patient's CRPS II was managed best after the placement of a spinal cord stimulator, reducing his pain by 60%. He is currently managed on Gabapentin and Amitriptyline. His injury is chronic. Conclusions: While CRPS type I and II are more commonly found in patients sustaining brachial plexus injuries, we describe here the case of a 32 year old male who developed CRPS II after sustaining a left foot isolated cuboid non displaced fracture misdiagnosed as an ankle sprain, resulting in the development of his chronic pain, erythema, and swelling. After multiple treatment modalities, he subsequently had a spinal cord stimulator placed which provided him with good pain relief.

 A case of two noncontiguous spinal cord injuries: A real international standards for neurological classification of spinal cord injury case with classification challenges



Daniela A. Iliescu, Sam Colachis

Case Diagnosis: Cervical and thoracic traumatic SCIs from a bicycle accident. Case Description: A healthy 27 year old male was admitted after being struck by a motor vehicle while riding his bike. He suffered multiple injuries including: non-displaced C7 facet fracture, unstable fracture of the T6 vertebral body, central canal narrowing between T5-T6, right transverse process fractures from T2 through T7, along with TBI, anoxic brain injury and fractures of his right upper and left lower limb. After a complicated hospital course, he was transferred to LTACH, then admitted for inpatient rehabilitation (IPR). On chart review, medical records were inconsistent with patient described with upper limb weakness, but labeled as a paraplegic. Upon admission to IPR, patient reported weakness in bilateral arms, inability to move bilateral lower extremities, neurogenic bladder and bowel, and neuropathic pain. An ASIA exam was completed and revealed two levels of SCI: an incomplete cervical SCI at C4 and a complete thoracic SCI at the level of T5. Discussions: The ISNCSCI were developed to provide clarity and consistency in defining the extent of a SCI. Despite revisions, SCI cases still arise that are very difficult to classify using the AIS. For this case, the patient appears to have an incomplete injury at C4 and concomitant complete injury at T5. The challenge is that the thoracic lesion prevents one from knowing the AIS for cervical lesion. Therefore, the current recommendation of the committee based on the consensus response from 2014 is to not document an ASIA impairment scale, but to clearly state what is seen on exam. Conclusions: Although not uncommon, patients with two non-contiguous SCIs are problematic for the AIS classification. This case exemplifies that it is important to clearly document physical exam findings when a single AIS classification cannot be assigned. Clear documentation is important for consistency in communication between providers.

 A case report of acute severe cubital tunnel syndrome following prolonged cell phone use



Gary L. Hoover, Travis Cleland

Case Diagnosis: Acute severe cubital tunnel syndrome. Case Description: A 44-year-old right-hand-dominant female presented with a two-day history of persistent right arm and ulnar-sided hand pain and paresthesia after using her cell phone for five consecutive hours with her elbows in prolonged elbow flexion. Physical examination at that time was significant for finger abductor weakness and abnormal sensation in the ulnar aspect of the right hand. One month later, electrodiagnostic studies demonstrated severe incomplete demyelinating and axonal ulnar neuropathy across the elbow without evidence of cervical radiculopathy. At that time, the patient also had first dorsal interosseous atrophy. The patient was referred for surgical evaluation, however was lost to follow-up and did not have surgery. Discussions: Cubital tunnel syndrome is an ulnar neuropathy at the elbow that presents with hand paresthesia, weakness, and in severe cases, intrinsic hand muscle wasting. Cell phone use is almost ubiquitous in the modern world and has been implicated as a cause. However, no case reports of acute severe cubital tunnel syndrome following prolonged cell phone use exist. Prolonged elbow flexion posture has been shown to result in slowed nerve conduction velocity across the elbow. Although other musculoskeletal disorders have been associated with frequent cell phone use, an association between ulnar neuropathy at the elbow and cell phone use has not been established. Diagnosis of acute cubital tunnel syndrome is based on history and physical exam, electrodiagnostic studies, and imaging. Management depends on the severity of symptoms and ranges from activity modification to surgical intervention. Conclusions: Cell phone use with prolonged elbow flexion should be considered as an etiology of acute cubital tunnel syndrome.

 A common nerve conduction study pitfall: Pseudo-conduction block of the ulnar nerve



Monica Barnes, Drew Parkhurst, Michael Andary

Objectives: To determine if differential hand positioning will artificially mimic ulnar nerve conduction block. Design: A prospective cohort study of 10 participants with a mean age of 30 years old underwent unilateral or bilateral nerve conduction studies (NCS) assessing the ulnar nerve (n=18). All patients were >18 years old. Exclusion criteria included paresthesias in ulnar nerve distribution, known nerve or muscle disease, diabetes, and disease of the thyroid or kidneys. Simultaneous two-channel recording was utilized to assess the motor response to the abductor digiti minimi (ADM) and first dorsal interosseus (FDI). Ulnar motor NCS were then completed in three positions: 1) with the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints in extension, 2) with the MCP joints in 90 degrees flexion, with PIP and DIP joints in extension, and 3) with the MCP, PIP, and DIP joints all maximally flexed to the subjects tolerance. Results: Eight out of 18 upper extremities (44.4%) demonstrated a greater than 20% difference in compound muscle action potential (CMAP) amplitude to ADM between the same stimulation sites with differential hand positioning. Six out of 18 upper extremities (33.3%) demonstrated a similar 20% CMAP amplitude decrement with ulnar motor studies to FDI. Conclusions: There are many common technical pitfalls when performing ulnar motor NCS. To date, much of the literature has been dedicated to discussing elbow positioning when assessing the ulnar nerve. The authors propose that hand and finger position also plays a critical role during ulnar motor NCS. Changes in hand positioning during ulnar motor NCS have the capability to mimic conduction block across the elbow or forearm, potentially leading to unnecessary surgery or antibody targeted therapy.

 A consecutive 25-week program of gait training, including 10 weeks of training using the hybrid assistive limb robot, and its effects on walking ability of a patient with a chronic thoracic spinal cord injury



Hirotaka Mutsuzaki, Atsushi Kanazawa, Kenichi Yoshikawa, Kazunori Koseki, Ryoko Takeuchi

Case Diagnosis: In this study, we examined the effect of a consecutive 5-week gait training program, using the Hybrid Assistive Limb (HAL) robot, on the walking ability of a 50-year-old man with a chronic thoracic spinal cord injury. Clinical features of this patient's paraplegia were as follows: neurological level, T7; American Spinal Cord Injury Association Impairment Scale Score, C; Lower Extremity Motor Score, 10; Berg Balance Scale score, 15 points; Walking Index for Spinal Cord Injury, 6 points. Case Description: The patient completed a 100-m walk, under close supervision, using a walker and bilateral ankle-foot orthoses. The intervention included two phases: Phase A, conventional walking practice and physical therapy for 5 weeks, and Phase B, walking using the HAL robot (3 day/week, 30-min/session), combined with conventional physical therapy for 5 weeks. A consecutive A-B-A-B-A sequence was used, with a 5-week duration for each phase. Results: The gait training intervention increased the self-selected and maximum walking speed and 2-min walking distance, as well as the Berg Balance and Walking Index for Spinal Cord Injury from 15 to 17 and 6 to 7, respectively. Walking speed, stride length, and cadence improved after Phase A (but not B). Overall, HAL gait training for patients with chronic spinal cord injuries improved standing balance and gait ability. Discussions: The walking ability of patients with a chronic SCI can be improved over a short period by combining gait training using the HAL with conventional gait training and physical therapy. Conclusions: Recognizing that a single case prevents generalization of findings, our findings support the potential for HAL-assisted gait training in improving the functional gait capacity after a chronic thoracic SCI.

 A magnetoencephalography study of information processing during picture naming task



Yuer Jiang, Feng Lin, Zhongli Jiang

Case Diagnosis: Approximately one-third of stroke patients experience aphasia, which leads to difficulty in understanding or producing spoken and written language. On the one hand, picture naming can improve the naming and discourse ability of aphasia patients as a treatment. On the other hand, it can also effectively evaluate speech function as an assessment. Picture naming tasks test the preset object better compared with the spontaneous speech task as well as avoid phoneme prompts compared with the task of retelling or reading. The study is aimed to explore the activation of brain regions during different naming tasks, which provide evidence for precious treatment. Case Description: Ten healthy right-handed adults were selected. The task is divided into two naming tasks consist of related and unrelated pictures. The brain structure of the individual was acquired by MRI, and the activation of the whole brain in different time windows was recorded by MEG (magnetoecephalography) during the picture naming task. Discussions: Comparing the activation of picture naming tasks over different time windows, the dominant brain region was located in the bilateral frontal lobe in naming of related pictures (P< 0.05) and the left temporal lobe in naming of unrelated pictures (P< 0.05). There was no significant difference in the semantic-related time window. The dominant brain region of unrelated pictures in the phonological-related time window was mainly located in the left temporal lobe (P< 0.05). Conclusions: The information process of picture naming will show activation differences with the change of time or tasks. The specific activation was located in bilateral frontal lobe in the visual-related stage during related picture naming and in left temporal lobe in the phonological-related stage during unrelated picture naming. It is suggested that the early stage may be related to category judgment, while the middle and late stage correspond to speech coding and self-monitoring process.

 A peripheral neurophysiological index is associated with upper-limb motor impairment and function in subacute stroke patients



Shintaro Uehara, Tetsuro Watari, Soichiro Koyama, Shin Kitamura, Yota Obayashi, Kazuki Ito, Hikaru Kondo, Eiichi Saitoh, Yohei Otaka

Case Diagnosis: Neurophysiological plasticity is thought to constitute a key element for motor recovery in post-stroke patients. Transcranial magnetic stimulation (TMS) has been used as a valid tool to non-invasively evaluate neurophysiological states in certain neural tracts/circuits, likely representing consequences of post-stroke plastic changes. It remains unclear, however, whether and which neurophysiological indices are associated with the current hemiparetic motor impairment and function. Case Description: Here we performed neurophysiological assessments using TMS and cross-sectionally investigated their relations with hemiparetic upper-limb motor function in stroke (n = 22) in the subacute stage where improvements in motor function could significantly occur. Based on TMS induced motor-evoked potentials (MEP) from the FDI muscle, we assessed resting motor threshold (rMT), corticospinal excitability (CSE), short- and long-interval intracortical inhibition (SICI, LICI), and cerebellar inhibition (CBI) in both hemispheres. We also measured compound motor action potentials (CMAP) induced by electrical stimulation to the ulnar nerve. As a measure of motor impairment and function, we performed clinical-based motor assessments for the upper extremity, Stroke Impairment Assessment Set (SIAS), Fugl-Meyer Assessment (FMA), and Action Research Arm Test (ARAT). Discussions: In a subgroup of patients who showed MEPs from the affected hemisphere (n = 10), we found a tendency to decrease in SICI and CBI in the affected than the unaffected hemispheres, but neither of them showed association with clinical motor scores. In contrast, we found smaller CMAP in the paretic than the non-paretic sides, the size of which was positively correlated with all motor scores of SIAS, FMA, and ARAT. Conclusions: These findings suggest that, despite specific neurophysiological states in the affected hemisphere such as less activity in certain inhibitory tracts/circuits, the more peripheral index, potentially reflecting use-dependent peripheral neuromuscular changes as well as central neural reorganization, may associate well with the current motor impairment and function in the upper extremity in subacute stroke.

 A rare case of limb paresis from the varicella zoster virus



Kelly M. Brander, Christopher Reger

Case Diagnosis: Limb paresis secondary to varicella zoster virus. Case Description: The patient is an 89-year-old female with a history of myasthenia gravis on chronic steroids who was in her usual state of health until she fell at home. She presented to the emergency department, imaging was negative for fractures, and was discharged home with pain control. After returning home, she developed worsening weakness and right knee and hip pain. She had difficulty using her walker and was bed bound for several days prior to returning to the emergency department. After being admitted to acute care, she had eruption of erythematous vesicular lesions along her right L3-L4 dermatomes. Varicella Zoster Virus PCR was positive and the patient was initiated on a one-week course of valacyclovir. She was admitted to acute inpatient rehabilitation for intensive physical and occupational therapy. She received a right ankle-foot orthosis and made gains in therapy but had residual right lower extremity weakness at the time of discharge. Discussions: Acute herpes zoster is a benign infection usually affecting the sensory part of the nervous system with a painful vesicular eruption. Most common complication of acute herpes zoster infection is post-herpetic neuralgia. There is no documented incidence of segmental limb paresis although, it is extremely rare given only a few documented case reports in the literature. Conclusions: Segmental zoster paresis is a very rare complication of herpes zoster infection and should be considered in a differential diagnosis of individual limb pain and weakness, with or without a rash, especially in an immunocompromised patient.

 A rare case of lumbosacral plexopathy secondary to a pelvic hematoma: A case report



Naveen Khokhar, Hannah Florida

Case Diagnosis: Lumbosacral plexopathy secondary to a pelvic hematoma. Case Description: A 76 year old female with a history of thrombocytosis presented to her Hematology clinic for a bone marrow biopsy. Post biopsy, the patient developed a right lower extremity weakness, dysesthesia, paresthesia, and edema. She was found to have a right pelvic hematoma on CT Abdomen and Pelvis. Of note, biopsy was consistent with Essential Thrombocythemia with JAK2 mutation positive. On exam the patient was noted to have 2/5 R hip flexion and knee extension and 0/5 ankle dorsiflexion and plantar flexion on manual muscle testing. Additionally, she had diminished sensation and pain in the L5-S2 dermatomal distribution. The differential diagnosis included lumbosacral plexopathy, and the patient required an ankle foot orthotic for ambulation. Electromyography confirmed lumbosacral plexopathy affecting the sciatic and superior gluteal nerves. Discussions: Lumbosacral plexopathy has a wide array of etiologies that can result in lower extremity weakness and foot drop with hematoma as a possible cause. Essential Thrombocythemia is a rare disorder in which the body produces too many platelets with an unknown etiology. This can lead to abnormal clotting or bleeding resulting in hematoma formation and nerve impingement. Conclusions: A patient with Essential Thrombocythemia is at an increased risk of bleeding with procedures. In this case, pelvic bone marrow biopsy resulted in the formation of a hematoma that affected the lumbosacral plexus causing lower extremity weakness. Rehab modalities can improve a patient's quality of life and EMG can be used to diagnose peripheral nerve injuries in such cases.

 A rare case of solitary fibrous tumor in the cervical spinal cord resulting in incomplete tetraplegia



Mollie Andreae, Veronica Chehata, Michael A. Kryger

Case Diagnosis: Solitary Fibrous Tumor (SFT) of the Cervical Spinal Cord Resulting in Incomplete Tetraplegia. Case Description: A 37 year old right-handed, previously independent female presented with ambulatory decline, left-sided weakness and neuropathic pain. Electrodiagnostic studies showed no evidence of peripheral neuropathy. Rheumatologic workup was negative. Symptoms progressed for two years despite conservative management. Cervical spine MRI revealed a 2.6 cm enhancing cystic lesion at C4-C5. She underwent tumor resection and C3-C6 laminectomy. Pathology confirmed an extramedullary SFT. Post-operatively, her deficits included right sided hemiparesis and loss of proprioception in bilateral lower extremities. On admission to acute inpatient rehabilitation, she was found to have C2 AIS D tetraplegia requiring maximal assistance with ambulation, transfers, and ADL's. Her main functional barriers included sensory and proprioceptive deficits and spasticity. On discharge, she ambulated long distances with bilateral ankle foot orthoses and performed transfers with supervision. She achieved modified independence for most ADL's. Discussions: SFTs are rare, slow-growing, mostly benign, mesenchymal tumors that are uncommonly found in the spinal cord. A recent literature review revealed 81 reported cases of spinal SFTs, 28 of which were located in the cervical region. Presentation usually includes pain, weakness, hyperreflexia, and bowel or bladder dysfunction. Treatment consists of surgical resection. In general, patients with spinal cord tumors who undergo inpatient rehabilitation have been shown to make functional improvements comparable to their counterparts with traumatic spinal cord injury. Conclusions: We present a rare case of a cervical spinal cord extramedullary SFT, to provide a greater understanding of this unique presentation, as well as the functional deficits and rehabilitation outcomes associated with cervical spinal cord tumors. Early recognition of the signs and symptoms of spinal cord tumors is critical for initiation of treatment, followed by inpatient rehabilitation on a dedicated spinal cord injury unit, allowing for the best possible functional outcomes.

 A rare case of spinal arteriovenous shunt and negative initial angiogram



Makinna C. Oestreich, James Dvorak, Wayne Hsiao, Parisa Salehi

Case Diagnosis: Lumbar extradural arterio-venous fistula. Case Description: A 73-year-old male with degenerative disk disease presented with progressive bilateral lower extremity weakness, paresthesia, and urinary retention. Over three months, he developed numbness and weakness in his legs after using an inversion table for chronic low back pain. Spinal MRI demonstrated an area of flow void residual at T7-8 concerning for thoracic AVM, however spinal angiogram was negative. He also had an elongated hyperintense signal through the cord suspicious for edema. An extensive inflammatory work-up for myelopathy was negative. Repeat angiogram to lower level revealed an extradural arterio-venous fistula (eAVF) near the conus. The internal iliac lateral sacral artery supplied the eAVF with venous drainage through L5 radicular branch. Endovascular embolization improved the patient's functional status. Discussions: Spinal eAVFs are an exceedingly rare type of spinal arteriovenous (AV) shunt. Typically, eAVFs are supplied by radicular branches and drain into the epidural venous plexus. A less common route of drainage occurs intradurally, as was evident in our patient. Morbidity from eAVFs Results from mass effect or venous hypertension. Possibly, the inversion table exacerbated venous hypertension surrounding our patients eAVF. Progressive myelopathy is the most frequently described neurological symptomatology for eAVFs. Intradural drainage of eAVFs is associated with worse bladder function compared with extradural. The initial angiogram of our patient failed to reveal his AV shunt since blood was supplied via the internal iliac artery. Though rare, pelvic arterial supply of eAVFs has been described and standard angiograms may miss this variation. eAVFs are a cause of significant patient morbidity, however are amenable to endovascular embolization and have high obliteration rates. Conclusions: Spinal eAVFs can be supplied pelvic arteries and caution should be taken when interpreting angiograms without visualization of the pelvic vasculature. The early identification of spinal AV shunts is vital to decreasing patient morbidity.

 A rare case: Reversible acute axonal polyneuropathy in the setting of recent heavy alcohol use and Wernicke–Korsakoff syndrome



Dayna Yorks, Anem Ankohli, Nida Gleveckas-Martens

Case Diagnosis: Acute alcohol-related axonal polyneuropathy. Case Description: A 28-year-old female with history of anxiety and alcohol use disorder (1-3 drinks daily for three years) was admitted to the intensive care unit with delusions and hallucinations in alcohol withdrawal. Brain imaging was consistent with Wernicke-Korsakoff syndrome, and she was treated with intravenous thiamine. History revealed recent heavy drinking. She complained of bilateral toe tingling for five months, which worsened to painful burning two days into her hospitalization. Exam was notable for diminished pinprick sensation in a stocking distribution, intact strength, intact light touch/vibratory sensation, and 1+ reflexes. After extensive work up, she was diagnosed with alcoholic neuropathy. Her symptoms resolved completely one month later with abstinence from alcohol and thiamine repletion. Electrodiagnostic testing performed 1.5 months later revealed normal bilateral lower extremity sensory nerve action potentials, decreased bilateral peroneal motor amplitudes, left dorsal interossei acute denervation, and left tibialis anterior subacute denervation consistent with acute/subacute polyneuropathy. Discussions: Chronic heavy alcohol consumption is a well-known cause of insidious symmetric polyneuropathy, typically with poor prognosis for complete recovery. Our patient represents a rare case of acute axonal polyneuropathy in the setting of recent heavy alcohol use confirmed with electrodiagnostic testing likely due to alcohol toxicity and Wernicke-Korsakoff syndrome. The prognosis for acute alcohol-related neuropathy is not well-established, but may be good. Our patient's symptoms completely resolved with abstinence from alcohol and thiamine repletion. Conclusions: Peripheral neuropathy is a common indication for electrodiagnostic testing. While chronic alcohol use is an established cause of peripheral neuropathy, physiatrists should include acute heavy alcohol use and Wernicke-Korsakoff syndrome on the differential diagnosis for patients who present with painful, symmetric, length-dependent symptoms. Electrodiagnostic testing will likely show an acute axonal length-dependent polyneuropathy. Given the potential for good recovery, it is important to encourage cessation of drinking and thiamine correction in these patients.

 A rehab dilemma in an aging population: An extreme incident of supine hypertension with orthostatic hypotension: A case report



Naveen Khokhar, Alexandru Dinu

Case Diagnosis: Supine Hypertension and Orthostatic Hypotension. Case Description: An 80 year old male with a history of subdural hematomas (SDH) presented with agitation and imaging noted an enlarging old SDH with mass effect requiring emergent burr hole placement. Hospital course was complicated by labile blood pressures requiring an as needed (prn) clonidine and midodrine regimen to control blood pressures. During rehab course, the patient had significant supine hypertension and orthostatic hypotension. This limited therapies as his baseline blood pressures were elevated, and he intermittently had near syncopal episodes with positional changes. To overcome this, moderately elevated blood pressures were permitted and prn antihypertensives were given only when systolic blood pressure was greater than 180 mmHg. Fluid status was optimized to improve orthostasis and midodrine's use was decreased. Abdominal binders and compression stockings were used. Therapies utilized temperature contrasting baths, tilt table, and aquatic therapy to train appropriate autonomic and vasogenic responses. Discussions: Supine hypertension with orthostatic hypotension is a condition affecting the aging population. Chronic hypertension and autonomic failure may result in poor vascular response to positional changes. This patient was on multiple antihypertensives due to his uncontrolled hypertension previously but developed syncopal episodes leading to falls and SDH. Carotid atherosclerosis also plays a role in syncopal episodes during orthostasis due to poor neuro-perfusion. Conclusions: It may be necessary to adjust goal blood pressure ranges in an aging population with supine hypertension and orthostatic hypotension. Therapeutic modalities to train the autonomic system and vascular responses may benefit improving patient symptoms and reducing falls secondary to syncope.

 A rehabilitation physician's role in the management of a critically ill patient in the intensive care unit: A case report



Varun Y. Goswami, Naveen Khokhar, Sudeep K. Mehta

Case Diagnosis: Acute Hypoxic Respiratory Failure secondary to Bilateral Phrenic Mononeuropathy with Axonal Injury. Case Description: Patient with a 6 month history of progressive weakness and neurogenic claudication was admitted to an intensive care unit (ICU) due to central cord syndrome and cervical myelopathy, with bilateral upper extremity strength of 1/5 and bilateral lower extremity strength of 4/5 on manual muscle testing. Cervical spine magnetic resonance imaging (MRI) demonstrated posterior disc osteophyte complexes at C3-C4 with severe ligamentum flavum hypertrophy, degenerative facet disease, and spinal cord compression. The patient underwent C3-C4 anterior cervical discectomy allograft/autograft placement. Post-operatively he developed acute hypoxic respiratory failure requiring ventilation. Physiatry was consulted to perform electrodiagnostic studies (EDXs). EDXs confirmed evidence of moderate bilateral phrenic mononeuropathy. Nerve conduction studies of the bilateral phrenic nerves revealed severely prolonged distal onset latency and severely reduced amplitudes, consistent with axonal injury. Discussions: Cervical spinal cord injuries have the propensity to lead to restrictive respiratory changes secondary to thoracic column degeneration, leading to accessory muscle weakness. Phrenic nerve involvement seen in higher cervical cord injuries can also lead to respiratory compromise due to denervation of the diaphragm. EDXs may be used to evaluate the function of the phrenic nerve in patients that are ventilator dependent in the intensive care unit. Findings of axonotmesis in this case demonstrates an intact epineurium indicating the opportunity for neuronal regeneration. This information helps prognosticate the possibility of weaning from ventilator support in the near future. Conclusions: Our physiatry team was consulted to perform a procedure on a critically ill patient in the ICU to help provide prognosis for respiratory failure. EDXs are helpful in diagnosing the severity of phrenic nerve injury. This delineates the degree of injury and helps to determine prognosis such as ventilator dependence or candidacy for diaphragmatic pacer in critically ill spinal cord injury patients.

 A retrospective study on inpatient rehabilitation outcomes of brain tumor patients in Singapore



Zhi-Yan Valerie Ng, Poo Lee Ong, Chien Joo Lim, Karen Chua Sui Geok

Objectives: To determine the characteristics that affect inpatient rehabilitation outcomes in Asian brain tumor patients. Design: A retrospective review of electronic medical records from a single brain injury rehabilitation unit was conducted over 5 years. Inclusion criteria included >18 years of age with confirmed first-ever brain tumors on CT/MRI. Exclusion criteria included incomplete data records. The brain tumors were subdivided into tumor types, benign or malignant tumors and locality. Main outcome measures were admission and discharge Functional Independence Measure (FIM), discharge disposition and days in rehabilitation. Results: In all, 57 out of 244 screened records met eligibility criteria. 82.5% (47) were benign and 17.5% (10) were malignant tumors including 3.5% (2) malignant meningiomas and 14% (8) Glioblastomas. The mean age of the population studied was 56 years, 40.4% (23) male, 59.6% (34) female and 73.7% (42) were Chinese. There was a significant difference between mean total admission FIM (71.88, SD 27.31, P=0.001) and the mean total discharge FIM (94.67, SD 27.61, P=0.001). The mean total FIM gain was 22.79 (SD 16.14, 95% CI 18.50-27.07, P=0.000). The mean days in rehabilitation was 32.26 days (SD 26.54) and 96.5% (55) patients were discharged home. Using multivariate regression analyses, it was found that malignant and benign brain tumors (P=0.007, Beta -0.199.), Rehabilitation length of stay (LOS) (P=0.050, Beta 0.858) and total admission FIM (P=0.000, Beta 0.156), were significant predictors of the total discharge FIM (R Square 0.739). Conclusions: This study demonstrated that brain tumor patients, including high grade malignancies significantly benefited from inpatient rehabilitation with the majority achieving functional independence and returning home. The presence of malignant brain tumors, longer rehabilitation LOS and lower total admission FIM significantly predicted a poorer total discharge FIM.

 A second-generation 3-dimensional printed myoelectric hand for improved functional ability in a developing world setting



Michael Hagen, Richa Sheth, Vinay Vanodia, Zachary G. Eichenberger, Nitesh K. Byrappa, Glenn Hutnick, Stephanie Rand, Matthew N. Bartels

Objectives: Transradial amputation of right hand. Design: The patient suffered a traumatic right long transradial amputation from machete attack in 1994. Despite preserved flexor and extensor muscles and good muscle control, the patient did not have a prosthesis. We provided the patient a modified open-source 3-dimensional (3D) body-powered hand modified for myoelectric control using a custom designed circuit and control program which converted surface electromyographic input signals to flex or extend the digits. We redesigned the hand based upon his feedback. Redesign elements included: 1. A more realistic appearance; 2. Shortened overall arm length to accommodate his long-transradial amputation; 3. A rechargeable miniature power supply, instead of a 9-volt battery, which provides him increased access to power; 4. Decreased number of motors; 5. Providing a protective case for increased water resistance from simple spills. The end product has increased water resistance and a more realistic appearance at a lower production cost. Results: Current barriers to myoelectric prostheses in developing countries are cost and accessibility. Readily available open-source 3D printed prostheses can be myoelectrically controlled or body-powered, engaging either wrist flexion or elbow flexion to close the terminal device. While such devices are not expected to have the same cosmesis, functionality, and longevity as traditional prostheses, our new generation open-source hand demonstrates that these open source devices made with readily available components on consumer grade printers are becoming more competitive for patients in economically constrained environments with limited resources or access to insurance coverage. Conclusions: Modified open-source 3D printed myoelectric prostheses can offer patients may of the benefits of a traditional prosthesis at a lower price.

 A seemingly innocuous symptom, the primary sign of a pulmonary embolism in an acute inpatient rehabilitation facility



Kishan A. Sitapara, Andrew Bloomfield, Benjamin Seidel

Case Diagnosis: 74 year old female admitted to an acute inpatient rehabilitation facility (IRF) after a right M1 MCA stroke found to have a subsegmental pulmonary embolism (PE). Case Description: Patient was admitted to a stand- alone rehabilitation facility where she tolerated therapy well for one week. At that time patient was noted to have hiccups for 1 day and a slight decrease in her oxygen saturations from 98% to 95%. Patient otherwise was at her baseline and despite a prior negative lower extremity DVT study, a CT angiogram of the chest was done which showed a subsegmental PE. Patient was subsequently started on therapeutic anticoagulation. Discussions: In most acute IRFs, especially free standing ones, rehabilitation physicians are responsible for monitoring patient's medical conditions. This often means identifying preliminary signs of post stroke complications such as falls, urinary tract infections, deep vein thrombosis, and pulmonary embolisms. A 2014 study showed nearly 1% of patients with acute ischemic strokes suffered from a PE as compared to an annual incidence rate of 0.50 to 0.69 per 1000 persons. This shows that patients in IRF after ischemic strokes are at a higher risk of developing a PE. Physiatrists thus need to be aware of atypical presentations of such a devastating complication. This was an interesting case because the patient did not present as a classic PE, her most concerning sign was a new onset of hiccups. Conclusions: One article has been published highlighting 3 cases of PEs presenting as hiccups, as was the case with this patient. This is extremely important because physiatrists often treat patients with a much higher risk of developing PEs. Furthermore, often rehabilitation facilities are free standing units without access to the ICU which makes detecting PEs early critical. This case highlights one atypical presentation of a PE that physicians need to be cognizant of.

 A severe case of critical illness polyneuropathy in a young woman following cardiac arrest



Aaron M. Greenberg, Daniel P. Spunberg, Karen Pechman

Case Diagnosis: Critical Illness Polyneuropathy. Case Description: A 29-year-old female with diabetes, morbid obesity, and hypothyroidism was initially found unresponsive at home, achieving ROSC after 3 minutes of CPR. She was subsequently intubated and admitted to a local ICU for management of severe DKA and cardiac arrest. While at acute care, she developed sepsis secondary to a central line infection. The hospital stay was further complicated by development of a popliteal DVT and the patient was started on a Heparin drip. Hours later, she was found to have a large retroperitoneal hematoma resulting in hemorrhagic shock. After reintubation, she was extubated and an IVC filter was placed. She remained stable and was discharged to an acute rehabilitation facility. Her physical exam at rehab was pertinent for bilateral lower extremity weakness, diminished sensation, and impaired gait. Electrodiagnostic testing confirmed the diagnosis of CIP. Discussions: Chronic Inflammatory Polyneuropathy is known to be a predominantly motor axonal polyneuropathy and can occur in up to 50-70% of patients who have developed SIRS and 50% of patients who have required an ICU stay. Across this patient's course, there were many elements consistent with known risk factors for CIP including severe sepsis, multi-organ failure, poorly-controlled diabetes, elevated CPKs, and the use of vasopressors and steroids. In addition, unique aspects of this case include the cardiac arrest, DVT, and retroperitoneal bleed which further increase the likelihood for development of neuropathy. On electrodiagnostic evaluation, the findings of profound axonal peripheral neuropathy across multiple nerves in three extremities confirmed the diagnosis. Conclusions: This case describes a medically complex patient who underwent an extended ICU/acute care course leading to significant functional decline and the diagnosis of CIP. The distinct complications over the progression of this case support the eventual findings, and emphasize the important role physiatrists play in overseeing the rehabilitation process and determining this diagnosis.

 A single-center retrospective analysis of incidence of tracheostomy and ventilator weaning for cervical spinal cord injury



Dahwi Jung, Ho Eun Park, Jin A. Yoon, Yong Beom Shin, Sang Hun Kim

Objectives: In this study, we estimated Results of early rehabilitation through multidisciplinary team approach for cervical spinal cord injury (C-SCI) since our trauma center opened retrospectively via incidence of tracheostomy and decannulation and rates of ventilator-free at discharge. Design: From September 1st, 2016 to June 30th, 2019, 49 patients were included for C-SCI patients who admitted through the trauma center with neurologic level of injury (NLI) of C1 to C7 and AIS A or B were enrolled. They received rehabilitation including chest physiotherapy such as mechanical insufflation-exsufflation and education of breathing exercise such as air stacking exercise and coughing training from intensive care unit. Results: Incidence of tracheostomy were 50% for AIS A and 50% for AIS B with NLI C1 to C4, whereas 44% for AIS A with NLI of C5 to C7. Incidence of decannulation were 46% for AIS A and 75% for AIS B with NLI C1 to C4, whereas 50% for AIS A with NLI of C5 to C7. Rates of ventilator-free for 16 hours a day were 88% for C3, 100% for C2, C4 to C6 and C8. Rates of ventilator-free for 24 hours a day were 63% for C3, 61% for C4, 86% for C5, 100% for C2, C6 and C8. Successful ventilator weaning rates of AIS A or B were 75% for C3, 96% for C4, 100% for C2, C5, C6 and C8. Patients with NLI of C1 was failed to ventilator-wean in all study. Conclusions: This study showed incidence of tracheostomy and rates of successful ventilator weaning rates at NLI level of our center. Incidence of tracheostomy was higher on higher NLI and rates of decannulation was higher on lower NLI. Reduced tracheostomy rates or increased rate improve life quality of patients. It is important to collect multi-center based database to establish standardization for C-SCI patients.

 A sinking feeling: Bone resorption following cranioplasty



Charonn Woods, Billie Schultz

Objectives: Autologous bone graft cranioplasty bone resorption. Design: A 34 year old male presented following a fall and loss of consciousness. Imaging demonstrated left subdural hematoma and intraparenchymal contusions. He underwent left, and later right sided decompressive craniotomies and bone flap replacement. After regaining consciousness and completing a brief rehabilitation stay, he presented for outpatient follow-up 9 months later reporting a “sinking” appearance of the left bone flap. Examination demonstrated a palpable and observable skull defect and imaging demonstrated new erosion of the left parietal bone flap. Consultation with neurosurgery resulted in no surgery and recommendation for repeat imaging; however the patient was lost to follow up. Results: Decompressive craniotomies are a commonly used treatment option for countering the effects of increased intracranial pressure. This procedure is followed by cranioplasty which has its own risks and complications that can be stratified into early and late. The early complications include hematoma, hemodynamic instability, and hydrocephalus. Late complications, most often seen in the outpatient setting include infection/dehiscence, bone resorption, and syndrome of trephined. Bone resorption, as demonstrated in this case, can occur in 6 to 50% of cases when autologous bone is used. Surface area of bone flap has been associated with resorption, which requires surgery to correct. Conclusions: Early complications of cranioplasty are often seen within the inpatient setting. Late complications, can develop months later in the post rehabilitation course and can have devastating effects if not treated. Because of the collaborative nature of rehabilitative care, physiatrists should be aware of potential post-surgical complications such as cranioplasty bone resorption that may go unnoticed once the patient no longer follows closely with the surgeon after being cleared. As in this case, a thorough physical exam and appropriate imaging, followed by referral to the appropriate provider can help expedite treatment of our patients and decrease poor outcomes.

 A spinal arteriovenous malformation in a transgender patient receiving exogenous hormone therapy



George R. Malik, Emily Marquez, Eleasa Hulon, Lynn Vidakovic

Case Diagnosis: Non-traumatic Spinal Cord Injury Secondary to an Arteriovenous Malformation (AVM). Case Description: A 26-year-old transgender male presented with bilateral lower extremity weakness and hypoesthesia. MRI confirmed spinal cord stenosis and cord compression at T3-T6 secondary to a T4 AVM (Schobinger stage III). The patient previously received weekly testosterone injections (200 mg) to induce gender affirmation, and likely contributed to the AVM development. He underwent successful vascular embolization, epidural hematoma evacuation, and T3-T6 laminectomy and fusion. His inpatient rehabilitation course was complicated by regression in strength and sensation throughout the lower extremities. A CT myelogram demonstrated severe narrowing at the T4 level secondary to hematoma recurrence. Patient underwent urgent T3-T6 decompression and hematoma evacuation. He resumed inpatient rehabilitation with improved lower extremity strength and sensation. In addition to common spinal cord injury impairments (pain, spasticity, neurogenic bowel and bladder), special attention was devoted to the patient's gender identity and the discontinuation of his hormone treatments. A multidisciplinary approach involving psychiatry and psychology was utilized. Discussions: Over one year, the incidence of spinal AVMs in the USA is near 300. It has been reported that both males and females experience a two-fold risk of AVMs during adolescence, correlating with increased levels of sex hormones in circulation. While our patient was not an adolescent, he had been receiving regular exogenous hormone therapies. Additionally, Schobinger Stage III AVMs exhibit increased expression of endothelial progenitor cells and growth factors that promote vasculogenesis. This corresponds with increased rate of recurrence and hemorrhage. Conclusions: AVMs are more susceptible to hemorrhage with progression of neovascularization, which has been associated with increased circulating testosterone and estrogen levels. Patients that are receiving exogenous sex hormone supplementation, especially at levels to induce gender affirmation, should be counseled on the potential development and advancement of AVMs as well as the risk of hemorrhage.

 A study of brain's compensation in anomic aphasia patients at the acute stage poststroke based on picture naming task functional magnetic resonance imaging



YuMei Zhang, Na Ye

Objectives: We tried to find the brain regions with functional impairment and compensation of anomic aphasia at the acute stage post stroke ( AAAPS ) based on picture naming ( PN ) task-state functional magnetic resonance imaging (task-fMRI ), and hope to provide evidence for new rehabilitation methods, such as repeated transcranial magnetic stimulation, etc. Design: Collected AAAPS cases from November 2016 to November 2018 as AAAPS group and collected Healthy volunteers as normal control (NC) group. All subjects were scanned by magnetic resonance imaging (MRI) system for T1 weighted phase and T2 weighted fluid attenuated inversion recovery imaging, and also scanned during PN-task, and then we compared the differences of activation of the brain regions during PN between the AAAPS and NC group. Results: We recruited twenty -four NC group and twenty AAAPS patients. The brain regions activated of NC group mainly include bilateral occipital lobe, bilateral frontalis inferior (mostly left), left frontalis medius, bilateral precentral (mostly left), bilateral superior parietal (mostly left), left supplementary motor area and left hippocampus, otherwise, the brain areas activated in AAAPS patients were mainly in the bilateral occipital lobe, as well as the left thalamus and the right angular gyrus. Controlling the influence of age, sex and educational level factors, using the general linear model method to compare the brain activation differences, we found that there was no significant reduction of AAAPS compared with NC, while AAAPS patients had a higher activation than the NC group in the right hemisphere. Conclusions: Compared with the NC group, there was no brain area where the activation level was significantly reduced in AAAPS patients, while the higher brain area was mostly in the right hemisphere of the brain.

 A study on long term functional outcome and disability in patients following stroke attending to neurology clinic at a tertiary care hospital



Sachithra H. Adhikari, Dinusha W. Dharmaratna

Objectives: To assess functioning and disability in patients following stroke, using ICF core data for stroke; To describe the impact of rehabilitation on long term functioning of the individual. Design: Descriptive cross sectional study on 104 patients with one to 5 years post stroke, attending to the outpatient neurology department in a tertiary care hospital were recruited. Functioning level was assessed using Brief International Classification of Functioning, Disability and Health questionnaire with qualifiers, in categories of body structure and function, activity and participation. Overall disability was assessed using mRS. Two sample t test was used to compare the disability before and after rehabilitation. Results: Out of the patients who attended the clinic 76% had received rehabilitation. The average mRS on admission was 4 and following rehabilitation mRS was 2 which was statistically significant (p< 0.05). The average mRS in non-rehabilitated group was 4 on discharge and was 3 at the time of interview, which was statistically insignificant. 45% had partial absence of function while 15% had qualitative changes in affected extremities, 10% had mild cognitive impairment, 35% had mild impairment in muscle power and muscle tone. 25% had mild impairment in gait. Activities of daily living were mildly affected in 16% while severely affected in 3%. 30% of people had mild difficulty in using transportation while 12% had severe difficulty. Community participation was impaired in 20% of patients and 5% did not engage in any social activity. Conclusions: Majority of patients attending to the clinic had only mild impairment in long term functioning, with statistically significant improvement in patient who received rehabilitation.

 A unique case of alien hand syndrome poststroke



Morgan Moore, Kelly Crawford

Case Diagnosis: Alien Hand Syndrome (AHS). Case Description: A 65 year old right handed male presented to the Emergency Room with right lower extremity weakness and aphasia. Magnetic Resonance Imaging revealed diffuse infarcts, including the left corpus callosum, left medial frontal lobe, and left posterior circulation. Upon admission to inpatient rehabilitation, he stated his right arm had “a mind of its own” and involuntarily “took over” when trying to perform activities with his left hand. On exam, he had a right grasp reflex and his right hand performed the activities his left hand was instructed to perform. Discussions: Alien Hand Syndrome (AHS) is a rare neurological syndrome of involuntary limb movement, often described as feeling the limb does not belong to the subject or it has “a will of its own.” There are various etiologies of AHS, including neurosurgery, trauma, tumor, and stroke. AHS is used to describe a wide spectrum of motor and sensory deficits that are broken down into three variants: 1. Frontal, 2. Callosal, and 3. Posterior. This patient had the frontal form, usually affecting the dominant hand and characterized by impulsive groping, compulsive manipulation of objects, and difficulty releasing objects. While AHS can improve or completely resolve weeks to months following a stroke, sometimes there is never an improvement. This patient reported 5 months post stroke his right arm continued to involuntarily reach out and pull or push objects. Conclusions: While this patient had infarcts throughout his brain that could cause all variants of AHS, his syndrome fit the frontal variant. Physicians should be suspicious of post stroke AHS if a patient has brain lesions within the corpus callosum, parietal region, or frontal region, and is manifesting associated symptoms. AHS post stroke is rare and can be distressing to patients, making appropriate diagnosis and education important.

 A unique presentation of isolated persistent trochlear nerve palsy following a midbrain stroke after cardiac catheterization: A case report



Summer C. Nestorowicz, Leslie Bagay, Sara Cuccurullo

Case Diagnosis: Patient is a 70 year old female who presented with sudden double vision following cardiac catheterization, consistent with a left fourth nerve palsy due to a right midbrain stroke. Case Description: The patient presented for cardiac catheterization and was found with mild non-obstructive coronary artery disease. Immediately post-procedure, after turning her head to the side, she developed sudden diplopia. CT head was negative for intracranial hemorrhage, she received tPA. MRI of the brain showed a small recent infarct involving the right periaqueductal midbrain. After discharge, she had persisting blurry vision at primary gaze, and double vision when looking down and to the right. Her exam showed a mild left eye hypertropia worse with right gaze and tilting the head left, and adductive depression was limited. While strength and sensation were intact, she had persisting visual difficulties which affected her balance. She was fitted with prisms to assist her primary gaze vision, and participated in outpatient physical/occupational therapies to address balance impairments and visual deficits. Discussions: Isolated trochlear nerve palsy is a rare diagnosis. The trochlear nerve nucleus originates within the midbrain (inferior colliculus) and the nerves then travel surrounded by the periaqueductal grey matter. Many trochlear nerve palsies resolve completely, however some become chronic and are a challenge to treat. Prism therapy can assist with primary gaze vision, but does not address muscle weakness. Combining prism therapy with positional therapies allows the patient to strengthen their extraocular muscles and improve function by incorporating visual exercises into daily tasks, gait and balance training. Conclusions: While many trochlear nerve palsies resolve, some patients have persisting symptoms which can be treated with multiple modalities including prism therapy and positional therapies. Although more recent literature has addressed if exploring other therapies may be effective in treating chronic trochlear nerve palsy, more research is needed.

 A unique presentation of spastic paraplegia following nonparaneoplastic anti-N-methyl-D-aspartate receptor encephalitis: A case report



Mina K. Shenouda, Brian D. Greenwald, Sara Cuccurullo

Case Diagnosis: Patient is a 28-year-old previously healthy, independent woman who developed spastic paraplegia following nonparaneoplastic anti-N-methyl-D-aspartate (NMDA) receptor encephalitis. Case Description: Patient initially presented to an acute care hospital with seizures and confusion. Magnetic resonance imaging of the brain showed parasagittal frontal cortical edema with associated mild cortical and sulcal enhancement, concerning for cerebritis versus vasculitis. Patient developed acute respiratory failure and underwent tracheostomy and percutaneous endoscopic gastrostomy tube placement. Cerebral Spinal fluid was positive for anti-NMDA receptor antibodies. Positron emission tomography showed no teratoma or evidence of malignancy. Patient received broad spectrum antibiotics, intravenous immunoglobulin therapy, nimbex infusion, high dose steroids, plasmapheresis, and rituxumab. Patient was transferred to acute rehabilitation where she was decannulated and progressed to a regular diet. She progressed functionally and cognitively; however, suffered from persistent spasticity in bilateral hip and knee flexion and ankle plantar-flexion, requiring dantrolene and ankle splinting. She was discharged to a long term extended recovery unit and then ultimately home at a wheelchair level. Discussions: Anti-NMDA receptor encephalitis is a rare autoimmune disease characterized by antibodies targeting NMDA receptors in the brain causing edema and neurologic dysfunction such as seizures, psychiatric disturbances, and movement disorders. The exact etiology is unknown. While most patients recover well, 25% of cases result in severe deficits or death. Motor deficits are less common and spastic paraplegia has to our knowledge never been described in the literature. Unfortunately, our patient had persistent impairments despite prompt treatment and comprehensive rehabilitation. Conclusions: Our patient exhibits the first described case, to our knowledge, of spastic paraplegia following anti-NMDA receptor encephalitis. As more information is accrued regarding anti-NMDA receptor encephalitis, it is important to make physicians caring for this population aware of this possible clinical presentation.

 Access to parenthood for young adults with motor disabilities



Sophie Achille-Fauveau, Elise Brindejonc, Claire Laforest, Marie-Pierre Reillon, Aurélie Durufle, Benoit Nicolas, Philippe Gallien

Objectives: The Breizh PC Handicap network focuses on the health and quality of life of people with disabilities, including the transition from childhood to adulthood, in support of health care pathways. This period is marked by breaks in the path and also by the development of a life project such as access to parenthood. Faced with the lack of literature on this subject, the illegibility of aids and the lack of articulation around this support, the network initiated the construction of training programs for people with motor disabilities and professionals. Design: In order to understand the issues surrounding parenthood in motor disability, eight semi-directive interviews were conducted by a psychologist with people with disabilities accompanied by the Pole MPR Saint-Hélier. Conferences on “Being parents: from desire to reality” and “Handicap and then? The question of sexuality “ have been realized in order to complete this collection of needs. Results: The people interviewed transmitted their knowledge, their practice and their experiences (physical, emotional, administrative, social...) both in their pregnancy project, the preparation and the coming of their child. During these unique exchanges, common issues (political, economic, medical, psychological, social and ethical) emerged, highlighting the necessary link between motor disability and parenthood. Conclusions: The results of this qualitative study emphasize the fact that access to parenthood requires exchanges, support and assistance from a network of relevant stakeholders. They also guide the content of training sessions for these young adults and provide the first steps towards the creation of a “parenting and disability resource center” for all.

 Accuracy of the scratch collapse test for carpal tunnel syndrome in comparison to electrodiagnostic studies



Daniel Areson, William Filer

Objectives: The Scratch Collapse Test (SCT) has been previously studied as a reliable and reproducible test to diagnose Carpal Tunnel Syndrome (CTS). The purpose of this study is to determine the diagnostic potential of the SCT, in a clinical setting, when compared to more reliable EDX testing. Previous studies evaluating this physical exam maneuver have shown bias and incomplete blinding, which may have lead to variations in reported sensitivity and specificity of the SCT for diagnosing CTS. Design: Forty patients were included in the study; all patients were referred to the EDX lab for examination of an upper extremity. The referrals that were included in the study were: mononeuropathy, arm numbness/tingling, hand weakness, hand numbness tingling, or cervical radiculopathy. One physician examiner performed the SCT on all forty patients. A different physician performed the EDX. The examiner performing the SCT was blinded to the referral diagnosis, patient symptoms, as well as medical history. The electrodiagnostician was blinded to the Results of the SCT. Results: The relationship between the SCT performed by blind examiners and EDX performed by blinded examiners shows a sensitivity of 48%, specificity of 59%, positive predictive value of 61%, and negative predictive value of 45%. These Results were not statistically significant with a p = .676. Conclusions: Our literature search revealed that previous research used examiners which were aware the patient had a referral diagnosis of suspected CTS. Our study attempted to demonstrate the usefulness of the SCT as it would be in an initial clinical evaluation. A setting where a patient may present with a primary complaint of pain, numbness, or weakness in an upper extremity. Currently with our study Results, we would not recommend relying solely on the SCT and abandoning other subjective physical exam maneuvers for the evaluation of CTS in the clinical setting.

 Accurate prediction of motor and language recovery in a stroke patient by multiple biomarkers



Xiaolong Sun, Hua Yuan

Case Diagnosis: This case report involves a 53-yr-old right-handed male patient diagnosed with left hemispheric infarction. He mainly showed severe paralysis of the right extremities and global aphasia when transferred to the rehabilitation department within one month after stroke. After clinical assessment, the patient underwent motor evoked potential (MEP), electroencephalography (EEG), and diffusion tensor tractography (DTT) examinations. The Results showed: (1) absence of MEP in the paretic upper or lower limb, (2) an ipsilesional loss of power in the alpha frequency band and increase in the delta frequency band in EEG, and (3) remarkably injured ipsilesional corticospinal tract (CST) and the Broca's area of arcuate fasciculus (AF), but the relatively well-preserved Wernicke's area, suggesting the poor recovery of motor and expressive language functions but better recovery of receptive language function. Case Description: The patient underwent comprehensive rehabilitative therapies, including administration of neurotrophic drugs, movement therapy, robot-assisted training, language training and navigated repetitive transcranial magnetic stimulation (rTMS) targeting ipsilesional primary motor cortex (M1), Broca's and Wernicke's areas, and contralesional M1. The eighteen-month DTT showed that the injury of the left CST and the Broca's area of AF were not restored; however, a number of new fibers in the Wernicke's area of AF were observed. Clinical assessment revealed that motor and expressive language functions recovered slightly but his receptive language function improved significantly. Discussions: For the first time, this report demonstrates that the clinical assessment, MEP, EEG and DTT within the early days of stroke help to predict the functional and structural recovery of the motor and language functions. Besides, the introduction of navigated rTMS is beneficial for the motor and language rehabilitation of stroke patients. Conclusions: The combination of clinical, neurophysiological and neuroimaging biomarkers provides clinically useful information for the accurate prediction of the motor and language recovery, which is helpful to assist rehabilitation planning.

 Acquired Arnold–Chiari malformation due to motor vehicle collision in an adult: Exploring rehabilitative challenges and successes



Saranyan Senthelal, Gurpreet Sarwan, Vivek Nagar, Shayan Senthelal, Erika Trovato

Case Diagnosis: 41 year old female with acquired Arnold Chiari malformation (ACM). Case Description: Patient was rear-ended in a motor vehicle accident, after which she presented with cerebellar ataxia, bilateral nystagmus, cervicalgia and occipital pain with progressively worsening bilateral upper extremity weakness and numbness. On presentation to the emergency room, CT scan revealed dorsal protrusion of both cerebellar tonsils through the foramen magnum, indicative of ACM, a rare complication of traumatic brain injury. She underwent suboccipital decompression with C1 laminectomy, however, her post-operative course was complicated by meningitis and hydrocephalus, which she was treated with intravenous antibiotics and ventriculoperitoneal shunt was placed to reduce intracranial pressure. After admission to the inpatient rehabilitation facility, a multidisciplinary approach was used, including neurosurgical and neurological services for shunt titration, and physical and occupational therapy that addressed her gait disturbance and upper extremity weakness. Functional gains included increases in ambulatory distance (10 feet to 290 feet), upper extremity strength, coordination and pain. Discussions: Review of the literature indicates only a handful of cases that attribute motor vehicle accidents to Arnold-Chiari malformation with a lack of reports detailing the rehabilitation challenges and successes that we discuss in this unique case. We will explore anatomic and genetic factors that may predispose adult patients from acquiring ACM along with a description of pathology and disease process. Conclusions: Serious, yet fascinating, complications can occur after seemingly minor trauma to the head and neck. Awareness of traumatic causes of ACM may expedite treatment and care for patients who present with cerebellar, cranial nerve and motor symptoms.

 Active translational shoulder stability is decreased in the apprehension posture



Constantine P. Nicolozakes, Emma M. Baillargeon, Daniel Ludvig, Amee L. Seitz, Eric J. Perreault

Case Diagnosis: Shoulder instability contributes to shoulder pain in individuals with paraplegia requiring use of a manual wheelchair. Instability symptoms typically occur in the apprehension posture of abduction and external rotation like one would move to when combing their hair or washing their back. Universally, rehabilitation for shoulder instability aims to increase shoulder stability by strengthening surrounding muscles, especially in the apprehension posture. It is unclear if these strengthening exercises can sufficiently augment shoulder stability in the apprehension posture, as biomechanical models suggest shoulder muscles contribute less to stability than in more neutral postures. However, this active shoulder stability has never been assessed in human shoulders. Thus, the purpose of this study was to determine if active shoulder stability is reduced in the apprehension posture. Case Description: 16 (8F) asymptomatic adults participated. A custom cast attached the upper arm to a linear motor at 90° shoulder abduction in neutral (0° rotation) and apprehension (90° external rotation) postures. The linear motor applied random anterior-posterior glenohumeral displacements. Displacements were applied while subjects produced isometric shoulder torque in six directions (abduction/adduction, internal/external rotation, horizontal abduction/adduction) at 5%/10% maximum voluntary contraction. Translational stiffness was estimated as a quantitative metric of shoulder stability. A linear mixed effects model computed active stiffness, the linear relationship between stiffness and torque magnitude. Discussions: Active stiffness was approximately 30% lower in the apprehension posture than in the neutral posture (P< 0.0001). This stiffness reduction was driven by decreased stiffness in the apprehension posture when subjects produced torque in abduction (57% decrease; P< 0.0001), horizontal abduction (37% decrease; P< 0.0001), and internal rotation (35% decrease; P=0.002). Conclusions: Active shoulder stiffness decreased in the apprehension posture. Shoulder muscle strengthening during rehabilitation may have reduced capacity to increase stability in the apprehension posture, suggesting additional emphasis needs to be placed on strengthening exercises in this posture.

 Acute C8 cervical radiculopathy with complete loss of finger function



Stephen K. Anderson, Whitney Luke, John Vetter

Case Diagnosis: Electrically severe acute left C8 cervical radiculopathy in an 83-year-old female after a brief yet intense period of shoulder abduction as demonstrated on nerve conduction study (NCS) and electromyography (EMG). Case Description: An 83-year-old right-hand dominant female presented with a 3 month progressive history of left neck, shoulder and upper extremity pain with complete loss of finger function in her left hand. She had a history of two previous cervical spine surgeries, with the most recent surgery occurring over thirty years prior. Her symptoms began 2 to 3 days after walking across a rope bridge. The rope was located higher than shoulder level; she reported an extreme fear of heights and reported “white knuckling” the rope for security with her left hand. Her symptoms of pain and paresthesia markedly improved after receiving a short course of oral prednisone; however, she continued with unresolved weakness in her left hand. Discussions: On exam, she demonstrated normal deep tendon reflexes and normal manual muscle testing with noted exception of 0/5 strength in left hand intrinsics and finger extensors. NCS and EMG were performed and demonstrated reduced amplitude in the left median and left ulnar motor nerves. Needle evaluation showed increased spontaneous activity and diminished recruitment of the left triceps as well as widespread spontaneous activity and no volitional activity of the left extensor digitorum, left first dorsal interosseous, left abductor digiti minimi and left pollicis brevis muscles. Additional imaging demonstrated extensive degenerative changes and spondylosis of the cervical spine and disc collapse noted at C7-T1 with severe narrowing of the neural foramina and mild narrowing of the spinal canal. Conclusions: Electrically severe cervical radiculopathy with profound muscular weakness can be devastating, especially in the elderly population striving for prolonged independence. Electrodiagnostic studies can provide an accurate diagnosis and guide patients and providers in considering age-appropriate treatment options.

 Acute cerebrovascular accident or inflammatory demyelinating polyneuropathy? Atypical Guillan Barre presentation: A case report



Daniel G. Colon-Conde, Eduardo Maldonado-Colon, Anelys Torres-Rivera, Irma Valentin-Salgado

Case Diagnosis: Primarily Motor Axonal Neuropathy. Case Description: 55-year-old male with history of hypertension, diabetes, and asthma, who suffered a gastrointestinal infection. Two weeks after patient presented with right lower extremity weakness progressing rapidly to involve the right upper extremity. Work-up for cerebrovascular accident including head CT and MRI, carotid Doppler, echocardiogram; came unremarkable. Lumbar puncture revealed albuminocytologic dissociation, serum anti-GM1 IgG elevated, 1:51200. Nerve conduction study revealed acute motor axonal neuropathy. Patient underwent therapy with intravenous immunoglobulins and intensive treatment in acute inpatient rehabilitation ward with excellent response. First Electrodiagnostic study 8 days after onset of hemiparesis not strictly met criteria for Acute Inflammatory Demyelinating Polyneuropathy. Study done two weeks later was remarkable for AMAN with more than 80% reduction in amplitudes, absence and latency prolongation of F-waves. Upon discharge from inpatient rehabilitation, patient's functional status improved. He achieved antigravity strength in right hemibody, modified independence in transfers, and ambulated at least 250 feet with rolling walker. Discussions: This case represents a very rare clinical presentation of AMAN. This patient presented with a right-sided hemiparesis that mimicked a stroke, which ultimately resulted in a delay in diagnosis and management. In addition, patient presented with diminished but preserved patellar reflexes initially, which is also uncharacteristic of AMAN. There are very few reported cases in literature of AMAN presenting with hemiparesis. In this particular case, patient responded well with high intensity rehabilitation and intravenous immunoglobulins. Conclusions: Atypical Guillain-Barre Syndrome may present with asymmetric weakness mimicking a stroke. Treatment with IVIG and intensive rehabilitation seems to improve functional outcomes.

 Acute paraparesis secondary to addisonian crisis



Shelly Hsieh, Jeremiah D. Nieves

Case Diagnosis: Addisonian crisis. Case Description: A 49-year-old male with prostate cancer presented to an acute care hospital with paraparesis. He was diagnosed with cord compression secondary to T5-T7 epidural metastases. He was started on a dexamethasone taper, and underwent T5-T6 laminectomy and tumor resection. He was transferred to an acute inpatient rehabilitation hospital, and made functional gains including ambulation without an assistive device. On post-operative day (POD) 15, he completed the steroid taper. On POD 26, he developed acute bilateral lower extremity weakness and hypotension. The patient was emergently transferred to the acute care hospital given concern for cord compression versus cord hypoperfusion secondary to hypotension. Work-up was significant for hyponatremia, hyperkalemia, and no acute changes on imaging. The patient was diagnosed with Addisonian crisis by endocrinology, and restarted on high dose steroids with a two-month taper. His strength improved the next day, and he was able to ambulate within a few days. Discussions: Addisonian crisis occurs due to an acute decrease in glucocorticoid and mineralocorticoid levels in people with primary or secondary adrenal insufficiency. This results in increased renal sodium loss and potassium reabsorption, leading to intravascular volume depletion. Common presenting symptoms are hypotension, abdominal pain, fever, nausea, vomiting, and confusion. It requires emergent treatment with glucocorticoid replacement therapy and fluid replacement. Without treatment, life-threatening shock progresses to coma and death. Conclusions: In this case, Addisonian crisis presented as acute paraparesis in a patient with secondary adrenal insufficiency 10 days after completion of the steroid taper. Addisonian crisis is a medical emergency, and should be included on the differential diagnosis for patients with adrenal insufficiency presenting with hypotension and non-specific clinical features. It is essential to recognize the early features of Addisonian crisis, as delayed identification and intervention is associated with high mortality.

 Acute poststroke psychosis in inpatient rehabilitation: A review of literature and rare case series



Kuntal Chowdhary, James E. Eubanks

Case Diagnosis: Post-stroke psychosis. Case Description: This case series consists of two females, 40 (patient A) and 63 (patient B) years old respectively, who presented with acute (1-2 weeks) post-stroke psychosis. Both patients presented with two separate ischemic distributions - right MCA and left external capsule/corona radiata respectively. Patient A had a past medical history of major depressive disorder; however, following her stroke, she developed profound personality changes and delusions. Patient B had a past medical history of alcohol use disorder and developed visual hallucinations. Both patients were managed while in inpatient neurorehabilitation. Discussions: Post-stroke psychosis is a rare complication found in certain stroke patient populations. This condition has typically been implicated in strokes of the right hemisphere of the cerebellum, thalamus, insula, basal ganglia, corona radiata, lentiform nucleus and inferior frontal lobe. Based on our literature review, we found several cases of progressive development of post-stroke psychosis. There are, however, very few cases of the acute development of post-stroke psychosis. The pathogenesis of acute post-stroke psychosis is also unclear, as the patients presented in this series had strokes in different areas, different past psychiatric histories and different post-stroke presentations. Conclusions: It is important to consider acute post-stroke psychosis in patients with signs and symptoms of delirium, especially as admission to inpatient neurorehabilitation occurs early in the course of recovery. There have been many cases of post-stroke psychosis documented several weeks to months following stroke; however, the course of psychosis may have been indolent and present in the acute period. Thus, it is imperative for physiatrists and neurorehabilitation clinicians to recognize and treat post-stroke psychosis during the acute period following stroke to prevent potential patient harm in the setting of untreated psychosis.

 Acute result of transcranial direct current stimulation and exercise in treadmill running in the autonomic modulation of hemiparetic patients postchronic stroke – Clinic test, controlled, randomized, double-blind



Glauber Heinz, Katia D. Angelis, Simone D. Corso, Maria Helena G. Sousa, Ariane Viana, Fernando D. Santos, João Carlos F. Corrêa, Fernanda I. Corrêa

Objectives: To evaluate the effect of Transcranial Direct Current Stimulation (tDCS) on the systolic blood pressure variability (SBPV) and heart rate variability (HRV) applied before a single session of physical activity on a treadmill in individuals who had a stroke. Design: Randomized sham controlled crossover trial. Were evaluated the SBPV and HRV of 12 individuals, in the moments before and after interventions with tDCS and during the treadmill exercise recovery phase. SBPV and HRV analyzed by the Variance R-R (ms) interval and by the variances of pulse intervals (PI) in time domain and frequency, linear method. Randomized interventions in 2 groups, 48-hour intervals: group1 (active tDCS before treadmill) and group2 (sham tDCS before treadmill). Duration of the protocol (40 minutes, being 20 minutes of tDCS followed by 20min of treadmill). Electrode anode on left temporal cortex and cathode on contralateral deltoid muscle, 2mA. Results: There were no difference in the VSBP and the HRV between the groups, compared with the baseline data, however, in the intragroup analysis the parasympathetic modulation after active tDCS increased by 18% over baseline by the RMSSD with IC 95% (-7.85 - -0.34). In group 1, the post-tDCS active and post-exercise periods presented a value of variance above baseline, indicating a better prognosis. In group 2, there was a significant reduction of 38% of Variance values (p = 0.003) after tDCS sham. Conclusions: The tDCS did not has significant immediate effects on HRV and SBPV, except for cardiac parasympathetic modulation (RMSSD and PI HF band). The results, by group, suggest that tDCS was able to maintain greater parasympathetic modulation after acute exercise. It is believed that studies with a longer stimulation time may elucidate these effects.

 Adjunctive hyperbaric oxygen therapy with intensive neurorehabilitation in improving neurological outcome in persons with disorders of consciousness with subacute brain injury



Faiz Mohamed, Abhishek Srivastava, Navita Purohit, Tushar Sonawane

Objectives: To assess the effect of adjunctive HBOT in improving neurological outcome in people with DOC with subacute brain injury & to find out the safety of using HBOT in patients with severe DOC. Design: Retrospective study of persons with traumatic/non traumatic brain injury, underwent rehabilitation and adjunctive HBOT from April 2017-March 2019. HBOT was given in Perry TM Monoplace Chamber 1.5 ATA for 60 minutes each session when neurologically and medically stable. Neurological status was assessed by Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) before and after the intervention. Medical complications observed in HBOT file was noted. Results: 99 persons (M:F:82:17) with brain injury (TBI : ICH : IS = 49 : 35 : 15), age 8 – 86 years (48.8) were included. 57 persons underwent surgery (24 TBI; 27 ICH; 6 IS). HBOT was started 10 days–240 days after the injury (mean 61days). HBOT sessions varied from 12 – 68 (mean 18). GCS score pre-intervention improved from E1M1VT – E4M4V2 (m 5.94) to E4M3VT – E4M6V5 (m 9.91). The post HBOT GOS was Grade- II-44, III - 34, IV-6 and V–12. 6 of 84 persons in GOSII pre intervention improved to GradeV, 2 to IV, 29 to III, 44 in II and 3 in GradeI. Of 12 in GOS III: 5 improved to GradeV, 2 to IV and 5 in Grade III. Of 3 in Grade IV GOS: 1 improved to Grade V and 2 in GradeIV. Complications during HBOT were Dysautonomia, hypoglycaemia and increased tracheal secretions. Conclusions: Adjunctive HBOT is safe and tolerated well by persons with subacute brain injury and can contribute in improving neurological and functional outcome of persons with DOC. The maximum improvement in GCS was in the component of spontaneous eye opening.

 Advocacy of disabilities group policy in realizing the inclusive and healthy university



Rapla Diarola Aparta, Erna Setijaningrum, Aguswan Nurdin

Objectives: Health and inclusive are the concern of people with disabilities to get the same opportunities as others. Design: This paper is to see how disability groups in Airlangga University strive to realize their desire for an inclusive campus and the accessibility they want to achieve. We use a study based on an integrated advocacy strategy developed by Roem Topatimasang as the blade of the analysis. Results: The findings in the field show that disability groups at Airlangga University form a group called Airlangga Inclusive Learning (AIL), hold Discussions, express aspirations through Focus Group Discussions and engage in forums created by universities, campaign for the importance of their rights through personal and group and conduct routine evaluations together. The Results of the policy advocacy produced positive Results in its implementation such as making elevators for disabilities, guiding blocks for the visually impaired, RAM for wheelchair users, special toilets with disabilities and easy access to other services. Airlangga University also provides free health services for students with disabilities and non-disabled students, and its officers have also been given special training in how to provide health services for persons with disabilities. Conclusions: Policy advocacy is an instrument to make policy change, in the case of Airlangga Inclusive Learning has success to advocate any issue needed by disabilities group.

 Age- and sex-specific effects in paravertebral surface electromyographic back extensor muscle fatigue in chronic low back pain



Gerold R. Ebenbichler, Richard Habenicht, Sara Ziegelbecker, Josef Kollmitzer, Patrick Mair, Thomas Kienbacher

Objectives: The impact of aging is not well understood, yet may hold clues to both normal aging and chronic low back pain (cLBP). In sustained high submaximum back extensions, spectral surface electromyographic (SEMG) fatigue, a surrogate measure of glycolytic muscle metabolism, may be decreased with increasing age, but increased with cLBP. Previous research by our group found the spectral SEMG fatigue method able to descriminate between older and younger back extensor muscles function, despite the fact that younger and older individuals demonstrated comparable maximum back extension strength scores. Thus, this study sought to investigate whether the spectral SEMG back muscle fatigue method would be as sensitive as it is in healthy individuals to detect age- and sex-specific differences in neuromuscular and muscle metabolic functions in patients with cLBP in a reliable way. Design: With participants seated on a dynamometer (20° trunk anteflexion), paraspinal SEMG activity was recorded bilaterally from the multifidus (L5), longissimus (L2) and iliolumbalis (L1) muscles during isometric, sustained back extensions loaded at 80% of maximum from a total of 117 younger (58 females) and 112 older (56 females) cLBP individuals. Tests were repeated after 1-2 days and 6 weeks. Median frequency (MF), the spectral SEMG variable indicating neuromuscular fatigue, was analyzed. Results: Maximum back extensor strength scores were comparable between younger and older individuals. Significantly less MF-SEMG back muscle fatigue was observed in older than younger, or in older female than male cLBP individuals. Relative reliability was excellent, but absolute reliability appeared large for this SEMG-fatigue measure. Conclusions: Findings suggest that cLBP unlikely masks the age-specific diagnostic potential of the MF-SEMG back extensor fatigue method. Thus, this method possesses a great potential for being further developed toward a valuable biomarker intended to very early detect back muscle function at risk for sarcopenia.

 Alien hand syndrome



Taehong Lim, Parisa Salehi, David Nguyen, Philip T. Kuball

Case Diagnosis: Alien hand syndrome. Case Description: A 60-year-old female with a prior history of left pontine hemorrhagic stroke presented with acute paresthesia and incoordination in the left side of her body. She reported involuntary movements of her left upper extremity, stating that her left hand was touching her chest or face without her will. Workup showed right pontine hemorrhagic stroke, and there was a concern for cavernous malformation within the pons. Physical examination revealed left hemiparesis, left hemi-sensory loss, severe dysesthesia, and apraxia of her left upper extremity. Her left upper extremity was moving outside of her voluntary control with complex movement beyond simple levitation. Discussions: Alien hand syndrome is a rare phenomenon characterized by involuntary, yet purposeful, hand movements that may be accompanied by agnosia, apraxia, weakness, or sensory loss. Etiologies include stroke, corticobasal degeneration, multiple sclerosis, mass effect (tumor or aneurysm), and following corpus callosotomy for refractory epilepsy. In general, lesions of the corpus callosum are associated with alien hand syndrome, but lesions of the supplementary motor cortex or posterior parietal cortex have been documented as well. Diagnosis can be challenging because it is a neurological disorder that lacks a psychiatric component; however, symptoms are often mistaken for a psychiatric or behavioral cause. Although there is no specific treatment for alien hand syndrome, managing these patients with cognitive therapy, botulinum toxin injections, and neuromuscular blocking agents has been attempted to reduce involuntary movement and restore voluntary control of the hand. Conclusions: Alien hand syndrome has been observed mostly secondary to a supratentorial lesion involving the non-dominant hemisphere; infratentorial lesions resulting in an alien hand syndrome is uncommon. This case is presented to raise awareness on this uncommon clinical manifestation as clinician's recognition of the disorder could help to reduce the patient's anxiety and a better outcome.

 An anatomically-based proposed technique for cervical paraspinal mapping EMG



Andrew J. Haig, Tyler J. McGuire

Case Diagnosis: Lumbar paraspinal mapping EMG has standardized and validated the use of EMG, showing it superior to imaging in many ways. However, no valid cervical technique has been proposed. This study devises an anatomically valid, quantifiable technique for Cervical Paraspinal Mapping needle EMG. Case Description: Papers and texts regarding cervical paraspinal anatomy and cervical paraspinal EMG techniques were reviewed to determine possible innervation patterns of the cervical paraspinal muscles. A technique was designed based on this information and clinical experience. Discussions: We found no study that specifies anatomical insertion site, angle, extent of insertion, standardization of scoring, and range of norms. Anatomical evidence suggests that the single-root innervated multifidus originates at any given cervical spinous process and inserts in a multipennate manner at 2, 3, 4, 5, 6, and sometimes 7 transverse processes below. This occurs in a small space between the spinous process and transverse process and deep to large superficial muscles innervated by C2, 3, and 4. Conclusions: The Cervical Paraspinal Mapping technique was proposed: Six scores are obtained as follows, then summed. At C5, C7, and T2 spinous process palpate a location 2 cm lateral to midline. At each of these locations insert a monopolar needle at a 60o depth, aimed at midline, until contact with bone. Withdraw, orient the needle 45o caudal, insert at 60o depth to bone contact. Insertions should be in ½ cm steps, eliciting any positive waves or fibrillations. These are scored from 0 (no fibrillations lasting more than 1 second) to 4+ (fibrillations occlude baseline. Total for 6 locations and findings at each level are reported. This Cervical Paraspinal Mapping technique has been found practicable in clinical situations, not reported here. Future work must develop norms, assess sensitivity and specificity for radiculopathy, and compare to imaging standards. The impact on treatment and outcomes needs to be evaluated.

 An exploratory analysis: Cloud computing big data query at an academic spine center



Dustin Anderson, Tiffany Callahan, Larry Hunter, Adele Meron, Venu Akuthota

Objectives: Cloud-computing equips researchers with opportunities to explore large data sets and obtain novel insights into disease patterns and patient outcomes. Advanced statistical learning allows extensive data sets to be evaluated rapidly. Here we explore a cloud-based health database in a representative sample population. Design: An IRB-approved retrospective cohort study was initiated to evaluate outpatient data. Patients seen at an academic spine center between the ages of 18-99 were included. Data was provided by Health Data Compass and stored/processed using Google Cloud Platform Tools. For this abstract, we focus on patients in the data set who had a diagnosis of radiculopathy (cervical, thoracic, or lumbar) and underwent a transforaminal epidural injection (fluoroscopically or CT guided). Our goal was to gauge the feasibility of the cloud platform for data analytics and assess the potential for more specific downstream studies. Results: Of 2,212,431 unique patient charts, 77,750 patients were eligible. A random sample of 27,550 patients was obtained from the eligible population. A query was run for all diagnoses, procedures, medications, labs, and genomics. These patients were predominantly female (56%), and white (82%) with a mean age of 58 (SD = 16). 13,150 (48%) had diagnosis codes consistent with thoracic or lumbosacral intervertebral disc disorders, 6,220 (23%) had cervical disc disorders, and a small subset of 950 (3%) had radiculopathy with associated spinal instability. Conclusions: Cloud-based health data tools allow for evaluation of extensive data sets. Our study included a query of 2.2 million patients. These samples are clinically meaningful and can be used for future cohort analyses. Limitations include the observational nature of the study and computational resources available. In summary, cloud-based health data tools represent a promising avenue to efficiently explore big data sets in the field of PM&R.

 An idiopathic syringomyelia patient presenting with bilateral upper limb sensory and motor deficits



Jun Hyun Choi, Jong Hoo Lee

Case Diagnosis: A 35-year-old woman with unremarkable past medical history, experiencing bilateral arm weakness along with tingling sensation, presented to our clinic. These symptoms were subjectively noted 3 weeks prior to presentation. Both biceps and knee jerks were mildly accentuated and Hoffmann sign was objectively noted. Babinski sign was absent. Bilateral arm strength was grade 4 by manual muscle testing. Central nervous system (CNS) lesions were suspected which prompted diagnostic evaluation by cervical spine x-ray (C spine X-ray), electromyography (EMG), somatosensory evoked potential (SEP) test and cervical spine magnetic resonance image (C-MRI) studies. Results of these studies were all normal with the exception of C-MRI, which revealed a localized syringomyelia at the C6-C7 spine level. The patient was treated conservatively and resulted in resolution of both arm pain and motor weakness following a course of pharmacotherapy. Case Description: Syringomyelia is a neurogenic disease which can damage the spinal cord due to formation of a fluid-filled space in the form of a cyst (syrinx), usually found in the high cervical level of the spinal cord. Arnold-Chiari malformation, spinal cord tumor, adhesive arachnoiditis and trauma are some of the more commonly known causes of syringomyelia. However, IS is not associated with any of the aforementioned conditions.We report herein, a case, of a patient without evidence of other underlying pathologic conditions who was subsequently diagnosed with IS and later was found to have improvement of the associated neurologic symptoms with supportive care. Discussions: The precise etiology and management for idiopathic syringomyelia is still unclear. Conclusions: We diagnosed IS in a patient who presented with neurologic deficits. The suspected diagnosis of IS was confirmed by imaging study with C-MRI. Subjective symptomatology was shown to have improved with supportive care. We recommend considering an MRI study when CNS pathology is suspected in patients presenting with neurologic symptoms including sensory and motor deficits.

 An inpatient poststroke model of rehabilitation patients with the history of heart transplantation: Retrospective observational study



Elzbieta D. Miller, Marta Niwald

Objectives: The aim of the study was to evaluate the safety, effectiveness and clinical problems during post-stroke model of rehabilitation patients with the history of heart transplantation. Design: We conducted a retrospective observational case study of 3 patients with left side paresis after first-life ischemic strokeand with the history of heart transplantation. Our 31 days model of rehabilitation was conducted as an intensive interval of 3-5 (10 min long exercises) with gradually increasing time of trainings (from 120 to 180 min/ per day 6 days per week), physical therapy (10-20 min/day) and psychological therapy (30-60 min/day). The Results were estimated in several scales: Barthel index, Rankin scale, Rivermead Motor Assessment, The National Institutes of Health Stroke Scale, Mini–Mental State Examination, Geriatric Depression scale. Moreover, the monitoring of heart rate (before and after training) and other clinical parameters were carried out. Results: As a result of comprehensive rehabilitation, functional status improvement was observed in all estimated scales. The highest differences (admission vs discharge) were reported in Barthel index 3.3 vs 13.7 and National Institutes of Health Stroke Scale 13.7 vs 7.7 . Main clinical problems were: heart rate (the mean value 94/min after training), depression (18.3 vs 7.0) and cognitive impairment (21.6 vs 26.7). Conclusions: In the case of patients with the history of heart transplantation despite the tachycardia gradually increasing physical effort was tolerated. Early post stroke rehabilitation may achieve significant improvement in functional status.

 An unusual case of miller fisher variant of Guillain–Barre syndrome with overlapping features of pharyngeal-cervical-brachial subtype



Amanpreet Saini, Gaurish Soni, Anthony Roviso, Padma Srigiriraju

Case Diagnosis: Miller-Fisher variant of Guillain-Barre Syndrome with overlapping features of pharyngeal-cervical-brachial (PCB) subtype. Case Description: A 72-year-old female presented with diplopia, ataxia, dysarthria, and dysphagia for several days after an upper respiratory infection. Further exam showed right ptosis, limited vertical/horizontal gaze, areflexia of the lower extremities, dysmetria and weakness in the upper extremities, and weak deltoids. Neurology was consulted, and stroke was ruled out, lumbar puncture showed elevated glucose with no albuminocytological dissociation. EMG findings indicated Miller-Fisher syndrome (MFS) with multifocal axonal polyneuropathy in the upper extremities. Patient had an elevated GQ1b IgG antibody titer. She completed a five-day regimen of IVIG and subsequent PLEX therapy. She was eventually discharged to acute inpatient rehabilitation (AIR) and made significant functional improvement. Her dysphagia resolved, and she was advanced to a regular diet. She progressed from two-person assist for ambulation and met goals for minimal assistance overall. Discussions: PCB-subtype of Guillain-Barre Syndrome is a rare condition with rapid onset affecting the upper extremities, neck, and oropharyngeal muscles. MFS is on a continuous spectrum with PCB with additional findings of ophthalmoplegia, ataxia, and areflexia. MFS patients commonly have positive titers for Anti-GQ1b which target tissue found in cranial nerves III, IV and VI. Multiple studies suggest cross-reactivity between anti-GQ1b antibodies and GT1a. One immunochemical study demonstrated that GT1a was strongly expressed in human cranial nerves III, IX, and X, consistent with the neurological presentation of MFS/PCB. Early intervention with IVIG and/or plasmapheresis along with a multi-disciplinary approach at an AIR with therapists, supportive counseling, and close medical surveillance has been shown to shorten recovery periods and decrease deficits. Conclusions: Patients usually show improvement in neurological function within several weeks after diagnosis of PCB-subtype of MFS-GBS. Because of its rarity, PCB can be misdiagnosed as a stroke, myasthenia gravis, or botulism. Therefore early diagnosis, management, and rehabilitation is essential.

 An unusual case of severe shoulder pain in a patient diagnosed with Guillain Barré syndrome



Léonie Verbeke, Carlotte Kiekens, Frans Bruyninckx, Sofie Rummens

Case Diagnosis: Neuralgic amyotrophy. Case Description: This case report presents a 69-year-old man initially diagnosed with Guillain Barré syndrome who additionally developed acute left shoulder pain during hospital admission. The patient mentioned severe nocturnal pain in the left shoulder (numeric rating scale (NRS) of 8/10) with weakness of the left arm. Initially a shoulder impingement syndrome was put forward as tentative diagnosis and symptomatic treatment with a non-steroidal anti-inflammatory drug was prescribed. Based on physical examination (arm elevation and abduction, Medical Research Council (MRC) scale 2/5) and atrophy of left m. supra- and infraspinatus, an electromyography (EMG) was performed 2 weeks after admission. This showed denervation potentials and neurogenic motor unit potentials in m. supra- and infraspinatus, compatible with suprascapular nerve neuropathy. Based on these findings the diagnosis of neuralgic amyotrophy (NA) was made. Discussions: The incidence of neuralgic amyotrophy (NA) is 1-3 per 100 000 per year. However, recent studies showed that the incidence of NA may be higher, possibly as high as 1 per 1000 per year, which suggests that the diagnosis is often missed. The exact underlying pathophysiology of NA is still unclear, however a genetic predisposition and precipitating conditions, such as concomitant infection, trauma, surgery and pregnancy, are often described. This suggests an inflammatory auto-immune origin such as in Guillain Barré syndrome. Although, some studies describe immuno-pathophysiological similarities, there is no evidence for a generalized immune dysfunction in patients with NA. Conclusions: Due to the higher incidence rates of NA than generally assumed we want to emphasize the importance of including NA in the differential diagnosis of a patient with severe acute shoulder pain. Further research is needed to reveal the exact pathophysiology of both diseases.

 Anklebot as a reliable measure of chronic lower extremity spasticity



Anthony Manfredo, Angela F. Davis, Bradley Hennessie, Richard Macko, Larry Forrester, Anindo Roy, Michael A. Dimyan

Objectives: Spasticity is difficult to quantify consistently, plagued with inter and intra-rater reliability errors. The objective of this study was to determine whether variables captured by a robotic ankle training device could be used to provide a more reliable measurement of spasticity. Design: The study included 4 subjects with spastic hemiplegia. Spasticity in the gastrocnemius, soleus, and tibialis posterior muscles were assessed wearing the robotic ankle device, Anklebot. Spasticity was rated by a single clinician on the Modified Ashworth Scale (MAS). The Anklebot recorded the clinician's actions and then played back the same actions. Testing was done at the time of chemodenervation and again approximately 6 weeks post-chemodenervation. A spastic catch was defined by the point of peak deceleration. Factors of interest were examined during clinician testing for correlation with an increase in MAS, including percent range of motion the catch occurred, speed pre and post-catch, acceleration post-catch, and change in acceleration post-catch. A model of spasticity scoring was created using linear regression and applied to the Anklebot recreations. Results: Factors that correlated with an increased MAS were identified as percent range of motion the catch occurred (R=-0.688, p< 0.001), peak speed pre-catch (R=-0.458, p=0.024), and change in acceleration post-catch (R=0.556, p=0.005). A linear regression model was created for an estimate of MAS scores based on the variables of interest (F(3,20)=8.285, p=0.001). Applying this model to the Anklebot recreations, spasticity values were calculated with a R2=0.83 (p< 0.001) and NRMSE of 0.116. Conclusions: Using an Anklebot to recreate spasticity testing maneuvers, a consistent quantifiable measure of spasticity can be created. The current model is limited by its basis on the MAS and assumption of a linear nature of spasticity. A larger sample size may provide better insight to factors of interest, allowing a more independent model (e.g. piecewise linear) for scoring of spasticity.

 Anoxic brain injury with dystonia and spasticity



Christopher Elmore, Garrett Lui, Ariel Savitz, Destiny N. Murphy

Case Diagnosis: 42 year old female developed severe anoxic brain injury including rigidity, alien hand syndrome, and severe dystonia. Case Description: Patient presented with drug overdose resulting in severe hypoxia. Post-pulseless arrest, hypothermia protocol was complicated by respiratory failure requiring intubation. Magnetic resonance imaging of brain demonstrated fluid-attenuated inversion recovery hyperintensity of bilateral thalami, cerebellum, and basal ganglia involving the caudate nucleus, globus pallidus and external capsule due to global ischemia. Clinical exam in acute rehabilitation hospital consistent with atypical parkinsonism including asymmetric rigidity, dystonia, and involuntary left upper limb movements due to alien hand syndrome. Rigidity and involuntary left upper limb movements responded to carbidopa-levodopa, but dystonia and spasms persisted. Her dystonia was minimally responsive to oral anti-spasmodics including high dose tizanidine and maximal dose oral baclofen necessitating an intrathecal baclofen trial proving so successful patient progressed from minimal assistance with rolling walker to supervision ambulation without a device. Discussions: Less than two months post anoxic brain injury, early intrathecal baclofen pump intervention and addition of carbidopa-levodopa significantly improved patient dystonia, alien hand syndrome, rigidity and spasms allowing patient to achieve modified independent to supervision level with dressing, bathing, toileting, and ambulation at discharge. Anoxic brain injury causes significant morbidity and mortality in all ages. Injuries can be widespread and severe including neuronal cell ischemia and death. Impact varies due to period of anoxia, preexisting comorbid conditions, and baseline cognition. This case highlights the need for an interdisciplinary team to improve functional outcome and the benefits of early intrathecal baclofen pump placement. Conclusions: Neurologic complications of anoxic brain injury such as rigidity and dystonia improve significantly through interdisciplinary rehabilitation. We need to rethink current practices to include use of carbidopa-levodopa for atypical parkinsonian features post anoxic injury and use of early intrathecal baclofen pump placement to improve patient's functional status and quality of life.

 Anton's syndrome in the setting of anoxic brain injury in 38-year-old male: A case report



Stephen W. Peirce, Alexandru Dinu

Case Diagnosis: Anton's Syndrome. Case Description: 38-year-old previously healthy male presented after cardiac arrest. Patient was drinking Redbull and smoking marijuana when he collapsed, requiring CPR, defibrillation and 5 doses of Epinephrine. Intubated on the scene and admitted to intensive care, extubated after 5 days and noted to have acute encephalopathy thereafter. MRI brain showed anoxic injury to cortical parietal and occipital areas bilaterally. He recovered well on the acute floor with residual cognitive, visual, and proprioceptive deficits. Physiatry was consulted and he was admitted to inpatient rehabilitation after 20 days of acute care. Discussions: Upon admission to rehab, he had limited orientation and unable to perform simple commands. There were obvious visual impairments but he denied his deficit and would confabulate answers when questioned or examined. Furthermore, he experienced visual hallucinations, possibly indicating a Charles-Bonnet Syndrome component. During his stay, visual evoked potentials (VEP) were performed and interpreted by our PM&R department revealing evidence of patent pathways. He worked intensively with therapies for 21 days and by discharge, his cognition had improved to premorbid baseline. His vision and proprioception had only mildly improved along with his insight into the deficit. PT and SLP FIM scores improved well, however OT scores lagged as his vision and proprioception remained an issue. Conclusions: Anton-Babinski syndrome is rare and results in visual anosognosia due to occipital brain damage; patient's denying their blindness despite obvious signs such as walking into walls and objects. VEP is a measurement of the electrical signal recorded along the pathways toward the occipital cortex in response to light stimulus. This is a rare syndrome with limited literature, however suspicion must be raised in patients with visual deficits in the setting of bilateral occipital lobe injury. VEP studies can be useful in identifying specific locations of neurologic deficit as it relates to visual deficits.

 Atypical polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes syndrome mimicking chronic inflammatory demyelinating polyradiculoneuropathy with anti-neurofascin antibodies



Alexandra E. Fogarty, Gurpreet Khakh, Mohammed Al-Lozi

Case Diagnosis: POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes) is a rare multisystem disease that is characterized by monoclonal plasma cell proliferation. A combination of clinical criteria and serum markers are used to make the diagnosis and to distinguish it from other entities, such as chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Neurofascin 155 and 140/186 are axonal proteins localized in paranodal and nodal regions, respectively. Pathologic antibodies to these proteins are thought to be implicated in a subset of CIDP cases. Case Description: A 60-year-old man presented with numbness, weakness and loss of balance over several months. Examination showed distal more than proximal weakness, sensory loss, and diffusely diminished tendon reflexes. Electrodiagnostics revealed mixed demyelinating/axonal neuropathy and nerve biopsy demonstrated abnormal epineurial vessels, subperineurial edema, and differential fascicular loss. Immunofixation and serum/urine protein electrophoresis, and light chain values and ratio were normal. The patient continued to decline despite immunosuppressive therapy. Further testing revealed pleural effusion, elevated VEGF level, and endocrine abnormalities. POEMS diagnosis was entertained and bone marrow biopsy revealed plasma cell dyscrasia. Chemotherapy resulted in rapid improvement. Discussions: POEMS is a rare condition characterized by the presence of a monoclonal plasma cell disorder (PCD) and peripheral neuropathy. POEMS syndrome with neurofascin 140/186 and 155 antibodies is rarely reported. Neurofascin antibodies are identified in 2-10% of CIDP cases, which are often refractory to immunosuppressant treatment. This case suggests that these antibodies are not specific, and can present in other diseases. Further workup should be pursued with a low threshold. Conclusions: The diagnosis of POEMS is often difficult and should be not be excluded in patient with Neurofascin antibodies, or with negative serum protein electrophoresis. POEMS may be misdiagnosed as CIDP. However, prognosis and interventions vary greatly, so early differentiation is imperative.

 Application of virtual reality vision therapy after brain injury: Case series



Andrew Y. Vassantachart, Brian Chau

Objectives: Traumatic brain injury (TBI) often causes visual impairments, such as accommodative dysfunction and convergence insufficiency. Current therapies for vision impairment after TBI include monocular eye patching, prism, and compensatory visual strategies which are often limited by poor compliance and are strictly visual. Virtual reality (VR) based visual therapies offer the opportunity to increase compliance by augmenting the therapy with scenarios and challenges that engage the patient and integrate the visual development with systems such as visuomotor skills and stereopsis. Design: Patients with TBI were recruited from a single-institution acute rehabilitation center to undergo 45-minute immersive VR therapy sessions using the VR Vivid Vision application with an HTC Vive head mounted display (HMD). Supervising occupational therapists guided patient treatment and patients completed a post-therapy satisfaction survey after their final session. Results: In the post-therapy survey, all patients (n=3) reported enjoyable experiences and positive impressions of the VR therapy. Two of the three patients reported that the VR therapy was more enjoyable than traditional vision therapy. Therapists involved in the study noted that patients were more motivated and attentive to the tasks during the VR therapy sessions compared to traditional visual therapy. Conclusions: This preliminary feasibility study explores utilizing VR vision therapy for patients with TBI within the inpatient acute rehabilitation setting. VR therapies have the potential to provide an enjoyable experience that motivates patients to engage in and remain attentive to tasks. The limitations of this study were the small sample size and the limited number of therapy sessions. Continued investigation into VR vision therapy efficacy and protocol is recommended for future studies.

 Artificial intelligence-cost effective alternative to conventional environmental control unit



Alice Hon, Hung Nguyen, Maureen Jennings

Objectives: To explore the use of artificial intelligence, Amazon Echo, as cost-effective device compared with the conventional environmental control unit (ECU), and how it can improve the quality of life for individuals with spinal cord injury (SCI) and spinal cord disorders (SCD) with limited hand and upper extremity function. Design: Thirty individuals with high level SCI (C1-C7), multiple sclerosis, and amyotrophic lateral sclerosis with limited hand and upper extremity function were recruited for this three month qualitative study. All individuals were given an Amazon Echo. Individuals who use an ECU at home also selected up to five smart devices. They completed three monthly surveys. Results: The majority used the Amazon Echo daily to listen to music, keep up with news media, and current events. A smaller number accessed social media, emailed or texted, played games, watched movies, and operated smart devices. The majority over all the three months indicated after using the Amazon Echo that their changes in health status, social participation, level of independence, and outlook on life were either “a little better” or “better”. They were able to use the smart video doorbell, smart light bulbs, smart outlets, and smart TV accessory. Some reported a preference for the Amazon Echo device over the convention ECU in operating certain aspects of their home devices. Conclusions: This is a pilot study investigating the use of Amazon Echo in the individuals with high level SCI and SCD with limited hand and upper extremity function. Overall individuals with high level SCI and SCD were able to use the Amazon Echo, and the majority reported that it improved their quality of life. There were individuals that reported a preference for the Amazon Echo device over the conventional environmental control unit in operating certain aspects of their home devices.

 Assessment of motion and muscle activation related to low back pain during pregnancy by musculoskeletal model



Saori Morino, Masaki Takahashi

Objectives: Specific postural and movement change during pregnancy impose excessive strain on muscles, such as erector spinae (ES), contributing to low back pain (LBP). Sit-to-stand (STS) motion can potentially cause LBP during pregnancy. Therefore, the purpose of this study is to investigate the relationship between muscle load and intensity of LBP in STS using musculoskeletal model for pregnancy. Design: At first, STS motion analysis was conducted for 11 pregnant women to obtain motion, force, and electromyogram data. Then, pain intensity of LBP in STS was investigated by a Numerical Rating Scale (NRS). Subsequently, ES muscle torque was estimated from obtained data using musculoskeletal model of pregnancy. Based on the value, root mean square of ES muscle torque (RMS-MT) was calculated as an evaluation index of muscle activation. The bigger values indicate the greater activation. Then, the difference of the RMS value in STS and at standing position (DRMS-MT-Stand) was also calculated in order to remove the individual differences of muscle activation in rest position. At last, the correlation analysis was conducted using the two indices and NRS score to investigate the correlation between the muscle activation and the intensity of LBP by using the data from pregnant women who have LBP in STS. Results: Among the participants, 9 women (29.4±2.9 years, 34.6±1.9 weeks of pregnancy) had LBP. No significant correlation between RMS-MT and NRS score was observed (r = 0.38 p = 0.32). On the other hand, significant positive correlation was observed between DRMS-MT-stand and NRS score (r = 0.74 p = 0.02). Conclusions: Greater ES muscle activation in STS motion compared with rest position might indicate a higher relationship with LBP during pregnancy. Therefore, the assessment and approach to muscle activation during motion and also rest position might be effective for the management of LBP in STS motion during pregnancy.

 Assessment of the social cognition by the mini-SEA in poststroke



Valentin Dobbelaere, Nelly Senal, Etienne Allart

Objectives: Social cognition refers to the cognitive processes used to assess and interpret the social and emotional cues around us. Disorders of social cognition are known in various pathologies of the brain, but only few evaluations are standardized and validated. The mini-SEA include a theory of mind assessment by a reduce version of the “Faux-pas recognition test “and the recognition of facial emotions test. Social cognition disorders are a major cause of disability after a stroke. Our main objective was to assess the social cognition disorders in subacute post-stroke patients using Mini-SEA. Design: We performed a cross-sectional study. We included 24 patients in a rehabilitation center in the subacute phase following a first stroke. We evaluated social cognition by the Mini-SEA. Other parameters were assessed, including executive functions, behavioral changes, activity limitations and anxiety-depressive symptoms. Results: Among the patients included 16 (66.7%) had a global pathological score in the mini-SEA test, 18 (75%) a deficiency in facial emotion recognition, more specifically the recognition of fear, and 16 patients (66 , 7%) a disorder in the recognition of “faux-pas”. The results of our group were significantly different from the norms of the test (p < 0.05). There was no significant difference between left and right hemispherical lesions, or correlation with executive function tests and those assessing anxiety-depressive symptoms. There was a significant correlation between the overall score of the mini-SEA and the behavioral changes assessed by the DEX questionnaire (p < 0.01). Conclusions: Social cognition disorders are common in the sub-acute phase of stroke, it brings an invisible disability, and it also has an impact on the daily lives of patients and their families. The mini-SEA is a tool to detect these disorders early to provide support and appropriate care for these patients.

 Association between self-reported cardiovascular exercise and health outcomes in chronic spinal cord injury



Andrew Park, Stephanie C. Ryder, Mitch Sevigny, Ricardo Battaglino, Leslie Morse

Objectives: Cardiovascular disease is a primary cause of morbidity and mortality in persons living with spinal cord injury (SCI) with higher prevalence and earlier occurrence than the general population. Exercise is a proven method to improve cardiovascular outcomes. Updated SCI-specific physical activity guidelines in addition to the previous recommendation, added an aerobic only conditional recommendation as more aerobic exercise appears to be necessary to achieve cardiovascular benefit in comparison to aerobic in conjunction with strengthening. Our study aims to characterize the association between physical activity and health outcomes based on those meeting the updated aerobic recommendations. Design: We assessed the association between those who met aerobic exercise guidelines ( >90 minutes/week) versus those who did not in 325 participants with SCI >1 year post-injury using multivariate models. Results: Of participants, 27% were active (289 min/week + 158.8) and 73% were sedentary. There was no difference in mean age, gender, race, and BMI. Participants with motor incomplete SCI or ambulators were both approximately 2 times more likely to be active. Smokers were nearly 50% less likely to be active. The odds of being active decreased with increasing years post-injury, CRP levels, % gynoid fat, history of heart disease, lower bone density at the distal tibial, and history of lower extremity fracture. The association between CRP and activity was independent of current UTI and current skin pressure injury. Conclusions: We report a high rate of sedentary behavior in SCI. Meeting the physical activity guidelines for aerobic exercise suggests an association with lower gynoid fat, self-reported heart disease, CRP, osteoporotic fractures, and greater proximal tibia density. Given the cross-sectional nature of this study, causality cannot be determined. Active smoking, wheelchair use, and motor complete injury may be barriers to meeting these guidelines. Future interventions to increase physical activity or smoking cessation programs may confer health benefits in SCI.

 Association between use of higher tidal volume and clinical outcomes among acute spinal cord injury: A retrospective cohort study



Radha Korupolu, Ellia Ciammaichella, Patrick Mollett, Hannah Uhlig-Reche, Emmanuel Achilike

Objectives: Approximately two thirds of people with acute spinal cord injury (SCI) will experience respiratory complications necessitating mechanical ventilation (MV) which is associated with higher morbidity and mortality. Current SCI clinical guidelines recommends tidal volume (TV) setting of ≥ 15 cc/kg ideal body weight for who require MV after acute SCI which is in contrast to the ARDSnet protocol which was developed for patients with acute respiratory distress syndrome (ARDS). Emerging evidence suggests favorable outcomes with low TV ventilation in patients with non ARDS lungs as well. We conducted a retrospective study to determine if higher TV MV in acute SCI is associated with poor outcomes. Design: Retrospective cohort study; 43 ventilator dependent people with SCI admitted to acute inpatient rehabilitation (AIR) unit between Jan 2016- Dec 2017 were included. MV with TV of ≤15 cc/kg IBW or >15 cc/kg IBW. Outcomes: Ventilator weaning days, AIR hospital length of stay (LOS) and incidence of pneumonia. Results: TV of >15 cc was utilized in 24 (56%) people. Demographics, apart from age, were similar between 2 groups; patients were older in the TV of >15 cc group. Median days to wean from ventilator after admission to AIR unit ((35 vs. 25 days, p= 0.002) and rehabilitation hospital LOS (56 vs. 42.5 days, p=0.01) were longer in TV of > 15 cc/kg IBW group. Tidal volume of > 15 cc/kg IBW was associated with a 1.98 times (p=0.1) increased incidence of pneumonia (p=0.1), though results were not statistically significant. Conclusions: While limited by sample size, our data revealed an association between TV >15 cc/kg IBW with slower weaning from ventilator, longer hospital LOS and increased incidence of pneumonia. Future research is required into optimal ventilation settings for acute SCI patients.

 Attainment of physiologic salivary flow rate with long-term incobotulinumtoxina treatment for sialorrhea in Parkinson's disease and other neurologic conditions



Fernando Pagan

Objectives: We present salivary flow rate from the 64-week SIAXI study, and investigate the effect of repeated incobotulinumtoxinA injections on salivary flow rate in adults with chronic sialorrhea due to Parkinson's disease (PD), atypical parkinsonism, stroke or traumatic brain injury. Design: SIAXI (NCT02091739) was a pivotal double-blind, randomized, placebo-controlled phase 3 study with a 48-week extension period (EP). In the main phase (MP) subjects were randomized (2:2:1) to incobotulinumtoxinA 75 or 100 U (n=74 each), or placebo (n=36) in a single injection cycle (IC). At completion, eligible patients entered the EP and received three further incobotulinumtoxinA ICs (each 16±2 weeks) of 75 U or 100 U. Outcomes assessed in subjects who received incobotulinumtoxinA in all four ICs included: unstimulated salivary flow rate (uSFR), modified Radboud Oral Motor Inventory for Parkinson's Disease (mROMP) speech symptom scores and dental adverse events (AEs). Results: In total, 140/148 subjects, who received incobotulinumtoxinA 75 U (n=68) or 100 U (n=72) in all ICs, completed the MP and entered the EP. With incobotulinumtoxinA 75 and 100 U, respectively, mean (SD) uSFR decreased in all ICs from MP baseline (0.42 [0.28] and 0.40 [0.27] g/min; including subjects who did not continue to EP) at all visits and to 0.26 (0.24) and 0.22 (0.18) g/min at the end-of-study visit. Maximal reductions were observed at 4 weeks and sustained at 16 weeks post-injection in all ICs. The most common dental AE was tooth extraction (4.4% and 5.6%) unrelated to treatment. Treatment-related gingivitis was reported in one 100 U recipient. Conclusions: Data demonstrate consistent reduction in salivary flow rate at each IC, within normal physiological levels. Subjects did not reach a level of hyposalivation. Stable mROMP speech symptom scores suggest that sufficient saliva remained in the oral cavity to prevent speech impairment. Assessment of dental health showed no safety issues due to hyposalivation.

 Atypical presentation of weakness and abnormal EMG findings in a patient with CML and ALS: A case report



Clarisse Melinda San Juan, Steven J. Mann, Getahun Kifle

Case Diagnosis: Amyotrophic Lateral Sclerosis. Case Description: 35 year-old female with a 7-year history of Chronic Myeloid Leukemia in remission on Imatinib, who presented with frequent falls. She initially developed muscle spasms and stiffness, which progressed to weakness of left lower, then right lower, followed by left upper extremity. An anterior truncal sensory level involvement at Right T2 and Left C3 segment was found. Blood and CSF studies were unremarkable. MRI revealed nonspecific foci of T2/FLAIR signal hyperintensity in the bilateral subcortical white matter. Differential diagnosis included neural invasion of CML, tyrosine kinase inhibitor toxicity, and ALS. EMG showed diffuse motor neuron pathology but did not have giant MUAPs with reduced recruitment seen in ALS. She was treated with plasmapheresis and IVIG with no improvement in symptoms. Sural nerve biopsy was scheduled, however, the patient suffered cardiac arrest while undergoing anesthesia and the procedure was aborted. After recovering she refused to undergo the procedure again. Discussions: The progression of her motor symptoms are typical of ALS although her EMG studies were not definitive. However, sensory findings are not typically found in ALS. Diffuse leptomeningeal disease from recurrence of CML and Imatinib toxicity, although typically sensorimotor, were both not excluded by the EMG. A workup of ruling out all other possible causes eventually led to the diagnosis of ALS. The atypical presentation in this case may be related to her underlying CML. Some studies have suggested that ALS is a paraneoplastic syndrome and its incidence is increased in certain malignancies. Conclusions: ALS is a rare disease, of which there is still much to be discovered. It is important to keep ALS in the differential diagnosis of patients with progressive weakness, even with non-definitive EMG studies, especially in patients with a history of cancer.

 Autonomic dysreflexia and neuropathic pain secondary to an eroding coccyx



Shiv Patel, Isaac Hernandez Jimenez

Case Diagnosis: Autonomic dysreflexia (AD) and neuropathic pain. Case Description: This study presents a 38-year-old male with a chronic SCI C2 AIS C after a pool injury in the setting of alcohol status post C4-C7 decompression & fusion presented to an acute rehabilitation facility due to severe back pain causing marked acute decline in functional status for 6 weeks leading up to admission. During the patient's admission, he had several episodes of severe, acute low back pain leading to AD with systolic blood pressures reaching 220 mmHg. During these episodes, elevating the head of bed would worsen AD symptoms and pain. X-ray of the sacrum-coccyx revealed an eroding coccyx. During episodes of pain, the patient was instructed to turn to relieve any pressure on the coccyx. Additionally, the patient was changed to a power wheelchair and a different cushion allowing him to better perform his pressure releases. Ultimately, these changes resulted in subsequent relief of pain and avoidance of AD. Discussions: During episodes of AD, the first step upon evaluating a patient is elevating the head of the bed to decrease blood pressure. In this case, elevating the head of the bed exacerbated symptoms due to the increased pressure on the coccyx. Additionally, the identification of the source of AD though believed be secondary to pain required an extensive work up to rule out other more common sources. Conclusions: Chronic spinal cord injury patients often present with AD secondary to many issues and identifying the source can be difficult. Coccygeal erosion should remain a differential diagnosis when the source of AD cannot be identified.

 Avoiding catastrophe: Left pontine stroke as the antecedent event to catastrophic antiphospholipid antibody syndrome



Nicole Pontee, Gary N. Inwald

Case Diagnosis: Catastrophic Antiphospholipid Antibody Syndrome. Case Description: E.C. is a 43 year old man with hypertension and autism who presented with right hemiparesis on 2/10/19 and was diagnosed with acute left pontine infarction. He was admitted to inpatient rehabilitation on 2/15. Thrombocytopenia work-up for heparin-induced thrombocytopenia was negative. On 3/2, he syncopized. On 3/4 he had acute abdominal pain with mild ileus on X-ray. On 3/6, patient had a fever and leukocytosis, but infectious work-up was unrevealing. On 3/7, patient was dyspneic, saturating at 91% on room air. CT imaging revealed emboli involving the pulmonary, superior mesenteric, and splenic arteries. He also had a right popliteal DVT. Testing revealed positive lupus anticoagulant. E.C. received rounds of plasma exchange and intravenous immunoglobulin. He underwent exploratory laparotomy on 3/14 for bowel ischemia. He was placed on lifelong anticoagulation. Discussions: Antiphospholipid syndrome (APS) is a pro-thrombotic autoimmune condition. Catastrophic antiphospholipid antibody syndrome (CAPS) is a severe and often fatal form of APS. CAPS is diagnosed when there is involvement of three or more organ systems, manifestations occur simultaneously or within less than one week, histopathology reveals small vessel occlusion, and antiphospholipid antibodies are present. Concurrent thrombocytopenia can be seen in half of cases of CAPS. CAPS shares clinical similarities to heparin-induced thrombocytopenia (HIT), disseminated intravascular coagulation (DIC), and other various thrombotic microangiopathies (TMAs), which can hinder a timely diagnosis and delay treatment. Conclusions: Recognizing the unusual pattern of concurrent arterial and venous thromboses over a short period of time should alert clinicians to investigate alternate rare and potentially fatal complications that can occur even in the rehab setting. This case demonstrates the potential manifestations of a rare disease that may initially present as a single thrombotic event, in this case, a stroke, with subsequent thrombotic sequelae that warrant immediate, escalated investigation and intervention.

 Axillary nerve palsy after low anterior resection



Richard Huynh, Ronak Tailor, Ricardo Cruz, Sony M. Issac, Briana Novello, Hamza Khalid

Case Diagnosis: Axillary Nerve Palsy, a rare type of brachial plexus injury, clinically manifests as sensory loss over the lateral aspect of the shoulder and variable levels of weakness with shoulder abduction, shoulder external rotation, and elbow flexion. The most common cause is trauma associated with shoulder dislocation or humeral fracture. It can also occur in a prone position with the arms raised overhead, such as during anesthesia or sleep. Case Description: A 52 year old female with recently diagnosed stage 2 colon cancer underwent laparoscopic low anterior resection. Post-operatively, she presented with left shoulder weakness and numbness. Physical exam showed left shoulder abduction and external rotation strength of 3/5 and elbow flexion strength of 4/5. Left shoulder ROM was limited to 30 degrees of abduction. On POD 2, MRI of the left brachial plexus, left shoulder, and cervical spine were unremarkable. On POD 15, EMG showed abnormal spontaneous activity in the left deltoid muscle. Discussions: Laparoscopic low anterior resection surgery typically involves lithotomy and trendelenburg positioning. Upper extremities are often abducted for ease of IV access. Hyperabduction of the arm and steep trendelenburg increases the risk of brachial plexus injury. Stretching of the nerves leads to the disruption of intraneural blood flow and in severe cases, endoneural edema and disruption of axoplasmic flow, which result in demyelination and segmental degeneration. Conservative management includes physical therapy. Severe cases or failure of conservative management may require surgical intervention. Conclusions: The patient's positioning should be considered from a safety standpoint rather than one of only operative convenience. Prevention of axillary nerve palsy requires minimization of operative time and trendelenburg position. Abduction of the arm should be avoided if possible. Increased awareness among healthcare providers will help to decrease the incidence of axillary nerve palsy.

 Baclofen toxicity from intrathecal pump in the setting of acute renal insufficiency



Natasha Bhatia, Joshua L. Elkin

Case Diagnosis: Baclofen Toxicity. Case Description: A 22-year-old man with cerebral palsy, spasticity treated with intrathecal baclofen pump, and stage 4 chronic kidney disease due to IgA nephropathy, presented with a 3-day history of decreased arousal. Admission labs showed creatinine 1.79 (baseline 1.4), GFR 53, and potassium 5.6. The patient was found to be in urinary retention requiring intermittent catheterization, which was thought to be the cause of his worsened renal function. Due to concern that his AKI on CKD due to urinary obstruction had resulted in baclofen toxicity, his nighttime bolus was discontinued and the continuous pump rate was reduced. His symptoms improved with this reduction in his baclofen dose and supportive management, and he was discharged home in improved condition. Discussions: Baclofen toxicity is a rare outcome which occurs more frequently in patients with impaired renal function due to baclofen's excretion by the kidneys. This patient had known stable renal disease and an unchanged dose of intrathecal baclofen. After an acute reduction in GFR due to urinary retention, he developed symptoms of baclofen overdose characterized by decreased level of consciousness. Baclofen overdose can also manifest with hypotension, bradycardia, seizures, and nausea/vomiting. It is treated with reduction in IT baclofen dose (or cessation of oral dose), and supportive measures. Hemodialysis, effective in clearing serum baclofen, must be initiated in some cases. Conclusions: Caution must be exercised with administration of baclofen in patients with underlying renal disease or those at risk of developing renal insufficiency. Baclofen is most often used in our patient population for spasticity after neurologic insult, but many of these patients are also more likely to develop neurogenic bladder, putting them at risk of post-renal acute kidney injury. In patients with both bladder/renal issues and spasticity treated with baclofen, any change in arousal or mental status should prompt consideration of baclofen overdose.

 Battlefield acupuncture for pain management in a tetraplegic



Samantha P. Mendelson

Case Diagnosis: A 64-year-old tetraplegic after a trauma 2 years ago with significant pain. He needed daily morphine and oxycodone. These medications caused many intolerable side effects. Case Description: We performed battlefield acupuncture on him. Within minutes of treatment, his neck pain and stiffness decreased from an 8 to 4/10 and within hours decreased to 1/10. This relief persisted for 5-7 days. The treatment was then repeated with the same Results. 2 weeks after initiating this treatment, we started decreasing his oral morphine dose. Within 6 weeks, decreased his daily dose by 83%. Discussions: Acupuncture is a treatment which originated in China 5,000 years ago. It has effects where the needles are placed as well as in areas distinct from where the treatment is performed. The treatment is believed to reduce pain by two mechanisms: first, it suppresses pain transmissions at the level of the spinal cord. Second, it causes the release of chemical transmitters in the brain, suppressing the sensation of pain. Traditional acupuncture commonly involves placing many needles at various points on the trunk and extremities. Various schools of acupuncture have developed different styles with more focused needle placement. In 2001, Dr. Richard Niemtzow, of the United States Air Force, discovered a specific sequence of needles placed into the ears provided rapid and effective relief of many types of pain. This treatment protocol is known as Battlefield Acupuncture. It's safe and effective for many patients and pain conditions. Conclusions: Pain is a complication in paralyzed people. It may impact a person's performance in social, vocational and leisure activities. It may interfere with quality of life, social functioning, employment, mood, as well as rehabilitation therapy. Battlefield acupuncture is a safe and effective treatment for individuals with SCI. We have integrated this treatment in our practice and have seen many positive outcomes for our paralyzed patients.

 Beneficial effects of 3'-sialyllactose in human chondrogenic and osteogenic differentiation



Junyoung Park, Sung Hoon Kim, Young Hee Lee, Ji Yoon Jang

Case Diagnosis: Three'-sialyllactose (3'-sialyllactose, 3'SL) is an oligosaccharide found in human breast milk and cow's milk and is known to inhibit the progression of osteoarthritis and rheumatoid arthritis. However, the therapeutic effects of 3'SL in chondrogenic and osteogenic differentiation have been unknown yet. In this study, we investigated chondrogenic and osteogenic differentiation of human bone marrow derived mesenchymal stem cells (hBMSCs) treated with 3'-sialyllactose. Case Description: The human bone marrow derived mesenchymal stem cells (hBMSCs) obtained from bone grafts in patients with bone defect in the lower extremities were used for the experiments. The chondrogenic differentiation culture was performed by 3-dimensional chondrogenic differentiation culture through micromass culture, and 3'-Sialyllactose was added to chondrogenesis medium. Likewise, 3'SL was added to osteogenesis medium to induce osteogenesis. Experiments were assessed by performing qRT-PCR, western blot. Alcian blue, safranine O and alizarin red S staining were used to confirm cell differentiation. Discussions: In the micromass culture treated with 3'SL, mRNA and protein expression of sox9 and aggrecan, which are cartilage differentiation indicators, were significantly increased. In addition, alcian blue stain confirming the positive mucous polysaccharide of the cartilage matrix, and safranine O stain confirming the positive of the proteoglycan, a cartilage-specific substrate, were stained more strongly in the 3'-sialyllactose treated micromass culture than the untreated group. mRNA and protein expression of MMP13 and Col10, which are cartilage hypertrophy markers, were significantly decreased compared to the untreated group. To the next, in the 3'SL treated group, mRNA and protein expression of RUNX2, an osteogenic differentiation master regulator, and osteopontin, an indicator of late osteogenesis, were increased. Alizarin red s staining was performed to confirm bone differentiation, and red dyed portion was increased at the site of calcium deposition. Conclusions: Three'SL significantly increase chondrogenic and osteogenic differentiation and suppress cartilaginous hypertrophy in human bone marrow derived mesenchymal stem cells (hBMSCs). Furthermore, 3'-Sialyllactose can be used for potential target for cartilage & bone repair for clinical application.

 Benefits of a continuum of rehabilitation for a young adult with Lennox-Gastaut syndrome and the essential components of the treatment plan



Ryan P. Nussbaum, Leslie Rydberg

Case Diagnosis: Lennox-Gastaut syndrome (LGS) has a prevalence between 1-10% for all childhood epilepsies, and there is limited data regarding prevalence in adults. However, the research supports many of these individuals live into adulthood with the assistance of their families or in a residential facility. This condition is characterized by a triad of: multiple drug-resistant seizure types, a specific interictal EEG pattern showing bursts of slow spike-wave complexes or generalized paroxysmal fast activity, and intellectual disability. Case Description: 23 year old male with a history of LGS whose seizures were well controlled until 2018 when he experienced non-convulsive status epilepticus (NCSE) that resulted in a prolonged hospitalization. His anti-seizure regimen increased to five medications and a ketogenic diet was started. He underwent vagal nerve stimulator (VNS) placement. A tracheostomy occurred for respiratory complications and PEG tube for nutritional requirements. At the inpatient rehabilitation facility, he initially was emerging from a minimally conscious state. He would have 3 seizures per hour lasting 5-10 seconds characterized by both arms slowly flexing upward. Neurology adjusting anti-seizure medication administration was instrumental in optimizing arousal. On admission, he required total assist for all ADLs and mobility. His communication and social cognition improved to moderate assistance. He was successfully decannulated and upgraded to a regular ketogenic diet. In outpatient rehabilitation, he does lower body dressing with minimal assist and walking with moderate assist. Discussions: There is limited research describing the benefits of inpatient rehabilitation for individuals with LGS. Given the susceptibility for NCSE, individuals with LGS benefit from inpatient rehabilitation for improving function. The patient's family had the goal of discharging their son home, and the patient's stay in inpatient rehabilitation made this possible. Further, outpatient rehabilitation has improved his independence. Conclusions: Inpatient and outpatient rehabilitation represent an ideal continuum of care to optimize function in patients with LGS after prolonged hospitalization.

 Beriberi presenting as Guillain-Barre syndrome in a young woman



Michael Gallagher, Allison Averill, Tejas Shah

Case Diagnosis: Beriberi. Case Description: A 23-year-old woman with history of gastric bypass 3 years prior to presentation presented to acute inpatient rehabilitation after she develop severe neuropathic pain and weakness in her bilateral lower extremities.Despite extensive rehabilitation and medication with gabapentin and pregablin she remained significantly weak with intractable neuropathic pain. After discussion with the patient's neurologist at her acute care hospital, it was felt she had developed Guillain-Barre syndrome (GBS) given electromyography showed abnormalities consistent with demyelination. However, on additional history, she had stopped all post-bypass vitamin supplementation three months prior to initial presentation as she had developed bouts of intractable vomiting which resolved after cessation of supplements. Her vitamin B1, B12, and D3 levels were tested at rehab and were all found to be markedly low. She diagnosed with likely dry beriberi and was initiated on thiamine supplementation. Discussions: There are a handful of case reports indicating that acute beriberi can sometimes mimic GBS in strict vegetarians. To the authors' knowledge this is the first reported case of dry beriberi presenting as GBS in a post-bypass patient. Additionally, literature indicating EMG data for beriberi mimicking the demyelinating process scene in GBS is rare. Interestingly, although the diseases present similarly on EMG, nerve biopsy shows beriberi begins as a process of axonal degeneration that progresses to demyelination in end-stage disease, whereas GBS is primarily a demyelinating process. However, recovery in beriberi is typically swift after thiamine is reintroduced, but GBS's clinical course can be fairly prolonged. Conclusions: The dry form of beriberi can mimic GBS symptoms, presenting as ascending flaccid peripheral neuropathy. Moreover, the case indicates that even nerve conduction studies cannot always distinguish the two processes. Therefore, in cases where history suggests a possible alternative etiology to GBS-like symptoms, thiamine levels can be easily tested and supplementation leads to rapid improvement in beriberi.

 Bihemisferic transcranial direct current stimulation therapy in stroke patients: A randomized double blind study



Oya Umit Yemisci, Dilek Cetinkaya Alisar, Selin Ozen, Seyhan Sozay

Objectives: Stroke is the leading cause of long-term disability among adults. More than 60% of stroke survivors are suffering from persistent neurological deficits. Mostly motor function is effected and activities of daily living (ADLs) are impaired. Post stroke neuronal brain imaging has shown that there is increased neuronal activity in the contralesional hemisphere and reduced activity in the ipsilesional hemisphere which results in dysfunctional brain activity. Two therapeutic strategies which are currently used in improving intra hemispheric cortical activity post stroke include; improving cortical excitability of the ipsilesional hemisphere or inhibiting excitability of the contralesional hemisphere. Transcanial direct stimulation therapy (tDCS) is a novel approach in stroke rehabilitation aiming to increase independence in ADLs. Currently tDCS is not routinely used in stroke rehabilitation. The aim of this study was to establish the effects of bihemspheric tDCS on upper extremity motor function in the subacute – chronic phase of stroke. Design: A total of 32 patients in a tertiary level inpatient rehabilitation hospital were randomized into two groups (16 tDCS group, 16 sham groups). Both groups received conventional upper extremity rehabilitation therapy and occupational therapy (OT) 5 days a week, for 3 weeks. In addition to that, the tDCS group received 30 minutes bihemispheric tDCS for 15 sessions while the control group received sham cortical stimulation simultaneously to OT. The tDCS was applied using a double channelled direct current stimulator (ZMI Electronics Ltd. Taiwan 2012). The consistency of the direct current was constantly monitored and determined by the direct current stimulator. Anodal tDCS stimulates ipsilesional motor cortex excitability whereas cathodal tDCS inhibits contralesional motor cortex excitability. Patients were evaluated before and after treatment using the Fugl Meyer upper extremity (FMUE), functional independence measure (FIM) and Brunnstrom stages of stroke recovery (BSSR) by the same physiatrist who was blind to treatment group. Results: The FIM values were significantly greater in the tDCS group in comparison to the sham group both before (65.44 ± 28.43 vs. 51.19 ± 27.53, p=0.05) and after (88.19 ± 24.61 vs. 58.37 ± 27.24, p=0.002) treatment. Analysis of within group outcome measures revealed a statistically significant improvement in FMUE scale, BSSR and FIM values after treatment in the tDCS group (p= 0.001). Conversely, there was no significant change in FMUE scale, BSSR and FIM values after treatment in the sham group (p >0.05). Furthermore the delta values of the FMUE scale and FIM scores in the tDCS group were significantly higher than those of the sham tDCS group (p< 0,0001). Conclusions: New therapies in the treatment of stroke aim to improve physical function and independence by regaining/ sustaining neuronal activity of the brain and encouraging neuronal plasticity. This study supports that bihemispheric tDCS treatment combined with conventional rehabilitation therapy methods was found to be superior to upper extremity motor and functional improvement in subacute stroke patients. The tDCS and transcranial magnetic stimulation (TMS) are safe, pain free and non-invasive brain stimulation techniques which encourage neuronal plasticity and reorganization following brain injury. In order to use tDCS routinely and find answers to questions, such as the duration and intensity of treatment in stroke rehabilitation, there is a need for further comprehensive, long-termed, randomized controlled clinical trials.

 Bilateral pontine strokes: A GAZE at the unusual presentation of a patient with eight-and-a-half syndrome



Yulia Rivelis, Jennifer M. Cushman, Mery Elashvili

Case Diagnosis: Unique case highlighting variants in the presentation of a horizontal-gaze in a patient undergoing rehab for a pontine stroke. Typical presentation of a left sided pontine stroke resulting in a one-and-a-half syndrome in our patient would expect to yield only right eye abduction and loss of eye abduction and adduction on the ipsilateral pontine stroke side. However our patient was still able to abduct left eye, signifying partial sparing of his left-abducens and oculomotor nerve innervating the superior rectus, which allowed for compensated eye movement in an up and out direction. Case Description: 70-year-old male presented to inpatient rehabilitation unit with eight-and- -a-half-syndrome. Course was complicated by an acute stroke to the left-dorsal-pons, and a chronic right-pontine infarct. With right-horizontal gaze, exam was notable for bilateral nystagmus with deficits in left eye adduction, with normal right-eye abduction. On left-horizontal gaze, patient's left eye was able to abduct, but right eye was unable to adduct. Patient also had left facial weakness-(CN7), all consistent with eight-and- -a-half-syndrome. Discussions: One-and-a-half syndrome refers to ipsilateral horizontal gaze palsy (”one”) combined with ipsilateral internuclear opthalmoplegia (”half”), due to lesions located near paramedian pontine reticular formation and MLF. Contralateral eye abductio typically remains intact. If ipsilateral facial nerve is affected, this is termed eight-and-a-half syndrome, since it is one-and-a-half plus a 7th cranial nerve palsy. Eight-and-a-half syndrome is a rare complication resulting from a pontine stroke occurring on the ipsilateral side of the lower motor neuron lesion which is affected by extension of the stroke into the facial motor nucleus. Conclusions: There are very few reports highlighting this rare syndrome. Our case emphasizes an even more unique presentation of a patient presenting with an eight-and-a-half syndrome, yet preserving retained abduction of the eye on the same side of the pontine infarct.

 Bilateral total knee arthroplasty in an incomplete C6 spinal cord injury



Michael Boeving, James Salerno

Case Diagnosis: Bilateral Total Knee Arthroplasty in an Incomplete C6 Spinal Cord Injury Patient Utilizing an Implanted Functional Electrical Stimulation System. Case Description: Here we describe a unique case of a C6 incomplete spinal cord injury (SCI) with central cord syndrome and persistent quadriparesis who was able to ambulate utilizing lofstrand crutches and an implantable functional electrical stimulation (FES) system. The patient developed bilateral knee subluxation with twenty degrees of hyperextension accompanied with knee osteoarthritis refractory to injections, NSAIDs, and arthroscopy. The resulting severe knee pain limited her mobility and functional independence. Consequently, the patient was evaluated for and underwent an elective bilateral total knee arthroplasty. On admission to acute inpatient rehab, the patient had urinary retention and patient was max-assist with min-assist with bed mobility, max-assist for transfers, with hip flexion and knee extension too weak to stand. With comprehensive inpatient rehabilitation, the patient had good functional outcomes in ADL's and transfers, is able to stand but will requiring ongoing outpatient therapies and FES reprogramming to walk. Discussions: Knee replacements in paraplegics, and quadriplegics are very uncommon occurrences, with only a handful cases described in the published literature. This is likely multifactorial due to a lack of development of traditional indications such as osteoarthritis, but may also represent the high risk-to-benefit expectancy of these surgeries in this population with a more post-operative complications related to SCI comorbidities and impaired mobility. However, new technologies such as the implantable FES gait system employed by this patient and more advanced systems are increasingly common, and orthopedic complications like the knee subluxation and osteoarthritis are likely complications in this ambulatory SCI populations due to gait abnormalities and muscular strength imbalance that predispose patients to these pathologies. Conclusions: Increasingly, more patients with SCI will present with similar orthopedic complaints which can functionally benefit and should be considered for surgical interventions.

 Biomechanical analysis of Cambré posture in salsa dancers



Iveth M. Urbano Chamorro, Andres Reyes Campo, Maria E. Zuluaga Ruiz, Diana Martinez Arce, Wilfredo Agredo, Jessica Quiceno, Victor A. Martinez Cortés

Case Diagnosis: Low back pain is a prevalent symptom in professional dancers, as well as structural changes of the lumbar spine and specific pathologies such as apophysitis. Salsa dance is characterized by repetitive movements and postures like Cambré, taken from the ballet, this posture consists of a rapid spine hyperextension movement. Currently, there are no studies that describe the biomechanical characteristics of postures practiced by salsa dancers. The aim of this study was to describe the biomechanical characteristics of the cambré posture in professional salsa dancers. Case Description: This is an observational descriptive study of musculoskeletal injuries in salsa dancers. A physical exam and a kinematic analysis was performed to each participant with a Visual 3D (C-Motion) system, 32 reflective markers (Rizzoli Orthopedic Institute model) and 5 electronic cameras at 120 Hz. 6 captures were taken for each dancer, executing the Cambré posture with and without training shoes (7,5 cm heel). Discussions: Three female dancers were recluted, two of them had a BMI > 26. Each participant had a different performance pattern during kinematic analysis. The maximum trunk extension respect to the pelvis was 73° and rotation up to 27 °, there were no differences in the angles of movement with different types of footwear. Conclusions: The high grade of hyperextension in thoracolumbar segment of the Cambré posture is the most relevant data and could be related to spinal pathologies and lower back pain. There is no uniformity in the movement technique between each participant, the factors that lead to this heterogeneity are unknown. Further studies to describe the injuries and characteristics of training in this population are required.

 Blind sports' blind spot: Contrasting the global epidemiology of vision impairment against participation trends in paralympic sports for the visually impaired



Xiang Li, Kristina Fagher, Henk Van Aller, Yetsa A. Tuakli-Wosornu

Case Diagnosis: The physiological and social benefits of sport for persons with visual impairment (VI) are well-documented. However, it is unknown whether access to blind sports is globally balanced, and matches global prevalence estimates of VI. This study compares the epidemiology of VI with global participation trends in blind sports. Case Description: A meta-analysis was conducted to estimate the prevalence of blind/VI sports participation among the blind/VI population of 123 member-countries registered with the International Federation of Blind Sports' (IBSA) in summer season 2019. The proportion of the global blind/VI population was compared to the proportion of registered blind/VI athletes in different world regions. Statistical models were built to estimate between-group correlation nationally and regionally. Discussions: Regionally, the largest number of blind/VI people reside in south Asia (72.9million, 28.86% of global blind/VI population), while the number of registered blind/VI south Asian athletes only accounts for 0.83% of registered blind/VI athletes worldwide. In contrast, western Europe has one of the lowest blindness/VI prevalence rates (3.9%, 7.49million, 2.97% of global blind/VI population), but the highest number of blind/VI athlete registrations (544, 20.54% of total registered blind/VI athletes). Europe as a whole contributes 47.6% of registered blind/VI athletes. Among 123 IBSA-registered member-countries, 31 do not have any completed blind sport registrations, of which 22 have a blindness/VI prevalence higher than global average. Regression analysis shows no significant correlation between regional prevalence of blindness/VI and blind sport participation prevalence. Conclusions: Blind sport participation is affected by factors other than regional blindness/VI prevalence. Blind/VI individuals in poor world regions are most underrepresented in blind sports, which mirrors trends in the broader Paralympic Movement: participation favors high-income countries. Closing this gap, in favor of globally balanced participation that accounts for trends in blind/VI density, would support IBSA's purpose and increase opportunities for optimal physical, mental and social health among those with blindness/VI.

 Blood neuropeptide Y concentration is increased over time in response to annular puncture in a rat model of intervertebral disc degeneration



Chaoming Zhou, Richard Wawrose, Brandon Couch, Joseph Chen, Dong Wang, Joon Lee, Nam Vo, Gwendolyn Sowa

Objectives: Intervertebral disc degeneration (IDD) is an age related and complex process, and improved biomarkers are needed to improve treatment of IDD. Serum biomarkers are an important indicator of pathogenesis, disease progression, and/or treatment response. The goal of this study was to examine the concentration of biomarkers NPY and RANTES in response to puncture induced IDD as confirmed by MRI. Design: A total of ten rats underwent a percutaneous fluoroscopically-assisted needle puncture procedure of the lumber intervertebral discs at levels L2-L3, L3-L4 and L4-L5. Ten rats served as uninjured controls. T2 weighted sagittal MRIs were obtained at baseline as well as 6, 12 and 18 weeks post puncture, and voxel signal intensities and disc volumes were quantified using DSI Studios fiber-tracking software. Serum samples were collected at before puncture, and 1, 6, 12, 18 weeks post puncture and assayed for NPY and RANTES using commercially available ELISA kits. Results: The stabbed intervertebral disc at levels L2-L3, L3-L4 and L4-L5 demonstrated MRI signal intensity decreased by 70%, 71% and 64% and disc volumes decreased by 73%, 74% and 73% from baseline through 18-week time point. A significant increase in serum biomarker NPY in post puncture animals at week 6 (p=0.03), at week 12 (p = 0.0002) and at week 18 (p=0.02). No significant change was observed in the serum biomarker RANTES from baseline through the 18-week time point. Conclusions: The results shown NPY expression in our stab model of IDD was upregulated post-puncture through the course of MRI observed degeneration. Previous work has reported a relationship of circulating NPY levels with stress and pain, as well as in humans with disc degeneration. These preliminary results suggest NPY as an important biomarker in response to disc degeneration. Animal behavioral studies will be needed to clarify the relationship of NPY and pain.

 Body fat and risk of cardiovascular disease of adults with cerebral palsy



Se Hee Jung

Objectives: We aimed to investigate the characteristics of body fat amount and distribution with regard to cardiovascular disease (CVD) risk in adults with cerebral palsy (CP). Design: This is a cross-sectional study in university hospitals and communities for persons with disabilities in South Korea. A total of 99 adults with CP (58 men, mean age of 41.8±8.95 years) were included. The body composition was analyzed using dual-energy x-ray absorptiometry. Body fat mass, body mass index (BMI), fat mass index, and fat mass and ratio in android and gynoid region were analyzed. Resting blood pressure was measured and fasting blood samples were obtained for measurement of plasma glucose, serum triglycerides and cholesterol. The Framingham risk score (FRS) was calculated for estimating the risk of coronary heart disease (CHD). Results: The mean body weight was 57.3±12.9 kg and the mean BMI was 22.5±4.6kg/m2. The rate of obese and overweight based on BMI and FMI criteria were higher than what was reported in general population in South Korea. The mean body fat percent was 27.6±11.6% The mean FRS was 4.4±5.5 and the mean 10-year risk of developing CHD was 2.5±4.0. The mean FRS was similar or higher than that of general Korean population. Simple and multiple linear regression analyses were performed to determine the factors independently associated with the FRS. Variables with p< 0.1 on univariate analyses were used for multivariate analysis. According to the results of the multivariate regression model with stepwise selection, a formula was driven for the FRS as “FRS = -18.79 + 0.42 * Age + 0.54 * Android body fat (%) (R2=0.741)”. Conclusions: The rate of obese and overweight and FRS was higher in adults with CP than the general Korean population. Percent android body fat was associated with the CVD in adults with CP.

 Body mass index and its effect on rehabilitation outcome during inpatient rehabilitation: Interim results from an Asian cohort



Sze Chin Jong, Karen Chua Sui Geok, Gobinathan Chandran, Jovic A. Fuentes, Angie En Qin Seow, Chien Joo Lim

Objectives: The “obesity paradox” in rehabilitation suggests an inverse relation between body mass index (BMI) and rehabilitation outcome. We examined the association between BMI and its effect on post-acute discharge rehabilitation outcomes and report interim results. Design: A prospective observational cohort study was carried out from 31/1/2019 to 31/4/19 after obtaining ethics approval. All patients admitted to a tertiary rehabilitation centre were recruited and followed till discharge. WHO Asian standards for BMI were used to categorise BMI: underweight (BMI < 18.5kg/m2), normal (BMI 18.5-22.9kg/m2), overweight (BMI 23-24.9kg/m2), obese (BMI 25-29.9kg/m2), or extreme obese (BMI >30kg/m2). The primary outcome measures were ΔFIM-Total and FIM efficiency by admission BMI levels. Results: A total of 205 of 500 intended subjects were recruited over a 3-month period. Mean age was 59.4 (SD 13.6) years, 70.2% (144) were male, mean admission FIM was 69.09 (SD 27.03) and mean rehabilitation length of stay was 29.97 (SD 16.74) days. The distributions of underweight, normal, overweight, obese and extremely obese patients were 11.7% (24), 30.2% (62), 19.5% (40), 28.8% (59) and 9.8% (20) respectively on admission, and 12.2% (25), 36.1% (74), 17.6% (36), 25.4% (52) and 8.8% (18) respectively on discharge. Significant differences (p< 0.001) were found in ΔBMI (Discharge BMI – Admission BMI) and ΔFIM total (Discharge FIM total - Admission FIM total) between patients with different BMI categories. There were no significant relationship between admission BMI with ΔFIM total (β=0.124, p=0.612) and FIM efficiency (β=0.021, p=0.197) after adjusted for age and gender. No correlation noted between ΔBMI and ΔFIM total (r=0.047, p=0.505). Conclusions: Our interim analyses suggest that admission BMI in either direction does not significantly impact the ability to achieve functional gains during inpatient rehabilitation, thus challenging the “obesity paradox”. Further studies are necessary to determine if BMI indeed impacts rehabilitation outcome.

 Bone mass is related to muscle strength in adults with cerebral palsy



Se Hee Jung

Objectives: Cerebral palsy (CP) causes skeletal muscle atrophy and impaired muscle growth, and individuals with CP are prone to weight-bearing activity limitations. A lack of physical activity and poor muscle strength were found to be important risk factors for decreased bone health. However, there is no study to investigate the relationship between muscle strength and bone health in adults with CP. Therefore, we aimed to determine whether the bone mass and bone mineral density are associated with muscle strength and physical function in a selected group of adults with CP. Design: This is a cross-sectional study in university hospitals and communities for persons with disabilities. A total of 99 adults with CP (58 men, mean age of 41.8±8.95 years, 72 bilateral CP) were included. For muscle strength measurement, we performed isometric muscle strength testing in lower extremities, hand grip strength measurement, and manual muscle strength testing (MMT). Information about physical activity and subjective discomfort in using limbs were also collected. Bone mass nd bone mineral density were assessed using dual-energy x-ray absorptiometry. Results: Leg bone mass was significantly associated with isometric knee extensor and knee flexor strength. It was significantly related to MMT and subjective discomfort in using the same leg. Arm bone mass was significantly related to hand grip strength, MMT and subjective discomfort in using the same arm. The Gross Motor Function Classification System, the Manual Ability Classification System, and the Short Physical Performance Battery scores were related to leg bone mass but not to trunk bone mass. The correlation between muscle strength and leg bone mass and between physical function and bone mass was not observed in subjects with unilateral CP. Conclusions: Appendicular bone mass of adults with CP was associated with the muscle strength of the limb and physical function. This correlation was observed only in bilateral CP.

 Bone mineral density and T-score discordance of adults with cerebral palsy



Se Hee Jung

Objectives: To investigate the prevalence of osteoporosis and osteopenia and describe characteristics of the bone mineral density of adults with CP. Design: This is a cross-sectional study in university hospitals and communities for persons with disabilities in South Korea. A total of 87 adults with CP (52 men, mean age of 42.0±8.29 years) were included. The bone mineral density and body composition was assessed using dual-energy x-ray absorptiometry. We investigated the correlation between the bone mineral density and CP-related characteristics. The T-score discordance and its prevalence were also assessed. Results: The prevalence of osteopenia was 42.5% (40.0% in men and 45.7% in women) and that of osteoporosis was 25.3% (30.8% in men and 17.1% in women). The mean L-spine (LS) T- and Z-score were lower in men than in women but T-score in femur neck (FN) and total femur (FT) did not show difference by sex. LS, FN, and FT T-score were negatively correlated with the Gross Motor Function Classification System (GMFCS) level. Non-ambulatory subjects showed lower FN (-1.4±1.5, -0.4±0.8, p< 0.001) and LS T-score (-1.2±1.9, -0.3±1.4, p=0.04) than ambulatory subjects. With controlling with the GMFCS level, the body mass index (BMI) was correlated with LS, FN, and FT T-score. The percent body fat was correlated with LS, FN, and FT T-score and LS Z-score. The total fat free mass was correlated with LS T-score and the total fat mass was correlated with LS, FN, and FT T-score. Conclusions: Adults with CP had decreased bone mineral density. The BMD was correlated with motor function, physical activity, BMI, and percent body fat. As T-score discordance was more frequent in adults with CP than in general populations, estimation of fracture probability may need more caution in adults with CP.

 Brain taken hostage! case report: Anti-NMDA receptor encephalitis



Kaila T. Yeste, Nevin Vijayaraghavan, William T. Riden, John Baratta

Case Diagnosis: Catatonia found to be anti-NMDA receptor encephalitis complicated by pain, seizures, and poor oral intake. Case Description: A healthy 23-year-old female presented to the ED for seizures. She developed dysarthria, involuntary movement of her right arm, and child-like verbalization. Her symptoms progressed and within one week of admission, she was nonverbal and unable to follow commands. A serum study ultimately diagnosed anti-NMDA receptor encephalitis. After her treatment plan was initiated, she was discharged to inpatient rehabilitation where she stayed for 36 days. Discussions: The patient made gradual functional improvements during inpatient rehabilitation. For ambulation, she progressed from requiring two-person maximum assistance to single-person moderate assistance with a rolling walker. For ADLs, she progressed from requiring maximum assistance to minimum assistance with extended time. Her cognitive deficits were slow to improve, however, her spontaneous speech improved at the time of discharge. She was cleared for a regular diet but refused to eat and her primary means of nutrition was via G-tube. She was discharged home in the care of her mother and home health therapy. At her two-month follow-up appointment, she demonstrated the ability to ambulate with a rolling walker. She is independent with most ADLs and requires minimal assistance for toileting and bathing. She tolerates soft foods and is anxious to liberalize her diet. She will continue with outpatient therapies and ongoing physiatry follow-up. Conclusions: Anti-NMDA receptor encephalitis is an uncommon syndrome which typically presents in young females of reproductive age and may be associated with the presence of a teratoma. These patients have complex medical needs requiring close monitoring and a multi-modal approach to rehabilitation. This patient required inpatient rehabilitation for physical, occupational, recreational, and speech therapy needs along with her complex medical needs for pain, seizures, hypotension, provoked pulmonary embolism, and tube feedings.

 Brain-computer interface system for lower extremity rehabilitation of chronic stroke patients based on functional electrical stimulation and avatar feedback



Nensi Murovec, Marc Sebastian-Romagosa, Woosang Cho, Sara Dangl, Rupert Ortner, Kartin Mayr, Fan Cao, Christoph Guger

Objectives: Brain-Computer Interfaces (BCIs) show important rehabilitation effect for patients after stroke. Previous studies have shown improvement, also for patients that are in chronic stage and/or have severe hemiparesis and are particularly challenging for conventional rehabilitation techniques. Design: For this pilot study five stroke patients in chronic phase with hemiparesis in the lower extremity were recruited. All of them participated in 25 BCI sessions about 3 times a week. BCI system was based on the motor imagery of the paretic foot and healthy hand with Functional Electrical Stimulation (FES) and Avatar feedback. Assessments were conducted to assess the changes in motor improvement before, after and during the rehabilitation training. Results: Our primary measures used for the assessment were 10-meters walk test (10MWT) and Timed “Up and Go” Test (TUG). The results show an improvement in the 10MWT of 8.54 seconds (25.5%) for all 5 patients in self-selected velocity. TUG improvement was 7.3 seconds (16% faster). One patient was not able to perform this test the results before the rehabilitation training due to the impermanent and difficulties in mobility, but was finally able to perform this test after the BCI sessions. Conclusions: These outcomes show the feasibility of this BCI approach for chronic stroke patients, and further support the growing consensus that these types of tools might develop into a new paradigm for rehabilitation tool for stroke patients. However, the Results are from only five chronic stroke patients so the authors believe that this approach should be further validated in broader randomized controlled studies involving more patients.

 Broca's area as an initiator of speech in a patient with left frontotemporoparietal partial lobectomy



Ihsan Balkaya, Alice Can Ran Qin, Eric L. Altschuler

Case Diagnosis: A 45-year-old right handed male without significant past medical history presented with right sided hemiplegia and aphasia after left frontotemporoparietal lobectomy secondary to traumatic brain injury. Case Description: Patient admitted 3 months after head trauma. On exam, the patient had right hemiparalysis with right sided facial paralysis and expressive aphasia. Patient's expressive language was limited to 2 to 3 word utterances, and he was able to follow commands. Interestingly, the patient had intact repetition with normal articulation. Then we initiated counting “1, 2, 3”; remarkably, the patient carried on until 10. Similarly, after starting the alphabet and days of the week, the patient was able to complete each sequence. When prompted by months of the year, he continued up to June. When skip counting was initiated “2, 4, 6”, he proceeded until 14. Patient was able to read audibly and demonstrated reading comprehension significantly above chance (7/12 correct matching read word to four picture or color choices). He pointed to salient activities in the “Cookie Theft Picture” but could not verbalize. Discussions: Broca's aphasia and apraxia of speech (AoS) are distinct phenomena, yet they frequently coincide, especially in dominant hemisphere stroke patients. The importance of Broca's area's role in speech production is widely accepted; however, the dynamics of language networks are still largely unknown. Stroke in the left premotor cortex--an area surgically excised in this patient-- is known to cause AoS. Thus, this case unequivocally illustrates that there is (an)other area(s) that can coordinate normal articulation (eg. left insula, right premotor cortex) with connection to this patient's Wernicke's area (WA) as evidenced by normal repetition. WA alone must be capable of “super-repetition”/sequence completion. Conclusions: Broca's area, absent in this patient, is essential for initiating speech. WA with connection to an articulation area might be more useful for function than previously appreciated.

 Brown-Séquard syndrome secondary to stab wound to thorax rehabilitation, a case report



Cecilia Cordova Vallejos, Devin Oakes

Case Diagnosis: Brown-Séquard Syndrome at T10 level of thoracic spinal cord. Case Description: 38 year old male presented to the emergency department with stab-wound to left upper thorax complaining of decreased sensation and loss of movement in left lower extremity, normal rectal tone. After washout and knife removal in the operating room, MRI showed penetrating SCI at T10-11 level. Later found to have decrease nociception and thermoanesthesia in right lower extremity below T11. Patient was admitted to inpatient rehabilitation unit whit 6 days a week therapy consisting of: ambulation, transfers, ADLs retraining, upper, more than lower, extremities strengthening, and education in compensatory techniques goals. Patient experienced progressive regain of function and sensation after 30 days. Main complication during rehabilitation stay was painful spasms/clonus of the left leg and foot, treated with oral baclofen and ankle-brace overnight. Upon discharge, patient had achieved “complete independence” or “supervision required assistance” for all ADLs, complete control over bladder and bowel function, and was ambulating with rolling walker. Discussions: Pure Brown-Séquard Syndrome presentations are rare, 1% to 4% of all traumatic SCIs considering the most frequent impure presentations “Brown-Séquard Syndrome plus”, affecting a young population, with known good functional prognosis among all other SCI syndromes, with a 75% to 90% of patients ambulating independently at discharge from rehabilitation. Despite the good outcomes, no descriptive guidelines regarding rehabilitation process and complications has been made. Barriers to discharge and complete independence have scarcely been reported without clear differences in treatment, prognosis, complications, and prophylaxis in traumatic vs non-traumatic, pure or impure presentations. Conclusions: The different presentations of SCI require a different approach to treatment, considering their neurological deficiencies and preserved status. In order to further improve patient's rehabilitation outcomes, more case reports are need to be published for future guidelines of treatment and anticipatory guides of complications during rehabilitation-course can be made.

 Brown-Sequard syndrome after cervical radio-frequency ablation



Adrian D. Sulindro, Audrey Kohar

Case Diagnosis: Brown Sequard Syndrome after Cervical Radiofrequency Ablation (RFA). Case Description: A 76-year-old woman presented to the emergency room with worsening numbness and weakness of all 4 limbs while undergoing a cervical radiofrequency ablation (RFA) for cervical spondylosis at an outpatient facility. MRI of the C-spine showed cord edema (C1-C3), focus artifact at C2 consistent with blood products and cord infarct, edema in interspinous ligaments C2-C3 and asymmetric edema in the right posterior paraspinal muscles. Symptoms included shortness of breath requiring supplemental oxygen, neurogenic bowel and bladder, left sided upper and lower extremity weakness, and right sided sensory and temperature impairment. Further imaging showed paralyzed left hemidiaphragm. Clinic picture was consistent with brown-sequard syndrome cervical spinal cord injury. Patient underwent 2 weeks of acute inpatient rehabilitation where focus on gait, neuromuscular re-education, bowel, and bladder management. Upon discharge, patient was ambulating with a walker, and regained full control of bladder and bowel movements. Discussions: The cervical dorsal ramus medial branch wraps around the convexity of the articular pillar of its respective vertebra and may be ablated for facet mediated pain. It is commonly performed under fluoroscopic guidance, although ultrasound guided techniques are available. Proximity to the spinal cord, exiting nerve roots, and vertebral artery makes skill, experience, and utilization of safety views imperative. Given radiolucency of the vertebral artery and spinal nerves, ultrasound guidance for visualization may be used alone or in conjunction with fluoroscopy to enhance safety and minimize radiation. Furthermore, sensory and motor testing prior to radiofrequency ablation should be performed to avoid damaging other structure in the event of anomalous anatomy. Conclusions: Brown- Sequard Spinal Cord Injury may be a rare side effect of cervical radiofrequency ablation. Multiple views and sensory/motor testing prior to radiofrequency ablation is imperative to ensure safety.

 Brown-Sequard syndrome following meningioma resection: A case report



Joseph M. Seldin, Samuel Jacob, Chanel Davidoff

Case Diagnosis: We herein present a case of a 58-year-old woman with history of meningioma, who presented to acute inpatient rehabilitation after undergoing elective C2 laminectomy and partial resection of meningioma due to chronic neck pain and was found to have clinical findings consistent with Brown-Sequard syndrome. Case Description: The patient was diagnosed on imaging with a meningioma November/2016 after suffering from chronic neck pain. At that time the patient had no deficits and advised to be monitored by her surgeon. However, the patient's pain increased and developed gait impairment. Upon re-evaluated by her surgeon, was advised to plan for elective C2 laminectomy with partial resection of meningioma and underwent the procedure May/2018. Post-operative course was notable for right sided weakness and gait imbalance. PM&R was consulted, patient was noted to be minimum assist for ambulation, transfers, ADLs and recommended for acute rehabilitation. On admission to our acute rehabilitation facility the following was noted on exam; Right elbow flexors strength 2/5, sensory impairments to light tough/vibration right C2 dermatome & below and diminished pinprick at left C4 / below consistent with Brown-Sequard Syndrome. The patient participated in aggressive therapy and was discharged to the community as modified independent. Discussions: Meningioma's although a benign mass of the central nervous system that can be treated surgically, it can cause neurological compromised due to local invasion of nearby structures leading to morbidity. It is important to perform a thorough physical exam as with this case, the patient was found to have Brown-Sequard Syndrome after spinal surgery. Conclusions: We thus present a case of Brown-Sequard following C2 laminectomy and partial resection of a meningioma. Though this is an uncommon finding after undergoing spinal surgery, and has an overall favorable functional prognosis, it is important to identify since it can help further explain patient presentation and inform on clinical decision making.

 Buccal hemineglect: Is it useful to evaluate the differences between the two halves of the oral cavity for the multidisciplinary rehabilitative management of right brain stroke survivors? A cross-sectional study



Alessandro de Sire, Alessio Baricich, Martina Ferrillo, Mario Migliario, Carlo Cisari, Marco Invernizzi

Objectives: 'Buccal hemingelect' has been recently defined as a particular form of unilateral spatial neglect (USN) with detrimental oral effects on right stroke survivors. Aim of our study was to compare the oral hygiene between the two halves of oral cavity in right stroke survivors with and without USN. Design: In this cross-sectional study, we assessed a cohort of right-handed subjects affected by right brain stroke with left hemiparesis, divided into two groups based on the presence of USN. We administered an evaluation protocol including: New Method of Plaque Scoring, Oral Hygiene Index (OHI), Gingival Index, Oral Food Debrise Index, and Winkel Tongue Coating Index (WTCI). All outcome measures were assessed in the entire cohort considering both left and right halves of oral cavity. Results: Of the 21 patients included (mean aged 64.19±7.60 years), the 14 affected by USN (mean aged 64.50±8.06 years) had significantly worse values in all outcome measures in the left oral cavity compared to the right one (p< 0.01). On the other hand, the 7 patients not affected by USN (mean aged 63.57 ± 7.16 years) showed statistically significant differences only in OHI (p=0.03) and WTCI (p=0.03). Conclusions: Hygiene of left oral cavity was significantly worse than contralateral in right brain stroke survivors with USN. This study highlights the need to develop an adequate oral rehabilitation program in right stroke survivors with USN.

 Carbidopa-levadopa improves speech apraxia after open traumatic brain injury: A case report



James J. Bresnahan, Philip J. Koehler, Mithra Maneyapanda

Case Diagnosis: Speech apraxia due to open traumatic brain injury. Case Description: A 24-year-old male with open traumatic brain injury (TBI) due to gunshot wound (GSW). Initial evaluation revealed a GCS of 3 with GSW to left arm, left abdomen, left flank, and left skull. Initial work up with CT-Head showed extensive subarachnoid hemorrhage and cerebral edema with residual bullet fragments in the posterior fossa. Thirty days later he was transferred to our rehabilitation hospital. His examination was notable for significant bilateral limb ataxia. He was also noted to have mutism without facial weakness. Speech-language pathology (SLP) evaluation noted effortful groping, frustration, mild facial weakness, and severe impairment most consistent with speech apraxia. Discussions: The patient was started on amantadine 25-100mg twice daily on day 40. On day 46 of rehabilitation he was able to consistently answer yes-no questions with ataxic head nods and attempted spontaneous communication but was unable to do so due to apraxia of speech. His speech did not improve further and on day 54 his carbidopa-levadopa was increased to 25-100mg three times daily. After two doses he was able to make unintelligible voice. He again plateaued and on day 64, carbidopa-levadopa was titrated to 50-200mg three times daily and on the same day he was able to phonate the entire alphabet with max cueing. Over the next few weeks he had improved intelligibility, consistently produced simple 2-3 word sentences, answered questions of preference with a single word, and correctly identified 50% of one-word images on articulation cards, 75% with phonemic or phrase closure cues, and 100% with verbal model. Conclusions: This case presents a patient with speech apraxia that had a dose-dependent response to carbidopa-levadopa. Carbidopa-levadopa should be considered for treatment of speech apraxia.

 Caring for a transgender female patient with spinal cord injury: A case report



Sarah M. Smith, Juan L. Asanza

Case Diagnosis: C4 AIS B spinal cord injury (SCI) in a transgender female patient. Case Description: A transgender female patient sustained a C4 AIS B spinal cord injury after MV ejection collision in July of 2016. The patient had initiated gender affirming transition therapies in 2004. She underwent orchiectomy in February of 2004 and was on estrogen therapy until 2009, when it was discontinued in the setting of multiple DVTs and a pulmonary embolism. She was subsequently started on oral progesterone to maintain feminization, which was continued until the onset of her SCI. After consulting with endocrinology, she was restarted on progesterone approximately eight weeks after her initial injury. Discussions: Several questions pertaining to this individual's care arose from providers and staff, including: (1) the appropriate gender of roommate(s) for this patient; (2) hormone therapy implications in the setting of an acute SCI; and (3) resources available at the VA for transgender individuals. The patient also had specific desires about clothing, hair styling, donning makeup, and other grooming that she could no longer accomplish independently. If staff had been unwilling to assist, the patient could not have maintained her appearance consistent with her gender identity. Conclusions: Transgender patients have specific care needs, including (but not limited to) hormone therapy, urogenital care, general health screening, and mental health. A principal aim of a physiatrist is to improve quality of life in the setting of life-altering injuries and diseases. Understanding the risks, benefits and general guidelines of gender-affirming therapies in the context of rehabilitation is important. Furthermore, it is essential for all provider team member to have an adequate level of comfort in treating LGBTQ+ patients and the specific health concerns that arise in this community. More information is needed for physiatrists and other staff to provide the optimal care for transgender individuals in the acute rehabilitation setting.

 Case of intractable hiccups in lateral Wallenberg syndrome relieved with baclofen and speech therapy



Bestin Kuriakose, Anuja Korlipara

Case Diagnosis: 68 year old Male with PMHx of HTN, HLD, Left CVA (2009) with residual prosopagnosia/balance issues presented to emergency room with dizziness, left sided facial droop, hoarseness, left upper and lower extremity weakness with MRI of brain showing left acute lateral medullary infarct, rehabilitation course was complicated with intractable hiccups. Case Description: On discharge to acute rehabilitation, patient had left facial droop, hemiparesis, ptosis, and loss of sensation on left side of face and was on a dysphagia III diet. Speech therapy focused on increasing swallow function and increasing normalized response to sensory stimulation. Patient developed intractable hiccups which were refractory to various forms of oral therapy. Initially patient was started on Thorazine and Ativan to help abate the symptoms with minimal relief. Reglan was also used with minimal relief. Patient had full resolution of symptoms with Baclofen in conjunction with speech therapy who used various modalities including Neuromuscular Electrical Stimulation (NMES) which helped with dysphagia symptoms. Discussions: Patients with Wallenberg syndrome have an occlusion of the ipsilateral vertebral artery that gives rise to the posterior inferior cerebellar artery. Common risk factors include hypertension (most common), being male over the age of 55 and history of smoking, all seen in the patient. Hiccups occurs due to an involuntary, intermittent, spasmodic contraction of the diaphragm and intercostal muscles and represent a reflex arc made up of several neural pathways. Baclofen activates GABA which is an inhibitory neurotransmitter that relaxes skeletal muscles. NMES focused on direct stimulation of muscles, including the epiglottis which is a spasmodic muscle seen with hiccups. Conclusions: Hiccups are an unusual and difficult to treat symptom associated with Lateral Wallenberg Syndrome, the use of Baclofen in conjunction with modalities used in Speech Therapy such as NEMS device helped abate the symptoms with improvement of dysphagia as well.

 Case report: Cognitive decline in a patient with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy



Christian B. De Allie, Diane Thompson, Kristian von Rickenbach

Case Diagnosis: Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL). Case Description: A 37 year old man with a history of migraines and erratic behavior resulting in MRI diagnosis of CADASIL (confirmed with Notch 3 genetic testing), presented with lethargy and declining cognitive function after recently being started on Haloperidol for mood changes. Initial MRI brain confirmed a right medial temporal acute punctate infarct and multiple white matter changes consistent with CADASIL. EEG was unremarkable for epileptiform discharges. The patient was subsequently transferred to acute inpatient rehabilitation unit for further management. At baseline, the patient was independent in ADLs and iADLS until 2018 when he experienced a rapid decline in cognitive function and was no longer able to work. He required frequent assistance and reminders from family to complete ADLs. While in inpatient rehabilitation, his exam was notable for paucity of movement and speech, delayed recall, and executive cognitive deficits in complex reasoning and problem solving. Expressive and receptive language were preserved. Discussions: CADASIL is a rare, inherited small vessel disease identified by Notch 3 mutation that presents with microvascular infarcts, diffuse white matter changes, and brain atrophy often leading to cognitive dysfunction, mood disturbances, and disability. 40% of patients with CADASIL display a lack of motivation and decreased voluntary behavior characterized as apathy. Mood changes secondary to dopaminergic blockade from Haloperidol was considered. Compensatory strategies for memory, attention, and planning were taught by an occupational therapist with observable improvements. With physical therapy, he worked on balance, strengthening and ambulation prior to discharge home with physical therapy and a home health-aide. Conclusions: This case illustrates a rare disease leading to rapid cognitive decline in a middle-aged man. Early cognitive impairments such as attention, recall, and planning are commonly displayed in patients with CADASIL, while episodic memory is typically preserved.

 Case report: Rehabilitation concerns in stiff person syndrome



Caroline Lee, Barthelemy Liabaud, Walter Valesky

Case Diagnosis: Stiff person syndrome (SPS) is characterized by progressive muscle stiffness, rigidity, and spasms involving the axial muscles. SPS has three variants: Classic, Partial, and Paraneoplastic. Diagnosis is made via glutamic acid decarboxylase (GAD) antibodies which causes a subsequent decrease in levels of gamma-amino-butyric-acid (GABA). Case Description: A 78 year old female with no significant past medical history presented for one year of bilateral knee, hip, and back pain. The pain started in her hips and knees and progressed to her back, wrist, and shoulders. The patient gradually regressed from independent ambulation to use of a rollator secondary to several falls, from which, she reported agoraphobia secondary to fall anxiety. Imaging demonstrated degenerative disc disease but was negative for acute pathology. Despite a full course of physical and occupational therapy, her symptoms persisted. Rheumatoid work-up was negative and the patient was referred to Neurology for neuromuscular work-up. GAD antibody testing was positive and the patient was diagnosed with SPS. The patient underwent twelve sessions of plasmapheresis and was started on valium for muscle spasms. Discussions: SPS is a rare disease that is more common in females in the 20-50 age range. Diagnosis is confirmed by the presence of anti-GAD antibodies and is treated with IVIG, plasmapheresis, and anti-spasmodics. Recent reviews note that patients may have the startle reflex, head retraction reflex, and agoraphobia secondary to fall anxiety. Without early intervention, patients can progress to severe joint contractures and immobility. Conclusions: As seen in our case, patients with SPS are difficult to diagnose as they present with complaints that are similar to those of aging: joint stiffness, pain, and difficulty ambulating. While our patient was older than typical, this differential should be considered in rehabilitation patients with multiple musculoskeletal complaints but whose work-up is otherwise negative.

 Central cord syndrome resulting in tetraplegia after chiropractic manipulation



James Cole, Sean Terada

Case Diagnosis: Central Cord Syndrome Resulting in Tetraplegia after Cervical Chiropractic Manipulation. Case Description: A 69 year-old male with chronic neck pain and numbness presented after an episode of quadriparesis during mechanical massage from chiropractor. Patient was moving from his back to his side after manipulation when he suddenly lost feeling in all four extremities but didn't experience acute pain. On presentation to emergency department, he was at his baseline numbness in his upper extremities with loss of sensation and new weakness throughout upper and lower extremities bilaterally with increased tone in upper extremities. He denied bowel or bladder incontinence, new pain, loss of range of motion of neck, or vision changes. Cervical spine MRI demonstrated degenerative disease with acute central cord compression and cord signal changes including edema from C3-6. Patient underwent decompression and fusion from C3-C6 and required short stay in ICU for monitoring. Patient was subsequently admitted to inpatient rehabilitation, where he regained some strength but remained tetraplegic. Discussions: Tetraplegia is a rare complication of chiropractic manipulation and current research is lacking on the need for evaluation of underlying pathology to assess patients at increased risk for adverse events. Underlying cervical spine pathology may increase risk for developing central cord syndrome from cervical manipulation but there are no current guidelines for determining patients who are poor candidates for this intervention. Conclusions: While chiropractic manipulation is a generally safe intervention for patients with chronic neck and back pain, some patients may be at increased risk for developing spinal complications with lasting sensory and motor deficits even after surgery with decompression and fusion. Further research should be done to examine risk factors for spinal injury after chiropractic manipulation with possible development of standardized assessment prior to starting chiropractic manipulation.

 Cervical arteriovenous fistula: A rare presentation of cervical myelopathy



Edward W. Ference, Jason Lauer, LaTanya Lofton, Leon Chandler

Case Diagnosis: Cervical Arteriovenous Fistula. Case Description: A 46-year-old African American male with a history of tobacco abuse, hypertension presented to the emergency department with complaints of neck stiffness and thunderclap headache. Non-contrast CT head demonstrated a small intraventricular hemorrhage in the third ventricle. CT angiography demonstrated enhancing tubular structures along the 4th ventricle and posterior spinal canal subarachnoid space extending to the C4 level, concerning for spinal arteriovenous fistula (AVF). Neurosurgery performed spinal arteriography confirming high flow fistula. The patient underwent complex endovascular embolization, requiring therapeutic sacrifice of the left vertebral artery at the C4 level. Postoperatively, the patient was found to have left greater than right sided weakness, loss of pin prick sensation, neurogenic bowel and bladder, with intact sensation to fine touch. MRI demonstrated T2 hyperintensity in the ventral cord from C4-C6. He made significant recovery with inpatient rehabilitation, ultimately discharging home with the ability to walk 400ft with a hemi walker. Discussions: Spinal vascular malformations make up 3-4 percent of intradural spinal lesions. The vast majority of spinal AVFs occur in the thoracolumbar area between T4 and L3. Spinal AVFs cause arteriolzation of the coronal venous plexus, resulting in vascular congestion, local spinal cord ischemia, and myelopathy. MRI is typically the fist study utilized to evaluate the classic progressive myelopathy, demonstrating T2 hyperintensity and spinal cord edema across multiple levels. Serpiginous perimedullar vessels can be seen along the dorsal or ventral spinal cord. Spinal angiography is the gold standard for confirmation, and treatment involves microsurgery or endovascular embolization. Outcomes are directly related to the severity of symptoms at the time of diagnosis, with prolonged, severe deficits carrying poor prognosis for recovery. Conclusions: Spinal arteriovenous fistulas are uncommon causes of spinal pathology, and cervical lesions are exceptionally rare. Our patient had neurological deficits following successful embolization, but made significant recovery with inpatient rehabilitation.

 Cervical dystonia postcervical rhizotomy: A case report



Rohit Nalamasu, Amy Hellman

Case Diagnosis: Cervical rhizotomy is a radiofrequency nerve-blocking technique that selectively severs problematic nerves in the intradural space. It is used frequently for neck pain in those where medial branch block trials have proven efficacious as well as spastic disorders like cerebral palsy. Despite being a primary treatment option for cervical dystonia, cervical dystonia is also an extremely rare complication of cervical rhizotomy. Most literature on the subject focuses on the effectiveness of cervical rhizotomy for treatment of cervical dystonia, stating 20-30% improvement, while there have been none to few recorded cases of cervical dystonia as a side effect. Case Description: We present a case of a 55-year-old female with a past medical history of bipolar disorder and drug-induced parkinsonism who underwent bilateral C2-C5 cervical rhizotomy for chronic neck pain who developed severe cervical dystonia with right torticollis and laterocollis with muscle spasm and hypertrophy post-operative day two. Our patient underwent physical therapy for four months post dystonia presentation and along with this she received continued botulinum toxin injections to cervical musculature. She had a stable left hand tremor previously diagnosed and attributed to drug-induced parkinsonism secondary neuroleptics. Discussions: This acute cervical dystonia was determined to be due to either peripheral nerve injury during rhizotomy or re-initiation of previously prescribed neuroleptics for bipolar disorder, but neither fit the timeframe. MRI brain did not show secondary causes of dystonia and MRI of cervical spine was contraindicated due to a spinal cord stimulator previously placed for left arm pain and paresthesias a year prior. Conclusions: This scenario may be concerning for those considering cervical rhizotomy.

 Challenges in rehabilitation of laryngotracheal injuries resulting in vocal cord paralysis in resource-limited tertiary care center



Mallikarjun Gunjiganvi, Siddharth Rai, Amit Agarwal

Case Diagnosis: Laryngotracheal injury with vocal cord palsy: Laryngotracheal injuries are rare. But the associated vocal cord paralysis is rarer. They require multidisciplinary team work including trauma surgeons, ENT specialists, physiatrists and speech therapists for restoring speech. Speech therapy in non-trauma scenarios follows established protocol strategies. But in trauma, due to unpredictable injuries to laryngotracheal complex, pose difficulty in rehabilitation. We present 2 cases of laryngotracheal trauma with vocal cord paralysis and rehabilitation difficulties. Case Description: Case 1: 19 year old female, accidental strangulation injury neck resulting in complete thyrotracheal disruption with avulsion of bilateral recurrent laryngeal nerves (RLN). Thyroid fracture fixation, thyrotracheal repair with tracheostomy was done. Post op fibre optic laryngoscopy revealed bilateral vocal cord paralysis. Case 2: 35 year old male with RTI, head injury, facial injury with laryngeal injury. Head injury managed non-operatively, thyroid cartilage grade 5 injury repaired with tracheostomy and later maxillary and mandibular fixation was performed. Fibre-optic laryngoscopy revealed bilateral vocal cord paralysis. Discussions: RLN injury can result from ischemia, contusion, partial avulsion or complete transection. In trauma, need of addressing life threatening injuries result in delayed diagnosis. It is difficult to evaluate the vocal cord paralysis due to injury to recurrent laryngeal nerve injury owing to need of securing airway urgently and need of tracheostomy for prolonged period. Rehabilitation strategy involves evaluation, observation for spontaneous recovery, RLN reconstruction, laryngeal framework reconstruction surgeries, adjunctive therapy and assessing need of prosthetics. India is yet to have dedicated trauma system and integrated rehabilitation centers for trauma victims. Also most of trauma victims are below average socio-economic status and can't afford dedicated prosthetics. Conclusions: Laryngotracheal injuries are rare but associated vocal cord paralysis causes significant mobidity. Integrated rehabilitation centers are required for effective training and restoring the voice to as near as possible.

 Challenges inherent to the rehabilitation of a corpus callosum infarction patient: A case report



Yashesh A. Parekh, Nadja Mencin, Gary N. Inwald

Case Diagnosis: 57-year-old male with a history of hypertension and diabetes who presented with left-sided hemiparesis, wide-based gait, and dysmetria. Case Description: The patient's MRI showed evidence of corpus callosum infarction. Subsequently, he was admitted to acute inpatient rehabilitation for functional optimization. His main limitations on exam were left-hand coordination and balance while standing. The therapists commented on his decreased self-awareness and insights into his deficits, along with his difficulty with visual-spatial reasoning. The patient often missed the chair when trying to sit and bumped into obstacles during gait training. He also perceived his left upper extremity deficit to be more severe than objectively recorded. Participating in therapy was challenging due to deficits in sustained attention, delayed recall, and working memory. He was also susceptible to unpredictable emotional outbursts and periods of apathy. Discussions: As the corpus callosum receives a rich blood supply from both anterior and posterior circulation, corpus callosum infarction is a rare diagnosis. The often complex clinical presentation, which also lacks specificity, can be attributed to the inherent complexity of physiologic function conducted by the corpus callosum. The most common initial presentation in these patients includes higher-level neurological dysfunction such as cognitive impairment, mental disorder, and sleep disorder with or without mild-to-moderate sensory and motor deficits. Given this wide spectrum of presentations, delayed diagnosis or treatment of these patients is common, which may contribute to the poor prognosis and higher recurrence rates associated with this diagnosis. Conclusions: The rehabilitation of patients suffering from corpus callosum infarctions can be uniquely challenging, as the patients' lack of self-awareness, difficulty following commands, and emotional lability can make it difficult for them to consistently participate in therapy. In light of these challenges, broader interdisciplinary approaches involving neuropsychologists, to more efficiently tailor therapy to a patient's specific needs, may be useful for preventing persistent functional impairment.

 Change in bone mineral density in patients with spinal cord injury during acute phase after injury measured through dual-energy X-ray absorptiometry



Muhammad Ikram

Objectives: To compare the mean change in bone mineral density (BMD) at initial presentation and after three months during acute phase of spinal cord injury (SCI) and correlate it with age, gender, neurological level and severity of injury. Design: After taking permissionfrom hospital ethics committee, traumatic SCI patients post one month were recruited and information was gathered through interviews and review of medical management charts, with consent. Examination and classification were established on severity and level of injury. DEXA scans were performed at admission and after three months, BMD measurements at lumbar spine and femoral neck expressed as T-score. Data was analyzed with SPSS 20. Paired sample t-test was applied to determine the mean change in BMD. Pearson's correlation analysis correlated age with reduction in BMD while controlling level and severity of injury. Univariate analysis of covariance using general linear model controlling for age was applied to compare the mean reduction in BMD score amongst groups based on different categorical variables. Results: Amongst 70 patients, 62 were male and 8 were female. The mean age was 33 ± 7. Majority had complete injury (71.4%) and had a level of SCI at or above T6 (54.3%). The mean T-score was significantly reduced after three months at lumbar spine (p< 0.001) and at femoral neck (p< 0.001).On comparing different variables, the mean T-score was significantly reduced at lumbar spine in patients with complete injury (p< 0.001) and neurological level above T6 (p< 0.001) and at femoral neck in patients with complete injury (p=0.003) . Age and gender did not significantly affect the loss in BMD. Conclusions: The BMD decreases following SCI at lumbar spine and femoral neck in the acute phase. The loss at lumbar spine and femoral neck is higher in patients with complete injury and neurological level above T6.

 Changed tolerance of cervical collar and weakness as the initial presentation of deep surgical site infection in central cord syndrome patient status post C2-5 posterior fusion



Gabriel Kim, Sean A. Lacey, Keith Myers

Case Diagnosis: Deep surgical site infection in central cord syndrome patient who underwent posterior fusion. Case Description: 60 year old man with cervical stenosis sustained a syncopal episode from a sitting height. He was found by a co-worker and reported being unable to move arms or legs. Diagnostic workup revealed C3-C4 fracture, ALL rupture and central cord syndrome. He underwent C2-C5 posterior fusion the next day and received post-operative course of steroids. Upon transfer to inpatient rehabilitation service on post-op day 11, patient was noted to have 4/5 strength in arms and 5/5 strength in legs. Two days later, OT noted patient's 2/5 strength in shoulder abduction with increased pain. Patient was afebrile with intact posterior neck surgical incision with no erythema, tenderness, or drainage. Plain film showed no hardware failure. Further evaluation with contrast CT C-spine revealed an epidural abscess measuring 6.0 x 2.2 x 8.6 cm. Prior to wash-out by neurosurgery on post-op day 18, patient described subjective left arm weakness and L'hermitte sign. Discussions: According to literature review, reported surgical site infection (SSI) incidence following spine surgery ranges from 0.5 to 18.8%. SSI has slow, insidious onset and is often difficult to diagnose due to paucity of exam findings, minor symptoms, and dependence on plain X-rays that lack sensitivity. Most common presenting symptom is pain usually 1month after the procedure. Intra-operative risk factors include surgical invasiveness, and type of fusion. Pre-operative levels of inflammatory markers such as ESR and CRP should be compared with post-operative levels when suspecting SSIs. MRI is diagnostic modality of choice when SSI is suspected. Samples from wound drainage should be sent for Gram stain and cultures. Conclusions: Patients who undergo inpatient rehabilitation after spine surgery should receive daily neurological exams and be monitored for increased pain or discomfort, especially in those with pre-operative and intra-operative risk factors.

 Changes in postural components during whole-body reaching training



Hiroshi Saito, Satoshi Kasahara, Hiroshi Goto

Objectives: A reaching movement is an important action adopted as a rehabilitation treatment. It is well known that motor components such as the peak velocity of arm movements improve through reaching training. However, it remains unclear how postural components such as ankle joint movements improve during reaching training. Therefore, we investigated that changes in joint movements and muscle activities of lower limbs during reaching training. Design: Fourteen healthy subjects (23 ± 1 years) performed reaching training to a small target placed in the maximum reach distance as quickly as possible. Reach movements were repeated 100 trials a day. The reaching training was consisted of five consecutive days included rest for one day. Hip, knee, and ankle joint angles were calculated using a three-dimensional motion analysis system. Muscle activities of tibialis anterior (TA) and gastrocnemius (GAS) was recorded. Mean value in the first 10 trials on the first training day was compared with that of the first 10 trials on the other training day using one-way repeated measure ANOVA and a post-hoc test. Results: The peak velocity of arm movement increased significantly through reaching training (p < 0.01). Also, the maximum ankle dorsiflexion angle increased (p < 0.05), and the appearance time of the maximum angle occurred earlier (p < 0.05). Furthermore, TA activities increased in the initial phase of reaching (p < 0.01). These effects were retained after rest for one day (p < 0.05). Conclusions: We found that ankle joint movements changed through reaching training and TA activity to drive the ankle joint movement increased. These Results suggest that reaching training leads to improvement in postural components related to initiation of forward whole-body movement. The changes in postural components may be contributed to the improvement in motor components during reaching training.

 Characteristics of nonlinguistic cognitive impairment in poststroke aphasia patients



YuMei Zhang

Objectives: Many aphasia patients had non-linguistic cognitive impairment, the study aimed to investigate the association between language functions and non-linguistic cognitive functions in patients with aphasia after stroke. Design: A total of 135 stroke patients were recruited. The Western Aphasia Battery (WAB) and the oral fluency scale of Chinese aphasia and their non-linguistic cognitive functions were evaluated. The patients were divided into post-stroke aphasia group and non-aphasia group. The LOTCA scores were compared. Potential confounders were adjusted in the multivariate analysis. Finally, partial correlation analysis between the sub-scores of various language functions from the WAB and the non-linguistic cognitive function scores from the LOTCA test was performed. Results: The total LOTCA score in the aphasia group was significantly lower than the non-aphasia group (75.34±17.48, 96.90±7.71, respectiv ely, P< 0.01), and the scores in both groups were lower than the normal group. Except for visual perception, other cognitive sub-tests were all impaired in the aphasia group. The LOTCA score of the non-fluent aphasia group was lower than the fluent aphasia group (67.58±17.43, 82.50±14.44, respectively, P< 0.01). The total score and each cognitive sub-score of the LOTCA in the aphasia group were linearly positively correlated with language function of the WAB and the aphasia quotient (AQ) (r=0.291, 0.738, P< 0.05, P< 0.01, respectively). Conclusions: Non-linguistic cognitive impairment exists in post-stroke aphasia patients. Non-fluent aphasia patients have more severe cognitive impairment than the fluent aphasia patients.

 Charcot joints due to cervical myelopathy



Evelyn Qin, Brittney Bettendorf

Case Diagnosis: Charcot Elbows and Wrists. Case Description: A 69-year-old male, with a twenty-year history of severe, cervicothoracic myelopathy, syrinx of the spinal cord from C2-T3, and repaired Chiari malformation presented with chronic spontaneous dislocation and painful, swelling of bilateral elbows. He reported his elbows spontaneously began swelling approximately 15 years after the diagnosis of his myelopathy. He described progression of swelling, and decreasing range of motion in his elbows and wrists over time, as well as development of weakness of the hands and numbness consistent with ulnar neuropathy. Physical exam revealed deformities of bilateral wrists and elbows. Palpable clunk was appreciated in the elbows with flexion and extension, consistent with non-painful dislocation. Workup showed minimal elevation in ESR and CRP, negative rheumatoid factor and CCP. X-ray of the elbows and wrists were consistent with neuropathic arthropathy with significant joint destruction. Orthopedic surgery felt surgery was not indicated for his condition so his condition was managed symptomatically. Discussions: The etiology of the patient's presentation is likely due to neuropathic arthropathy from cervical spine myelopathy resulting in Charcot joints. The loss of sensation to a joint may result in a chronic, progressive, and destructive arthropathy. Lack of proprioception secondary to peripheral neuropathy may result in ligamentous laxity, increased range of joint movement, instability, and damage by minor trauma. Conclusions: While Charcot joints are classically associated with neuropathy secondary to diabetes mellitus, it is important for providers to keep in mind that Charcot joints may develop from other neuropathic conditions such as cervical myelopathy.

 Chronic optic system gliosis and neurodegeneration in a murine model of traumatic optic neuropathy



Shelby Cansler, Emily M. Shalosky, Nathan K. Evanson

Objectives: Traumatic optic neuropathy is a known comorbidity of head trauma that can lead to vision loss. It has been reported in mild to severe head trauma. Although there are animal models of optic nerve trauma available, the chronic progression of such injuries is not well understood. This study was undertaken to understand the chronic evolution of optic nerve injury after head trauma in an animal model. Design: We used a closed-head weight drop model of head trauma in adolescent male mice. This injury reproducibly causes bilateral optic nerve injury with associated visual deficits. We used an injury group and sham group, and evaluated histologic measures of gliosis, neurodegeneration, and neuroinflammation in separate cohorts at 7, 14, 30, 90, and 150 days after injury. Astrogliosis was measured using immunohistochemistry for the astrocyte marker glial fibrillary acidic protein. Microglial activation was measured morphologically, using Iba-1 as a microglial marker. Neurodegeneration was detected using Fluoro-jade B. Results: There was increased astrogliosis at all time points except 30 days after injury. There was also increased neurodegeneration at all post-injury time points, with the lowest levels of degeneration seen at 30 days post-injury. Microglial activation was increased in optic tract at all time points measured. We performed similar measures on central optic nerve targets including superior colliculus and lateral geniculate nucleus of the thalamus. Conclusions: Our histologic results suggest that there is recovery of the optic nerve injury over the first 30 days after injury, followed by delayed worsening of astrogliosis and axonal degeneration. Therefore, traumatic optic neuropathy appears to result in delayed worsening of injury in this model, potentially due to gliosis and ongoing neuroinflammation.

 Classic presentation with Foville's syndrome after resection of pontine tumor: A case report



S. M. M. Mohar, Xiaofang Wei, Ruth Alejandro, Eric L. Altschuler, Kristopher Kahle

Case Diagnosis: 8-year-old male, with initial presentation of double vision and difficulty going upstairs, found to have MRI findings of 3.0 x 2.8 x 2.6 cm3 enhancing heterogeneous mass in the right pons extending to the right middle cerebellar peduncle and superior aspect of right cerebellar peduncle, biopsy showed GFAP positive high-grade glioma. He was admitted to inpatient rehabilitation, 2 weeks after resection. We observed good functional recovery of iatrogenic Foville's Syndrome after 4 weeks of inpatient rehabilitation. Case Description: The child developed transient mutism after surgery, lasting for 2 days. On rehab admission he complained of double vision and headache. Physical examination showed intact orientation and recall, slight dysarthria (nucleus ambiguous), no aphasia, medial deviation of right eye (CN VI), right sided Horner's syndrome (central sympathetic fiber), right facial sensory loss (CN V), and right facial paralysis (CN VII), right sided tongue deviation and hearing impairment (CN VIII), left sided proprioception and hemisensory loss (medial lemniscus), 3+/5 strength in left upper and lower extremities (Corticospinal tract), 4/5 in the right upper and lower extremities, brisk tendon reflex in left knee and ankle, and clonus in left ankle. Gait was severely ataxic, and sitting balance was poor. Patient showed good improvement of dysarthria, ataxia, tongue deviation and muscle strength. Dysmetria and strength improved more in right side. Discussions: In 1858 Foville described a case of pontine stroke presenting with conjugate ocular deviation to the left, left sided facial paralysis, right hemiplegia and vomiting. Our case is a necessary surgically induced Foville's syndrome plus showing marked improvement of ataxia, dysarthria and muscle strength. Conclusions: Post-surgical Foville's syndrome is a rare condition that shows better functional recovery than following diagnoses, e.g., ischemia stroke, or hemorrhage in the pons. Improvement of adjacent brain tissue edema, recovery of stunned neurons and faster recovery pattern from diaschisis may explain our findings.

 Climate change: Experiences and educational needs of rehabilitation professionals working in spinal cord injury



Marcalee Alexander, Jagger Alexander, Mohit Arora, Chloe Slocum, James W. Middleton

Objectives: Climate change is known to affect the frequency and severity of extreme weather events. Persons with disabilities and, in particular, individuals with a spinal cord injury (SCI) are especially vulnerable to extreme weather events due to impairment of temperature regulation, mobility, personal care, and everyday functioning. Yet the effects of climate change and extreme weather events on persons with disabilities have received little attention to date. We sought to determine the experiences and educational needs of rehabilitation professionals regarding these topics in a global survey. Design: International, cross-sectional survey. Results: Respondents included 125 rehabilitation professionals working in SCI. Fifty percent were from Europe, 19% from North America, 19% from Asia, 7% from Oceania, and 6% from Africa and South America. Most (74%) were physicians, while 12% were physical therapists. Of respondents, 58% acknowledged local climate had changed, 22% reported it had not, and 18% were unsure. Of those reporting a changing local climate, 70% noted an impact on patient's health. Temperature, dehydration, fatigue, respiratory problems, mood changes, and accessibility were the greatest concerns. Provider-reported preparedness to address climate change and weather disasters for patient's had a median score of 4 on a 0-10 scale (SD 2.1) whereas provider-reported patient preparedness had a median score of 3.45 (SD 2.26). Only 25% of respondents acknowledged providing education to their patients with SCI about disaster preparedness; however, 85% expressed interest in further information about extreme weather and climate concerns for people with SCI. Conclusions: Many rehabilitation professionals working in SCI acknowledge issues about extreme weather and climate change but are inadequately prepared to address these issues. Further education and resources must be made available for health care professionals. Moreover, climate change is an ongoing, increasing problem without borders. Therefore, resources must be developed in multiple languages and future research needs must be anticipated.

 Clinical and functional aspects of the remaining limb of lower limb amputees: Equipment difficulties in an African context



Koffi Benjamin Manou, Konan Joseph Kouakou, Cisse Ali, Awo Dorcas Akadje, Abdouramane Mohamed Kaba, Abdouramane Coulibaly, Manse Beatrice Nandjui, Kan Serge Pacôme Yao

Objectives: Describe the different residual limb anomalies post lower limb amputations and the adjustment challenges in a black African population secondary to various amputation causes. Design: A descriptive prospective study where patients underwent clinical examination on the quality and functional tests of the residual limb prosthetic construction and deambulation specific to amputees fitted at the Orthopedist Center”Vivre Debout” at the University Hospital center of Yopougon in Côte d'Ivoire from 2016 to 2018. Results: The study recruited 323 patients with lower limb amputations identified from a total population of 1792 patients admitted to the orthopedic center with a frequency of 18.02% Traumatic and vascular causes were the most represented with 52.94% and 32.5% respectively. The majority of sit of amputations were transtibial at 70.28%. There were 123 cases of stump abnormalities (38.08%) including: trophic disorders with111 cases, 54 cases were abnormalities of length, and 11 cases of painful neuroses of stump. Skin pathology related to the maladjustment of the prosthesis was seen in 37 cases. The mobility performance of the fitted amputees showed that the degree of autonomy according to Houghton's score was on average 9.6/12. The average distance to the TM6 was 479.33 meters. Univariate analysis revealed a statistically significant association between the quality of the residual limb and the mobility performance of the amputee. Conclusions: Traumatic and vascular amputations of the lower limbs are surgically managed on the one hand under emergency conditions with the priority objective of saving the life of the patient and on the other hand belatedly related to limited financial means of the neediest patients. This still does not lead the often-junior surgeons in our context to make a useful stump for a future prosthesis adapted to an adequate mobility performance and a quality locomotor function. Amputation of the lower limbs whatever the cause is stigmatized with negative consequences on the autonomy and quality of life. The hope of eventual recovery of locomotor function as close as possible to the amputee's previous condition depends on the quality of the residual limb. However, the residual limbs of the amputees are the frequent site of stump anomalies with a consequence of difficulties in prosthetic use.

 Clinical chaplaincy: The new element in brain injury rehabilitation



Jordan Adler, David H. Glazer, Brad M. Bradley

Objectives: The Richmond Veterans Administration Polytrauma Rehabilitation Center (PRC) is a 20-bed inpatient unit which specializes in the rehabilitation of veteran and active duty service members who have sustained traumatic brain injuries. A clinical chaplain is embedded as a full-time member of the interdisciplinary rehabilitation team. The chaplain provides clinical pastoral care for all patients. The primary goal of the chaplain is to improve rehabilitation outcomes. Prior studies have demonstrated that spirituality helps improve rehabilitation outcomes. However, these studies have not examined the value of a dedicated chaplain for patients with a brain injury. Design: An anonymous survey was administered to PRC patients asking them what they find valuable in their clinical chaplaincy sessions. The PRC chaplain, in addition to other hospital wide chaplains were also administered the survey asking them what they find different about working with patients with a brain injury and their families in the PRC versus in other hospital units. Results: Responses from the patients were very positive. The chaplain responses were also positive but identified some of the challenges they face when working with patients with a brain injury. Conclusions: The results of this study are similar with prior studies which demonstrate that spirituality helps improve rehabilitation outcomes. This study also provides justification for the implementation of full-time unit chaplains in an inpatient brain injury center as well as the importance of educating chaplains on how to interact with a patient who has sustained a traumatic brain injury.

 Clinical highlight of electrodiagnostic testing in diagnosis of tarsal tunnel syndrome: A case report



Vishal Bansal, Ankur D. Mehta

Case Diagnosis: Tarsal tunnel syndrome; posterior tibial nerve entrapment. Case Description: A 65 year old female presented with a one week history of right knee and right foot pain associated with numbness and tingling sensation on the plantar surface of her right foot. Past history reveals a recent knee replacement surgery and a well-healed incision in the anterior line of the knee on physical examination. She reported her symptoms started shortly after the surgery. Further evaluation revealed mild vascular changes but did not meet Budapest criteria that would qualify for complex regional pain syndrome. Electromyography and nerve conduction studies were ordered and revealed posterior tibial nerve entrapment. Positive Tinel sign inferior to the medial malleolus was also noted, further supporting the diagnosis. A posterior tibial nerve block with a corticosteroid was recommended and provided relief of symptoms. Discussions: The clinical presentation of tarsal tunnel syndrome can vary depending on the exact segment of the tibial nerve or its branches (calcaneal, medial and lateral) that are involved. Electromyography and nerve conduction studies demonstrate high sensitivity and specificity. Nerve conduction studies in this patient revealed prolonged distal onset latency and reduced amplitude in the right tibial motor nerve. Conclusions: Detailed electrodiagnostic testing in addition to clinical evaluation can prove to be a powerful diagnostic tool in diagnosis of tarsal tunnel syndrome. This case highlights the clinical importance of electromyography and nerve conduction studies to determine idiopathic causes of tarsal tunnel syndrome that have not responded to conservative management.

 Clinical neurologic level of injury and early MRI level of injury in traumatic spinal cord injury: Is there a correlation?



Lisa Pascual, Debra Hemmerle, Talbott Jason, Jacqueline Bresnahan, Michael Beattie, Vineeta Singh, Jonathan Pan, William Whetstone, Philip Weinstein, Xuan Duong Fernandez, Thomas Leigh, J. Russell Huie

Objectives: Following SCI, determination of the neurological level of injury (NLI) and American Spinal Injury Association Impairment Scale (AIS) grade may be difficult due to medical instability. Retrospective studies have examined the role of early MRI as a surrogate for classifying injury severity. Correlations between the longitudinal extent of injury on MRI and clinical NLI (cNLI) and between MRIs and AIS grades (using the Brain and Spinal Injury Center [BASIC] score) has been demonstrated. Our objective was to ascertain if early MRI accurately correlates with cNLI in SCI. Design: Prospective data (2015-2019) for Level 1 Trauma Center SCI patients (N=120) were analyzed. Early MRIs (< 24 hours post-injury) and cNLIs (< 48 hours, 2-4 days, and 6 and/or 12 months post-injury) were obtained. Neuro-radiologists determined three NLI measures: cranial and caudal margins of the manually segmented lesion and injury epicenter using the BASIC score. Experienced clinicians determined cNLIs and AIS grades. Non-parametric Spearman correlation analyses were used to compare cNLIs to MRI NLIs and Bland-Altman agreement analyses to determine whether bias existed in either modality. Results: MRI NLIs and cNLIs performed < 48 hours and 2-4 days post-injury significantly correlated. The strongest correlation was 2-4 days post-injury between the cranial margin and the cNLI (Spearman rho = 0.57, p< 0.01). Follow-up correlations did not approach significance. AIS-A grade significantly affected the relationship between the MRI NLIs and cNLIs 2-4 days post-injury, with cNLIs found to be more rostral (p< 0.05). The closest agreement with cNLI and least overall bias was at the BASIC epicenter. Conclusions: Our prospective data demonstrate significant correlations between MRI NLIs and cNLIs within 4 dpi. However, present data reveal no correlation with long-term cNLIs. The injury epicenter demonstrates the closest agreement with cNLIs, although at 2-4 dpi, the relationship differed as cNLIs were more rostrally located.

 Cognitive assessment in virtual reality after traumatic brain injury



Daria Mukhametova, Eduard Novak, Natalia Slepneva, Vadim Daminov

Objectives: Patients with traumatic brain injury (TBI) have everyday life problems due to cognitive impairment. While the traditional neuropsychological examination combines the assessment of separate cognitive functions (e.g., memory, attention), the everyday performance is underestimated as a combination of these functions. Virtual reality (VR) is promising to solve this issue in an integrative approach applied in a safe and controlled environment. Design: All patients with TBI admitted at the Department of Rehabilitation of Pirogov Center in the first decade of 2019 were assessed with the traditional quantitative and qualitative neuropsychological tests and with the tests adjusted to VR environment. The latter aimed to stimulate daily activities with different cognitive demands. Results: In total, 62 patients were included. The results revealed a dissociation between paper neuropsychological tests and VR-based daily functioning assessment. On the one hand, the majority of patients with cognitive impairment were able to function independently and perform everyday life tasks in VR, which is expected for mild cognitive impairment by neurological tests. Such Results were obtained in 39 patients. Interestingly, 11 patients experienced difficulties in some daily life activities such as following their schedule and preparing meals due to memory (they forgot about their plans or ingredients order) or executive deficits (they showed impulsive behaviour and were unable to make a proper plan) while the traditional neuropsychological test did not pick up these impairments. Conclusions: Neuropsychological tests applied via VR could be more sensitive to find cognitive impairments via simulated daily performance. This means that the evolution of neuropsychological methods could go in more holistic approach. VR can become a convenient, informative and safe method for assessing daily functioning in patients with TBI.

 Cognitive behavioral therapy for traumatic brain injuries: A systematic review and meta-analysis



Xin Li, Qing Du

Objectives: Over the last years, many scientific studies showed that cognitive rehabilitation and psychological therapies are beneficial to brain injuries, but it is still not clear whether cognitive behavior therapy (CBT) has a favorable effect on traumatic brain injury (TBI). This systematic review and meta-analysis aimed to assess the effects of CBT on TBI. Design: Five databases, including PubMed, EMBASE, the Cochrane Library, Cumulative Index to Nursing and Allied Health (CINAHL), and Web of Science were systematically searched for English-language parallel-group studies reporting the effect of CBT in TBI patients published up to July 2019. Outcomes, including depression, anxiety, post-concussive symptoms, self-reported sleep quality, cognitive deficits and dysfunctional behavior and adverse events were investigated. Differences were expressed using mean difference (MD) with 95% confidence interval (CI). The statistical analysis was performed using Review Manager (RevMan 5.3). Results: 13 trials with 700 TBI patients were included and provided data for the meta-analysis. Statistical improvement was shown in depression, reported as HADS-D (MD -1.31, 95% CI, -2.56 to -0.05; P = 0.04), and BDI-II (MD -2.66, 95% CI, -4.96 to -0.36; P=0.02); as well as in anxiety, reported as HADS-A (MD -1.22, 95% CI, -2.05 to -0.39; P = 0.004). Significant difference for self-reported sleep quality and dysfunctional behavior was shown as improvement on Pittsburgh self-reported sleep quality index (PISQ)( MD -1.73, 95% CI, -2.3 to -1.17; P<0.00001) and child behavior checklist (CBCL) (MD -2.78, 95% CI, -4.55 to -1.01; P = 0.002). No significant decrease was reported regarding post-concussive symptoms or the cognitive deficits. Furthermore, no major adverse events related to CBT was reported in the included trials. The overall quality of evidence ranged from moderate to very low. Conclusions: Evidence is underpowered to suggest that CBT is effective in the management of TBI. Future studies with a larger population are recommended to determine significance.

 Combination of drugs treatment and physical therapy in a myasthenia gravis patient associated with Parkinson's disease



Jinfeng Li, Haoyu Xie, Zhiqin Xu, Xi Chen

Case Diagnosis: Myasthenia gravis (MG) associated with Parkinson's disease (PD). Case Description: A 55-year-old male patient was diagnosed as MG 42 years ago with bilateral ptosis, double vision, and the neostigmine test (+). The symptoms increased at night and decreased in the morning. The patient was treated long-term with pyridostigmine, and the ptosis improved significantly. 10 years ago, he developed bradykinesia and no swing on the left upper limb when walking. Then he was diagnosed as PD by neurologists in 2010. At present, the symptoms of the patient manifested as bilateral ptosis, head drop, pelvis with left lateral tilt, scoliosis in the thoracic vertebra, and typical Parkinson's features of resting tremors, bradykinesia, and rigidity in the left upper limb. Discussions: To our knowledge, this case is the third in the world to be reported where MG predisposed PD. Drug treatment alone is difficult to re-establish the neurotransmitter equilibrium because increasing dosages of anti-PD or anti-MG drugs will aggravate the symptoms of each other. Physical therapy, including posture correction, gait training and technical training with the visual and auditory feedback, was added to improve the symptoms of PD, thereby maintaining or reducing the dose of anti-PD drugs and improving the symptoms of MG which anti-PD drugs will aggravate. Considering the low exercise tolerance of patients with MG and PD, the core principles are low-intensity, short-duration to control the fatigue accurately, and to raise the quality of life. Moreover, physiotherapists should continuously pay attention to patients' conditions and be alert to MG crisis during therapy. Conclusions: When MG and PD coexisted in patients, personalized medical treatment plans should be scheduled. Both physical therapy and drug treatment play essential roles in patients with MG and PD.

 Comparing weight changes in the postacute setting across different diagnoses



Beendu Pujar, Jillian M. Williams, Vikram Madan, Carolin I. Dohle

Objectives: Strokes are the World's leading cause of disability. Approximately two-thirds of patients do not fully recover after strokes and one third cannot walk on their own. Studies have examined whether stroke alters metabolism the same way as other neurological injuries, and not found a change in resting energy expenditure. Weight loss after stroke is a phenomenon reported in the literature, but it is unclear whether this is due to stroke specific sarcopenia or due to deconditioning as result of hospitalization. We here investigate whether weight loss differs between stroke, traumatic brain injury and debility patients. Design: This is a retrospective study of patients admitted to Burke Rehabilitation Hospital with a diagnosis of stroke, traumatic brain injury or debility. Charts were retrospectively assessed and measures like preadmission/acute care weight, weight upon admission to Burke, discharge weight, Functional measure of Independence Scores (FIM) demographics and diet ordered were recorded. All the measures were analyzed to examine whether weight loss is similar between patients with debility, stroke or Traumatic Brain Injury (TBI), and whether degree of weight loss is correlated with functional outcomes. Results: Paired t-test within the groups for acute care admission to discharge weight in TBI patients n=17 showed P value 0.018, mean difference -12.9 and in stroke patients n=25 showed P value 0.0026, mean diff = -8.29 which implies the change in body weight from acute care admission to discharge has significant weight loss at the time of discharge. However, there was no significant weight loss in the Debility patients n=27. Conclusions: There is significance in weight loss in both the Stroke and TBI patients which gives the opportunity to further assess the body composition changes after stroke.

 Comparison between elderly gymnastics and 30-min walking to improve endurance in the elderly group



Noeniek Noegraheni, Alip Nofiani Devi, Dewi Masrifah Ayub, Akhmad Susiloaji

Objectives: Elderly, elderly gymnastics, 30-minute walking exercises, endurance, six minutes walking test. Design: This was a quasi-experimental study with pre and post test group design involving 40 elderlies in a senior citizen health center. They were split non-randomly into two groups of 20 people each: (1) Elderly Gymnastics group (2) 30-minute walking exercise group. All exercises were done for 3 times a week for 4 consecutive weeks. The endurance was measured using Six Minutes Walking Test. Analysis data was performed using EZR (Easy R). Results: In group 1, the pre and post results showed significant improvement of 17.72 minutes and 19.19 minutes respectively (p=0.000179). In group 2, the pre and post results were 17.87 and 17.86 minutes respectively (p=0.966). The comparison between the pre and posttest difference of both groups showed that there was a statistically significant difference (p=0,00278). Conclusions: Elderly Gymnastics showed better and significant improvement in Six Minutes Walking Test compared to 30-minute walking exercise. Elderly Gymnastics can be an alternative to improve endurance in the elderly.

 Comparison between right and left antihyperalgesic effect of auricular vagal nerve neurostimulation in a mouse model of persistent inflammatory pain



Afonso Salgado, Daiana Cristina Salm, Francisco J. Cidral Filho, Edsel Bittencourt, Bruna Hoffmann de Oliveira, Júlia Koerich, Carlos Omura, Rodolfo Parreira, Lisandro Ceci, Leidiane Martins, Ari Moré, Daniel Fernandes Martins

Objectives: Osteoarthritis (OA) is a predominant pathology with aging and occurs mainly in women. OA is refractory to various forms of treatment and is accompanied by persistent inflammation. Noninvasive auricular vagus nerve (aVNS) stimulation has shown surprising results in the treatment of inflammatory conditions, including OA. Objective: To compare the effects of left and right ear aVNS at different times on mechanical hyperalgesia in an animal model of inflammatory pain. Design: The study was approved by the ethics committee under No. 18.048.2.07.IV. Female Swiss mice (35-45g) submitted to intraplantar injection of Complete Freund's Adjuvant (CFA) were distributed (n = 8 animals / group) into the following groups: CFA + aVNS off 30'; CFA + aVNS 10', CFA + aVNS 20' and CFA + aVNS 30'. aVNS parameters were: Frequency (1) = 2 Hz; Pulse width (1) = 700 μs; Time (1) = 5 seconds; Resting time = 0. Frequency (2) = 10 Hz; Pulse width (2) = 200 μs; Time (2) = 5 seconds; Resting time = 0. Mechanical hyperalgesia was evaluated with von Frey monofilaments (0.6g) applied to the right hind paw at 6 and 96hs after CFA injection. Results: The results showed that aVNS for 10 min induced better antihyperalgesic effect (p < 0.05) both at 6 and 96 hours after CFA injection, when compared to 20 min and 30 min stimulation. Conclusions: aVNS for 10 min in the left ear was more effective in reducing mechanical hyperalgesia in both phases of the inflammatory profile induced by CFA intraplantar injection.

 Comparison of electrodiagnostic study with clinical and ultrasonographic parameters before and after treating patients of carpal tunnel syndrome with extracorporeal shockwave therapy



Renu Ambardar Diaa Shehab

Objectives: To find out improvement in Electrodiagnostic study in patients with Carpal tunnel syndrome treated with Extracorporeal shockwave therapy. Design: Adults with mild to moderate carpal tunnel syndrome (MAYO CLINIC CLASSIFICATION) were included. Patients presenting with tingling, numbness in first, second or third digits, pain, positive Tinel sign were evaluated using Boston carpal tunnel syndrome questionnaire (BCTSQ) scores calculating symptom severity score (SSS), functional status score (FSS), ultrasonographic evaluation and nerve conduction study to confirm the diagnosis. Patients were given extracorporeal shock wave therapy (ESWT) once a week for 4 weeks and received total of four sessions. BTSQ was used to record SSS and FSS. Visual analogue scale (VAS) was used for evaluating the pain. Ultrasonographic measurement of median nerve cross sectional area (CSA) at the carpal tunnel inlet was calculated for each patient. Nerve conduction study (gold standard for diagnosing carpal tunnel syndrome) was done and latency and conduction velocity for both median motor and median sensory was recorded. All the parameters were repeated after treating patient with ESWL. Results: Five patients were included in the study (5 hands) with average age 46.5 (Four female and one male). There was improvement in BTSCQ score (SSS improved 47.14% and FSS 40.14%) VAS score (70.89%) and there was marginal improvement in ultrasonographic evaluation. Nerve conduction parameters motor latency improved by 13.37% motor CV 13.76% as well as sensory latency 16.52%and sensory CV 23.15% which was consistent with improvement in clinical findings, BTSCQ SCORE, VAS SCORE as well as ultrasonographic findings. Conclusions: This is the first Preliminary study showing clear benefit of extracorporeal shockwave therapy in mild and moderate carpal tunnel syndrome using the gold standard Electrodiagnostic study which correlated with the clinical signs and symptoms, BCTSQ, VAS score and ultrasonographic evaluation. We recommend larger study to validate the finding of our study.

 Comparison of learning styles among postgraduate residents and full time specialty clinicians pursuing higher educational degree



Nasir Mansoor Sahibzada

Objectives: To compare the different learning styles preferences among full time specialty clinicians and post graduate residents. Design: quantitative cross sectional comparative study. Participants were sampled by convenience. informed consent was obtained.participants were divided into two groups, pist graduate residents and full time specialty clinicians currently enrolled in higher education degree program. self administered questionnaire including demographic data and Honey and Mumford learning style questionnaire was distributed. spss version 22 was used for statistical analysis. Results: there were 70 participants, 40 residents and 30 consultants. Mean age for consultant was 46.53 and for resident was 27.63. there were 45 males and 25 females.average weekly study hours for consultants was 12.67 and resident was 11.13 (0.741). 96.7% consultants used internet while 75.7% of residents used internet. self study was used by 90% of consultants and 62.25 % of residents (p=0.0009). all the consultant managed time by scheduling, time management, weekends, late nights, leaves, early mornings and peer assistance. 72.55 residents did not use any strategy for time (p=0.000). Majority of both groups had mare than one learning style (2-3). learning style combination of consultant was Reflector theorist (56.7%), reflector pragmatist (16.7%), activist pragmatist (10%) and activist reflector (13.3%). learning style combination for residents was activist theorist and activist reflector 22.5% each, reflector theorist 27.5% and reflector pragmatist 12.5% (p=0.023). Conclusions: consultants have a much better learning style and better time management techniques as compared to residents. Reflector, theorist and pragmatist are the predominant learning style of consultants while Activist theorist is the predominant learning style of post graduate residents.

 Comparison of microanalytes and self-reports in people with myofascial pain, with and without widespread pain



Naomi Lynn Gerber, Vy Phan, Jay Shah, Hannah Tandon, Secili DeStefano, Matthew D. Bird, Siddhartha Sikdar, John Z. Srbely, Dinesh Kumbhare, Katherine Mireles, Sasha Stoddard, Aybike Birerdinc

Objectives: Distinguishing widespread (WSP) from non-widespread (nWSP) pain is challenging in patients with myofascial pain syndrome (MPS). Comparison of self-reports, biomarkers and operator determined measurements between these two groups may help distinguish them. This study compares self-reports of pain and physiological measures in patients presenting with/without WSP. Design: Thirty-eight participants (25 women, mean age 42 yrs) were included. MPS duration was 1-3 yrs (n=13), 3-11 (n=14) and >11 (n=11). All were examined for myofascial trigger points (MTrPs). Pain measures included: Brief Pain Inventory (BPI), Widespread Pain Index (WPI), Pain Pressure Threshold (PPT) and quantitative sensory test (QST). WSP was assigned if the WPI ≥ 7. Fasting peripheral blood was assayed using Bio-plex and Elisa techniques. Data were analyzed using Mann-Whitney statistics and pain metrics, using chi-square. Results: Eight patients of 38 (21%) had WSP, 36 were analyzable (2 were out of measurement range). WSP and nWSP had significantly different microanalytic profiles. Those with WSP showed mean IGF1 concentrations of 183.12 ng/ml (SD +/-44.83) compared with nWSP 140.54 (SD+/-40.04) (Mann-Whitney: p-exact 0.006). The WSP group showed significant increases in DHEA of 2.38+/-mg/ml (SD+/-1.29) versus 1.33 (SD+/-.77) in nWSP (p-exact 0.014), dopamine of 0.97 (SD+/- 336) in nWSP cohort and 1.53 (SD+/-695) in WSP (p-exact 0.021). WSP cohort had a mean concentration of nor-epinephrine (NE) of 23.27 (SD +/-7.29) while nWSP had 16.15 (SD+/- 6.82)(p-exact 0.006). Participants with WSP had a lower PPT threshold, higher BPI pain scores than nWSP (p=ns). QST ratings did not correlate with WSP. Conclusions: Our findings distinguish patients with WSP from nWSP on the basis of micro-analytic profiles including NE, DHEA, dopamine and IGF1. A higher NE concentration suggests WSP is associated with pain facilitation. These findings offer promise for future applications of biomarker profiles the diagnostic workup of patients presenting with MPS. Future studies are needed to assess mechanisms contributing to the unique biomarker profiles characteristic for each condition.

 Complete vocational rehabilitation after complete isolated hand paralysis following stroke: A case report



Mahmut T. Kaner, Joel Fandel, Kathy Wann, Kasandra Erazo, Rasha Kakish, Maria Chiechi, Eric L. Altschuler

Case Diagnosis: Isolated hand paralysis following left cortical hand knob area ischemic stroke. Case Description: A 68-year-old man presented with near complete paralysis of his dominant right hand following stroke with nearby muscle groups only minorly and transiently impaired. Sensation remained fully intact; no facial droop or dysarthria. Strength was 5/5 throughout bilateral shoulders and elbows, with right wrist extension 5-/5 and right wrist flexion 4/5. Hand muscle strength ranged from 1+ to 2-. CT scan confirmed an acute ischemic infarct of the left frontal lobe, a location consistent with the cortical hand knob area. Recovery of adjacent muscle groups was observed within hours, and the patient's only lasting deficit was severe weakness of all hand muscles with sparing of the wrist and face. He underwent occupational therapy manipulating putty, strengthening with resistance bands, and performing fine motor tasks like picking up coins and rolling a pen through his fingers. Long finger extensors and flexors returned to 5/5; residual weakness in hand intrinsic muscles remained. Discussions: This case serves as an example of complete vocational recovery following stroke and brings to question the unusually favorable prognosis of strokes of the cortical hand knob area. We discuss how simple noninvasive studies of patients with isolated hand paralysis from ischemic stroke may be helpful in revealing mechanism of recovery. Conclusions: Within 6 weeks our patient had complete clinical recovery with independence in all activities of daily living (ADLs) as well as the ability to return to manual labor as a custodian, though with some residual deficits in fine dexterity of the right hand and weakness of hand intrinsic muscles. Formal study of the rehabilitation patterns of patients with complete hand paralysis following stroke may improve our understanding of the neural substrates of recovery of this stroke entity and appropriate treatment protocols for optimized recovery.

 Completion rates of sleep apnea screening measures in TBI survivors undergoing inpatient neurorehabilitation



Marie Dahdah, Risa Nakase-Richardson, Jessica Ketchum, Emily Almeida, Kathleen Bell

Case Diagnosis: Sleep apnea (SA) has been effectively screened in community populations without known neurologic or cognitive sequelae. Several measures have been developed to screen for suspected SA. Some are established as gold standard measures by the American Academy of Sleep Medicine (AASM). This study examines completion rates for three well established SA screening measures/indices in TBI survivors: Berlin, STOP-BANG, and MAPI. SA is an important condition to screen, given that 67% of individuals with TBI were diagnosed with SA in our sample. Case Description: Cross-sectional. Consecutive admissions of TBI survivors to six U.S. medical rehabilitation services between 05/2017 and 02/2019, able to sleep ≥ 2 contiguous hours (N=248). Administration of: (1) Berlin Sleep Apnea Questionnaire, (2) STOP-BANG Questionnaire, and (3) the Multivariate Apnea Prediction Index (MAPI) to patients ~4 weeks post-TBI. Medical records were used to impute unavailable information. Discussions: Response rates for individual items, subscales, and traditional risk cut-off scores for the three screening measures were examined. MAPI had the highest number of participant responses (85-87% across items) compared to STOPBANG (75-88%) and Berlin (74-90%). The phrasing of certain items on the Berlin proved to be challenging for some respondents resulting in high levels of missingness on items comprising Category 2 [n=53] and items comprising Category 1 [n=35]. A risk profile could not be calculated for 75 participants. The Berlin item with the highest rate of missingness was related to sleepiness while driving. Across all scales, snoring questions were commonly missing responses. Conclusions: Response rates varied across the three sleep apnea screening measures evaluated, with MAPI evidencing the highest participant response rate, followed by STOP-BANG, and Berlin. Differences in verbiage for similar items partially impacted response rates. A future study conducting receiver-operating characteristics (ROC) curve analyses to analyze differential sensitivities and specificities of each screening measure at the item-level would be beneficial.

 Complicated rehabilitation course of a patient recovering postcraniectomy from a neurosurgical resection of rare paraganglioma: A case report



Jennifer M. Cushman, Raj Murthy

Case Diagnosis: Rare case presentation of a paraganglioma of the head that resulted in dizziness and balance impairment, swallowing and speech pathology, right sided diplopia, and severe headaches, as well as severe hypertension. This case discusses the multidisciplinary approach to the rehabilitation management following a craniectomy of a rare brain neoplasm. Case Description: 38 year-old female with no significant PMH presents to IRF in order to engage in inpatient rehabilitation to address problems with diplopia, balance, speech and swallow impairments, and management of emesis and vomiting following a craniectomy of a rare brain paraganglioma. Discussions: Paragangliomas are rare neoplasms that arise from extra-adrenal chromaffin cells. Larger neoplasms that are localized in the head and neck region may cause cranial nerve palsies, commonly impinging the vagus and hypoglossal nerves causing swallowing impairment. A paraglanglioma that lies close to the structures, Glomus tympanicum and Glomus jugulare can present as a middle ear mass resulting in tinnitus. About only 3% of paragangliomas are found in the head and neck region. Many can present with findings such as malignant hypertension, headache, and visual and balance abnormalities depending on location of the brain tumor. Many complications such as speech and swallow impairment, balance, diploplia, and impairment of breathing resulting in intubation following resection of brain tumor may result. Conclusions: This patient presented with a rare brain neoplasm that required extensive inpatient therapy due to worsening of her mental status and impaired cognition throughout therapy. This case outlines a multidisciplinary approach necessary to optimize therapy and strategize the management of patients presenting with this rare neoplasm. Our case stresses the importance of a multidisciplinary team approach during a patient's inpatient rehab course dealing with the various complications resulting from this rare brain neoplasm.

 Complications of orbital compartment syndrome in an amputee following craniotomy



Michael E. Farrell, John Aseff

Case Diagnosis: Orbital compartment syndrome resulting in visual deficits following craniotomy and frontal lobe mass resection. Case Description: A 76 year old male with past medical history of PVD, and subsequent above the knee amputation, was admitted for acute inpatient rehabilitation following elective resection of a right sided brain mass. While in the community he experienced head trauma when his motorized scooter tipped. Head CT revealed a frontal mass suggestive of a meningioma. He underwent bifrontal craniotomy with resection of the mass. Following the procedure he developed elevated right sided orbital pressure, altered vision, and anisocoria. He was diagnosed with right sided orbital compartment syndrome and underwent right lateral canthotomy. Deficits following the procedure included complete vision loss and afferent pupillary defect from an optic nerve injury. He received a course of dexamethasone as well as a short course of acute inpatient rehabilitation to address new challenges with ambulation and doffing and donning his prosthesis given vision loss. Discussions: Compartment syndrome is a surgical emergency that can arise in an acute inpatient rehabilitation setting. It is caused by an increase in pressure within a fascial compartment from bleeding or rapidly accumulating edema. Compartment syndrome most commonly occurs in the limbs where increased pressure and swelling leads to the hallmark findings of pain, numbness or tingling, and lack of a pulse. In rare cases of compartment syndrome occurring outside of the limbs recognition of classic signs and symptoms may become difficult. In patients who have undergone craniotomy it is important to consider cranial compartment syndrome as a differential if neurologic structures become compromised following a surgical procedure. Conclusions: In patients who have undergone recent craniotomy, cranial compartment syndrome is a rare but serious surgical complication which must be considered while a patient is recovering in the acute inpatient rehabilitation setting.

 Compression versus ischemia: An acute onset of transient paraplegia, paresthesia, and urinary retention during hypertensive urgency



Elaine K. Gregory, Ray Chang, Arshia Etesam

Case Diagnosis: Acute onset of Transient Spinal Cord Ischemia and Spinal Cord Injury in the Setting of Hypertensive Urgency and Radiologic Evidence of Multilevel Lumbar Stenosis. Case Description: 71-year-old active male, while seated had an acute onset of paraplegia and paresthesia. On exam, systemic blood pressure (SBP) was 220, lower extremities were cold, pulseless, with loss of reflexes. One dose of Labetalol, decreased his SBP to 180 with return of doppler signals, motor, and sensory function. Extensive imaging, Electromyography/Nerve Conduction Studies (EMG/NCS) and laboratory exams on blood and spinal fluid were performed. Magnetic Resonance Imaging (MRI) of the Lumbar Spine revealed moderate to severe spinal canal stenosis (L2-4), and moderate to severe bilateral foraminal stenosis (L2-L5), Investigations for inflammatory causes were negative. EMG/NCS revealed chronic right L5 radiculopathy. He received steroids, but had poor response. His neurologic symptoms slowly improved with mild strength and sensory deficits upon discharge. Discussions: Lumbar spinal stenosis (LSS) causes significant disability in the aging population. LSS includes pathologic anatomic narrowing at; the intraspinal canal, lateral recess or neural foramen. Compression and/or ischemia at the nerve roots can produce neurologic symptoms. MRI can identify sites of compression, but findings often don't correlate with symptoms. Unlike lumbar disc pathology, currently for LSS, consensus guidelines aren't established. Alternatively, transient ischemia, due to spinal stroke, severe vasoconstriction or decreased perfusion with his existing lumbar pathology might explain the rapid reversibility of his symptoms. Conclusions: The exact pathophysiology of LSS is unknown, but compression and/or ischemia at the nerve roots is proposed. Compression can be direct (osseous) or indirect (increased intrathecal pressure, venous congestion or decreased arterial perfusion). MRI findings don't necessarily correlate with disease or prognosis. Physiatrists should be aware of the pathophysiology of LSS and the pitfalls in its diagnosis, interpreting all information in the context of their history and physical exam findings.

 Concomitant neuromyelitis optica and systemic lupus erythematosus in HIV/AIDS patient presenting with brown sequard syndrome: A case report



Steven Tijmes, Joanne Delgado Lebron

Case Diagnosis: Transverse myelitis secondary to systemic lupus erythematosus and neuromyelitis optica spectrum disorder (NMOSD). Case Description: 61-year-old female with a history of HIV/AIDS who presented with left sided weakness which began two days PTA. Physical exam revealed severe left sided weakness with right sided diminished pain/temperature sensation from the right mid-thorax extending to the toes. MRI showed longitudinally extensive signal abnormality from C2-C7 slightly eccentric to the left without cord compression. Patient was diagnosed with transverse myelitis, an infectious etiology was ruled out and she received 5 days of IV methylprednisolone with good response and minimal residual deficits. While admitted to inpatient rehabilitation facility, rheumatologic workup revealed positive anti-DsDNA/RNP/Smith antibodies and ANA titer of 1:640 suggesting SLE as well as positive Aquaporin-4 antibody leading to the diagnosis of NMOSD. Discussions: This rare case of concomitant SLE and NMOSD presenting as a Brown Sequard Syndrome in the setting of HIV/AIDS provides an opportunity for discussion regarding the coexistence of these multiple disorders and possible impact in patient's functional capacity. Prior reports have described the coexistence of NMOSD with a variety of immune-mediated disorders. However, many questions have yet to be answered, including the possibility of a shared autoimmune pathophysiology, prevalence of co-occurrence, type and severity of attacks, response to treatment, prognosis, etc. Another question involves the potential for long-standing HIV/AIDS to affect this patient's susceptibility to auto-immune diseases. One proposed mechanism linking NMOSD with HIV involves early detection of HIV life cycle markers in astrocytes which, when damaged, are the predisposing factor to developing NMOSD. Conclusions: The above case offers a rare presentation of multiple co-existing disease processes. While further epidemiological and clinical studies are necessary to determine a true association between these diseases, our hope is that reporting such cases may lead to further awareness, investigation and improved management of such patients in the future.

 Constipation or syrinx? the strange case of severe refractory abdominal pain in spinal cord injury



Neal Rakesh, Jonathan Ramin, Stephen Kornfeld

Case Diagnosis: Syrinx in spinal cord injury (SCI) presenting as severe abdominal pain. Case Description: A 71-year-old male with T7 ASIA A after a fall (status-post T7-12 posterior fusion and T9-10 laminectomies) initially presented with mild abdominal pain. Six months later, he was admitted to the hospital for severe refractory generalized burning abdominal pain. An extensive workup by gastroenterology was unremarkable. The pain was refractory to duloxetine, cyclobenzaprine, gabapentin, and ibuprofen. Additionally, his opioids were stopped to prevent worsening constipation. He endorsed mild pain relief with diazepam. An MRI revealed a large thoracic syrinx from T3-5. Four months later, the patient underwent bilateral C2/C7 laminectomies with C3-6 laminoplasties for cervical spondylosis. Subsequently, he reported a complete resolution of abdominal pain. A repeat MRI revealed significant thoracic syrinx shrinkage. Two weeks later, his abdominal pain returned with a subsequent MRI revealing an increase in thoracic syrinx size with extensive cord atrophy around the area. Currently, he is undergoing evaluation for surgical syrinx drainage. Discussions: SCI is associated with a variety of complications such as autonomic dysreflexia, neurogenic bowel/bladder, sexual dysfunction, osteoporosis, spasticity, and syringomyelia. Syrinx formation is common in the SCI population as a likely result of focal necrosis and cord tissue liquefaction. Within 3-4% of SCI patients, it can progress towards worsening myelopathy presenting as motor/sensory symptoms, bowel/bladder dysfunction and pain. While constipation is a common complaint in the SCI population, severe refractory abdominal neuropathic-type pain can be indicative of a worsening neurologic status from a syrinx. Conclusions: Syrinx formation while often benign in the SCI population can cause progressive myelopathy. Many SCI patients present with abdominal pain and constipation, which can easily be confused with a more insidious process. Clinicians must be cognizant of the various sources of pain within the SCI population and explore the underlying etiologies when assessing persistent refractory symptoms.

 Constraint-induced movement therapy combined with robotic training after botulinum toxin injection in chronic stroke patients with severe or moderate affected upper extremity



Yuki Uchiyama, Saya Iwasa, Yasunari Hashimoto, Jun Aoyagi, Toshiki Yasukawa, Kazuko Takahashi, Norihiko Kodama, Kazuhisa Domen

Objectives: Constraint-induced movement therapy (CIMT) is a standard therapy to improve affected upper extremity motor function in chronic stroke patients. However, it is known that CIMT has limited practical significance for stroke patients with severe or moderate hemiparesis. Recently, robotic training and botulinum toxin injection have been interesting options as an add-on intervention to CIMT. This study aimed to examine the effect of combined therapy of robotic training and botulinum toxin injection with CIMT on improving upper extremity function in chronic stroke patients with severe or moderate hemiparesis. Design: This retrospective study included chronic stroke patients who underwent CIMT at a college hospital between 2012 and 2019. The study received ethical approval for the use of an opt-out methodology by the ethics committee. From one week after botulinum toxin (Botox) injection, the patients received one hour of robotic training (ReoGo-J) and 0.5 hour of CIMT three per week for 10 consecutive weeks (total 45 hours of training). The Fugl-Meyer Assessments (FMA), Action Research Arm Test (ARAT), and Motor Activity Log (MAL) were used before and after intervention. Between-group differences were analyzed by Wilcoxon single-rank test. Results: A statistically significant increase between before and after intervention was observed in the all outcomes (FMA, ARAT, MAL amount of use and MAL quality of movement). Conclusions: This study suggested that CIMT combined with robotic training following botulinum toxin injection may enhance the recovery of motor function with practical significance in chronic stroke patients with severe or moderate hemiparesis after stroke.

 Constraint-induced movement therapy for upper extremity impairment after stroke: A case report



Elaine Cristina Silva, Andrely Aguiar, Gisele L. Antunes, Thais Contenças, Erik Martins

Case Diagnosis: We described a case of a 52-year-old woman who had an ischemic stroke two years previously with left hemiplegic and asymmetric upper extremity (UE) function. Case Description: The patient underwent a Constraint Induced Therapy (CIMT) protocol of three/hours day for 10 days. The purpose of this study was to assess CIMT effects in her hemiplegic UE function. The following outcome measures were Wolf Motor Function Test (WMFT) and Motor Activity Log (MAL). It happened pre and post intervention. After a month of intervention, we did a follow up. The unaffected UE was restrain during the protocol period with a glove. The specific tasks were chosen according to her most difficult UP motor abilities. As far as it improved, other tasks were chose. We assessed different UE movements as forearm's pronation and supination, wrist extension, finger's flexion, extension and abduction. Post intervention, the function of upper extremity decreased from 26,55 seconds to 3,17 seconds in WMFT. MAL showed an increased from 1,88 to 4,5 points. These mean a better velocity and useful function motor of upper extremity hemiplegic. Discussions: CIMT protocols has been a useful technique for the affected UP. The Results in post intervention as WMFT and MAL, showed improvement in velocity and how often the upper extremity affected started been using in daily activities. The follow-up tests showed some decline in the scores when compared to those at post intervention. Nevertheless, we could still see better responses in comparison to the begging moment. This outcome showed the continued use of UP even after the intervention ends. This may indicates the occurrence of behavioral change and reversal of non-learned use. Conclusions: CIMT protocol proved to be effective for improving post stroke UP functionality in this case report.

 Conus compression from spinal epidural abscess after trial spinal cord stimulator lead removal: A case report



Gaurish Soni, Satyum Parikh, Anita Kou

Case Diagnosis: Conus Compression from Spinal Epidural Abscess after Spinal Cord Stimulator Trial Lead Removal. Case Description: 39 year old male with chronic back pain syndrome underwent trial Spinal Cord Stimulator (SCS) placement with marked symptom improvement and subsequent removal of leads. Four days later, patient developed intractable back pain, fever, and urinary retention. MRI revealed fluid collection dorsal to thoracolumbar dura with conus compression. Elevated inflammatory markers, leukocytosis, and fevers resulted in repeat imaging, confirming epidural abscess. Patient completed eight weeks of IV antibiotics. Physiatry was consulted for comprehensive rehabilitation after patient demonstrated impairments in mobility and self-care. After a twelve day acute rehabilitation course, patient was discharged to home at a modified independent to complete independent level. Discussions: Removal of trial external SCS has not typically been associated with epidural complications such as abscesses. Spinal epidural abscesses have notoriously been secondary to bacteremia, surgical intervention, or spinal injections. A handful of cases have been associated with SCS implantation; however, there are no documented cases of abscesses after a trial SCS removal. It is essential to be familiar with clinical presentations in order for prompt attention and management. Conclusions: This case further supplements evidence of variations in spinal epidural abscess etiology. Even with aseptic removal of a successful trial SCS, the risk remains. Aforementioned in prior literature, the prompt diagnosis depends on clinical presentation of back pain. Upper motor neuron signs such as urinary retention can develop alongside fevers and elevated inflammatory markers. Prompt recognition of these symptoms are imperative for favorable treatment outcomes.

 Correlation between heart rate variability and bladder sensations during filling and voiding phase of urodynamic study in patients with myelopathy



Anupam Gupta, Tenzil Gomez

Objectives: Correlation between heart rate variability (HRV) and bladder sensations during filling and voiding phase of urodynamic study-UDS in patients with myelopathy. Design: Myelopathy patients (traumatic and nontraumatic) within 6 months of illness were included. Demographic data, ethiopathological diagnosis & urinary complaints were noted. UDS was performed and simultaneous HRV calculated at each event of filling and voiding phase by recording and calculating standard deviation of normal-to-normal (NN) interval-SDNN, Root mean square of successive differences, total power-TP, average heart rate, high frequency-HF, low frequency-LF and LF/HF ratio and data analyzed. Results: Study included 30 patients (23 males) with mean age of 31.2 years (range 18-60 years, SD11.6). The mean of LF in normalized units showed an increase from 43.6 ± 14.1 at baseline to 48.9 ± 17.4 at strong desire to void (SDV) and at urgency to 44.1 ± 14.5. HF at baseline 40.4 ± 14.1 reduced to 36.4 ± 12.8 at SDV and rose at urgency to 41.2 ± 13.2. LF/HF at baseline was 1.3 ± 0.8, which increased to 1.6 ± 1.1 at SDV and reduced at urgency to 1.2 ± 0.6. Significant change in mean value was seen in TP (p=0.01) and SDNN (p=0.009) at First Desire to Void-FDV. Significant positive trend was seen in TP (p=0.048) and SDNN (p=0.042) during filling. Conclusions: Comparison of HRV measures failed to show significant rise in sympathetic or parasympathetic component in myelopathy patients during urodynamic study and requires more critical evaluation.

 Correlation between state of consciousness (WHIM) and feeding modality (functional oral intake scale) in severe traumatic brain injury



Anna Cadeau, Remi Mallart, Eric Verin

Objectives: 80% of severe TBI suffer from swallowing disorders, with complications of pneumonia, and denutrition impacting their outcome. The aim of this retrospective study was to look for a correlation between feeding modalities (FOIS, functional oral intake scale) and the state of consciousness (WHIM), or the level of post traumatic amnesia (GOAT). We also looked for a benefit of VFSS over the over evaluation modalities, and an exploratory correlation analysis was realized. Design: We reviewed the clinical information of 68 VS (vegetative state) or MCS (minimal conscious state) patients (mean age 44 ± 6) regarding oral feeding and psychometric parameters. VS or MCS diagnosis was made after repeated behavioural assessments using the WHIM scale (Wessex Head Injury Matrix). Post traumatic amnesia was assessed using the Galvestone outcome amnesia test (GOAT). Swallowing evaluation was made using either videofluroscopy (VFSS), fiber endoscopy (FEES) or clinical examination. The main outcome statistics were performed using Pearson correlation analysis. Results: the feeding modality FOIS depended on the level of consciousness evaluated by WHIM (ρ= 0.60; p < 0.001). A VFSS evaluation seemed to increase that correlation (ρ= 0.80; p < 0.001), and to decrease the time needed to switch from semi-liquid to solid texture in oral feeding. The level of post-traumatic amnesia measured by GOAT (ρ= 0.34; p < 0.05) was also correlated to FOIS. The effect of the coma arousal unit on refeeding was important d = 1.6, with an increase in FOIS of 3. There was still a positive evolution of FOIS after discharge. Conclusions: FOIS is strongly correlated to WHIM and moderately correlated to GOAT, suggesting an impact of post-traumatic amnesia on swallowing. GOAT and WHIM scales could be used to determine the more appropriate moment to perform VFSS, adjusting the benefice risk balance in this frail population. Swallowing stimulation should be maintained after discharge.

 Correlation of muscle activation changes with functional improvement after functional electrical stimulation intervention in patients poststroke



Tong Wang, Chih-Hong Chou, Yong Bao, Manzhao Hao, Lin Gu, Chuanxin M Niu, Qing Xie, Ning Lan

Objectives: Functional Electrical Stimulation (FES) assistance enables activation of target muscles to restore impaired muscle synergies toward normal patterns. It provides a technology for rehabilitation of motor functions in the post-stroke. Muscle synergies can represent a central neural module that organizes and activates a group of muscles for performing a certain task. This study examines whether muscle synergy changes in post-stroke patients after FES intervention is correlated to improvement of motor ability. Design: Muscle synergies and movement kinematics before and after a 5-day FES intervention in the post-stroke are evaluated, and Pearson correlation analysis is used to evaluate the relations of these performance indices with Fugl-Meyer clinical scores. Electromyography (EMG) signals and movement kinematics were recorded in 9 patients in FES group and 8 patients in control group before and after the intervention. The baseline synergies from a normal subject are used as the template for formulating the FES pattern. Similarity indices are computed to indicate the closeness of muscle synergies before and after FES intervention with the normal template. Results: The results showed that compared with the control group, synergy similarity in the FES group was significantly increased, but the kinematics did not demonstrate a significantly improvement. The changes in synergy similarity was correlated significantly to the increase in Fugl-Meyer scores in all patients in both groups. Conclusions: The results imply that even in a short-term (5 days) intervention, synergy-based FES assistance starts to show its effectiveness in reorganizing neural circuits in the brain, which leads to repairing of the impaired muscle activation pattern towards the normal pattern. However, the recovery of motor ability has not been reflected in kinematics yet, such as velocity and duration time during the movement. Nevertheless, the results suggest that a larger scale efficacy study of long-term intervention using the synergy-based FES strategy is justified.

 Corticobasal syndrome in the inpatient rehabilitation setting: A case report



Erol Jahja, Morgan Pyne, Melita Theyagaraj, Henry S. York

Case Diagnosis: Corticobasal Syndrome (CBS) secondary to Progressive Multifocal Leukoencephalopathy (PML). Case Description: 69-year-old man actively undergoing chemotherapy for MALT Lymphoma, who developed progressive left-sided weakness over three months, resulting in three falls. Brain and Cervical MRI showed an old right frontal infarct, stable dolichoectatic right vertebral and basilar artery with mass effect on the right side of the medulla and a tiny cervical syrinx extending from C5-C7. Spinal tap showed albuminocytologic dissociation and oligoclonal bands. Neurology reported apraxia due to CBS from either an autoimmune or paraneoplastic process. Symptoms responded well to plasmapheresis. During inpatient rehabilitation, he was able to ambulate with moderate assistance until he rapidly developed apparent left-sided hemiparesis, including trapezius weakness. Brain imaging was negative for CVA and more careful examination utilizing distraction revealed severe apraxia. Imaging subsequently showed increased signal intensity in the gray matter extending into the periventricular and subcortical white matter, consistent with Progressive Multifocal Leukoencephalopathy (PML). He was again treated by plasmapheresis with good response. Discussions: CBS can be seen in many conditions, including PML. CBS is an atypical parkinsonian syndrome presenting with varying degrees of ideomotor apraxia, akinesia, rigidity, myoclonus, and cortical sensory loss with an un-sustained response to levodopa. Although CBS was originally thought to solely be a motor disorder, it is now known to have a cognitive component, with cognitive deficits often presenting before the onset of motor symptoms.2 Utilizing the Modified Bak and Hodges Criteria, physicians can support the diagnosis of CBS over CVA in the setting of neurological changes.2. Conclusions: CBS remains a difficult diagnosis given the wide range of cognitive, behavioral and motor aspects that can vary greatly amongst patients. While treatment remains symptomatic, disease-modifying agents targeting the pathologic process are currently undergoing development.3.

 Cranioplasty: Timing, outcomes and quality of life



Harry Mee, Angelos Kolias, Fahim Anwar, Peter Hutchinson

Objectives: Following a craniectomy for TBI or an MCA infarct, a cranioplasty is usually performed between 6-12 months later with the main aims of restoring skull integrity and cosmesis. The number of early cranioplasties is increasing; however, the timing of 'early and late' remains varied and debated 1,2 . The evidence base is expanding but there is a lack of high-quality prospective studies. Moreover, the definitions of neurological recovery vary significantly. A randomised trial will help answer the question around optimal timing of cranioplasty. A core outcome set (COS) will hopefully standardise the endpoints that should be measured and will facilitate cross-study comparisons. Design: A single-centre, pilot, prospective, parallel group randomised trial with 1:1 allocation ratio to early vs late cranioplasty of participants 16 yo. The Cranioplasty COS is a mixed methods study divided into 2 phases: Phase 1 is information gathering of current outcomes used in cranioplasty studies. Phase 2 is the Delphi study and formation of the core outcome set. Alongside is a phenomenological qualitative study exploring the issues and hurdles that affect the patients quality of life before and after a cranioplasty. Results: Recruitment is for 12 months from April 2019. To date, 12 patients have been screened, 7 eligible and 6 enrolled (86%). Participants are stratified depending on aetiology. Baseline data at 2 months and further timepoints at 6, 12 and 18 months from craniectomy date. The primary outcome is the GOSE at 6 months. Conclusions: A cranioplasty has so many different dimensions and although its complications are well documented there is no universal consensus on the optimal time for the operation, and only minimal, inconclusive, evidence base to aid clinicians. This work, hopefully, will help to tackle a few of these issues and help better understand the hurdles and difficulties a patient may face before and after a cranioplasty.

 Cryptogenic stroke and heterozygous methylene-tetra-hydro-folate-reductase polymorphism



Lawrence G. Chang, Mery Elashvili, Shirin Ardeshirzadeh

Case Diagnosis: Multiple Stroke Infarcts and Heterozygous MTHFR Gene Mutations. Case Description: MS is a 42 year old female with history of heavy alcoholism, preeclampsia, recent Mirena IUD placement about a year ago, and family history of myocardial infarctions, who was admitted to acute rehabilitation for acute infarcts in left midbrain, pons, and bilateral cerebellar hemispheres, and right parietal lobe with microhemorrhages in the pons and cerebellum. On genetic testing, patient was found to have both heterozygous MTHFR A1298C and 677T gene mutations. She was also found to have a small patent foramen ovale (PFO). Discussions: A literature review was conducted to examine the relationship between MTHFR and stroke as a new biomarker for stroke predisposition. Most studies postulate that MTHFR gene mutations increase hyper-homocysteinemia with risk of thrombotic events and abortions. The homozygous MTHFR form is associated with an increase in strokes. On one hand, the MTHFR A1298C variant increases ischemic stroke risk. On the other hand, the MTHFR 677T variant increases hemorrhagic and ischemic strokes risk in the lacunar region and small cerebral or intracranial arteries. Heterozygous MTHFR is cited as less likely to cause strokes due to a 50% reduction of MTHFR activity compared to homozygous MTHFR. Conclusions: MTHFR can increase risk of ischemic strokes, but the extent to which the heterozygote form contributes is still unclear. In this case, however, it is theoretically plausible that the heterozygous form predisposed the likelihood of multiple acute stroke infarcts when other risk factors were in play such as having a PFO and a heavy alcoholic history. Mirena IUD does not seem to be stroke related since no studies support this but IUD removal may be advised if one develops a new stroke. The public health significance is to raise awareness of genetic risk factors for strokes and discuss about preventative measures for this.

 Colony-stimulating factor-1 regulates microglia activation via AMPK/autophagy pathway and may implicate induce neuropathic pain



Ge Yang, Qian Tan, Zhenghui Xiao, Jiangnan Wu, Kun Liu, Weihua Ye, Haibo Mei, Hui Yu

Objectives: Increasing evidences suggested that colony-stimulating factor-1 (CSF-1) was involved in microglial activation and may further induce pain, however, the mechanisms remain unknown. Studies demonstrated AMPK-dependent autophagy has been implicated in the pathogenesis of neuropathic pain, suggesting AMPK-dependent autophagy may play a critical role in that. Here, we observed the biological events that link the CSF-1 induced microglial activated consequences for pain processing. Design: Invitro, the primary microglia were collected from mice brain and treated with CFS-1 or compound C respectively. Using flow cytometry, western blot, qRT-PCR and immunofluorescence staining to analyze the microglial activity and cellular AMPK pathway. Transmission electron microscope was used to evaluate microglial autophagy. Invivo, CSF1 intrathecal injection was performed on mice, the mechanical withdrawal threshold was measured to reflect its pain behavior. Besides, the spinal cords were collected and further evaluated the degrees of central sensitization by testing c-Fos and BDNF mRNA expression. Results: Flow cytometry showed the microglial activity was markedly increased after CSF1 stimulation. Western blot showed the increased expression of p-AMPK, p-S6k, p-P38 and LC3-II/LC3-I. qRT-PCR exhibited the IL-1, TNF-α and BDNF were simultaneously upregulated in the activated microglia, whereas the specific AMPK inhibitor compound C exhibited reversed effects. Using immunofluorescence staining and electron microscopy, we found CSF-1 decreased p62 expression and induced the number of autophagosomes in microglia. Invivo, compared with the control, the mice with CSF-1 intrathecal injection increased CSF1R and LC3b expression in spinal microglia. More important, CSF1 intrathecal injection arose mice pain behavior corresponding to the upregulated BDNF and c-Fos expression in spinal cords. Conclusions: Findings demonstrated CSF1 induced a significant upregulation of microglial activation via AMPK signal pathway and resulted in increasing microglial autophagy. Increasing CSF1 level in central nervous system can mimic and arise pain syndromes by up-regulation AMPK-depended autophagy, thus offering a new target for therapy of neuropathic pain.

 Delayed neurological deficits following spinal cord stimulation and the importance of patient education: A case report



Eric Liu, Tomas W. Salazar, Beverly Hon, Sara Cuccurullo

Case Diagnosis: Paraplegia following spinal cord stimulator trial. Case Description: This is a 70-year-old male with a past medical history of lumbar spinal fusion, left sided foot drop, and gout, who initially presented to the acute care hospital for lower extremity weakness with bowel and bladder incontinence. History was significant for a spinal cord stimulator (SCS) trial five days prior to presentation. Patient reportedly did well following the procedure and was discharged home. Three days later he started developing gait abnormalities with associated bowel and bladder incontinence. Upon presentation, the spinal cord stimulator leads were removed by neurosurgery and CSF leakage was noted. Steroid taper was initiated and he was noted to have improvement in his lower extremity strength before being discharged to acute inpatient rehabilitation hospital for intensive therapy program. Discussions: Risks and side effects are discussed with patients prior to any procedure. These often include bruising, bleeding, tenderness at site, or infection. Documented complications related to SCS implants include lead migration, lead fracture, hardware malfunction, infection, CSF leak, and hematoma. Although the risk for neurological deficits remains rare, providers are still obligated to educate patients regarding warning signs and symptoms that necessitate immediate evaluation. While this patient experienced delayed onset of neurological decline, prompt evaluation resulted in improvement of his neurological and functional status. Further delay in treatment could have led to more permanent disability. Conclusions: While newer techniques and leads have reduced overall complications, adverse events can still occur. Early identification of neurological deterioration following spinal cord stimulator implantation can be critical for patient outcomes. Detection of acute changes in strength, sensation, bowel and bladder continence warrants immediate evaluation. This case highlights the importance of physician and patient education. Awareness of serious complications following SCS procedures and early recognition of symptoms can have a significant effect on a patient's functional outcome.

 Delayed onset neuromyelitis optica



Erica R. Eldon, Sammy Wu, Charles Kent, Michael Chiou, Yashesh A. Parekh, Vincent Huang

Case Diagnosis: Neuromyelitis Optica. Case Description: An 88-year-old male presented with chest pain and low grade fever, was started on antibiotics for presumed pneumonia, and awoke the next morning with bilateral lower extremity weakness and numbness. MRI revealed central cord edema from C3 to T11. LP was significant for elevated protein to 91.5. He was found to have positive anti-aquaporin-4-IgG antibody by neuromyelitis optica/aquaporin-4 fluorescence-activated cell sorting. He was treated with methylprednisolone, one round of rituximab, and five rounds of plasma exchange without significant improvement. Discussions: Neuromyelitis optica (NMO) has a prevalence of 1-to-10 per 100,000 people. Typically, NMO has a median onset of 40 years of age, and there are limited reports of NMO in octogenarians. To our knowledge, there is no published literature to date that identifies why the diagnosis is more rare in the elderly. NMO is an autoimmune-mediated, demyelinating, inflammatory disorder where the immune system primarily targets the optic nerves and spinal cord but may also attack the brain and brainstem. Tests for the presence of anti-aquaporin-4 antibody should be carried out when an extensive cervical spinal lesion is encountered. More than 70% of NMO patients test positive for NMO-IgG, (also known as the anti-aquaporin-4 antibody). For patients with acute or recurrent attacks of NMO, initial treatment is with high-dose IV methylprednisolone. In patients with severe symptoms unresponsive to glucocorticoids, treatment is with therapeutic plasma exchange. Conclusions: Although NMO was not considered as the first-line diagnosis in our patient, it is important to consider neuromyelitis optica, regardless of age in patients with comparable signs and symptoms. Medical providers should be aware that disease onset can occur at late onset ages. Early diagnosis and treatment is essential to prevent further morbidity and mortality.

 Delayed posthypoxic leukoencephalopathy: A case report



Genevieve Jacobs, Priya Chandan, Matthew Adamkin

Case Diagnosis: Delayed post-hypoxic leukoencephalopathy. Case Description: A 56-year-old male with a history of alcoholism, hypothyroidism, and anxiety undergoes elective cervical spine fusion. One week following discharge, he was found down at home after ingesting pain medication and alcohol with subsequent hypoxic brain injury. Within 2 weeks of injury, the patient was able to talk and follow commands before then developing profound functional deficits including decreased mobility, cognition, swallowing, and Parkinsonian symptoms. Upon arrival to acute inpatient rehabilitation, the patient demonstrated akinetic mutism. Pertinent negatives included EEG, CT head, chest and abdominal imaging, blood and urine cultures, and pituitary labs. Vitals were stable throughout. Neurology and psychiatric evaluations failed to identify the etiology of the patients symptoms. Discussions: It was suspected the patient had developed a rare sequelae of anoxic brain injury - delayed post hypoxic leukoencephalopathy (DPHL) - which is characterized by cognitive decline after several days of lucidity following an anoxic brain injury. Case reports detail a similar clinical picture with akinetic mutism, cognitive impairments, and Parkinsonian symptoms that improved with Sinemet. MRI 18 days following anoxic event demonstrated T2-hyperintensity in the centrum semiovale which has been documented in the literature as being pathognomonic for DPHL. After initiation of Sinemet, the patient was able to consistently answer questions and repeat his name aloud. Based on clinical presentation, MRI findings and response to pharmacological treatment the leading diagnosis became DPHL. Conclusions: Of the case reports reviewed, all patients experienced some recovery in the 3-6 months following anoxic injury with resolution of MRI findings. On patient's last day of rehabilitation, he was able to verbalize his full name, and his location. At subsequent outpatient visits, he continued to progress verbally, cognitively, and physically. At his 18-month visit he was ambulating without assistive devices and could communicate complex thoughts. He continues to make monumental improvements from baseline.

 Delayed presentation of traumatic arteriovenous fistula in two traumatic brain injury patients



Anna Weingart, Steven Flanagan, Fabienne Saint-Preux, Rosa Pasculli

Case Diagnosis: Two traumatic brain injury (TBI) patients with pulsatile tinnitus secondary to traumatic dural arteriovenous fistulas (AVFs). Case Description: Both patients were followed in TBI clinic for prior mild TBI complicated by post-concussion syndrome. Patient One is a 68-year old female; four months after her trauma, her primary symptoms included vertigo, headaches, anxiety, impaired balance, and recent pulsatile left ear tinnitus. Physical examination was unremarkable. MRA brain revealed left transverse and sigmoid sinus dural AVF. Patient Two is a 47-year-old male; eight months after his injury, his symptoms included concentration difficulties, anxiety, insomnia, headaches, and new right-sided pulsatile tinnitus. Physical exam was unrevealing. MRA brain revealed a right sigmoid sinus AVF. Both patients underwent uncomplicated coil embolization with subsequent resolution of tinnitus. Discussions: Dural AVFs are uncommon vascular abnormalities. They are typically idiopathic but can be caused by pathologic insult, such as trauma. Presentation is non-specific and may include headache, visual disturbances, seizures, or pulsatile tinnitus. In a TBI patient, these vague symptoms are usually manifestations of post-concussion syndrome. When considering alternative causes, AVF in particular may be overlooked as delayed presentation of traumatic AVF is exceptionally rare. Only two other cases of traumatic AVFs presenting over 72 hours after injury exist in the literature. The two patients in this report had traumatic AVFs which presented months after injury, highlighting the importance of keeping AVF on the differential throughout ongoing follow-up. Conclusions: Traumatic AVFs are an uncommon but serious cause of neurologic symptoms after TBI. Traumatic dural AVFs typically present within 48 hours of trauma, but the two patients in this report presented months later. Identification of AVFs is especially important because treatment may improve symptoms and prevent significant morbidity and mortality. In both of these patients, work-up of pulsatile tinnitus led to appropriate diagnosis and treatment of dural AVFs with ultimate resolution of symptoms.

 Demonstration the importance of early rehabilitation in stroke patients based on diffusion tensor imaging data



Berna Urkmez, Yaşar Keskin, Bahar Atasoy, Ayse Aralasmak, Teoman Aydin

Objectives: The purpose of our study was to evaluate, through clinical examination, whether there was any difference between patients who underwent early rehabilitation and those who underwent late rehabilitation in terms of improvements in motor and functional impairment after rehabilitation, and also to evaluate this difference objectively by analyzing white-matter pathways (corticospinal tracts) using DTI. Design: Twenty-eight (28) adults (12 women, 16 men, average age 58 years) with first-time stroke who met the study criteria were divided into two groups depending on the duration of their stroke at the time of their presentation to our facility. Group 1 consisted of patients who underwent rehabilitation program within the first 1–4 weeks after stroke, whereas Group 2 consisted of patients who underwent rehabilitation program within 5–8 weeks after stroke. Both groups were evaluated using the BRS, FMA scale, FAC and BI scales. For cranial imaging, DTI was obtained 1 day before and 1 day after treatment. FA and ADC values of corticospinal tracts were performed using DTI. Patients were enrolled in a rehabilitation program, which was designed for a total of 4 weeks, with daily sessions lasting a total of 1 h on 5 days of a week. Results: There was no significant difference in terms of functional gains between the two groups. In both groups, the FA values of the corticospinal tract obtained with DTI before the treatment were similar, whereas the mean FA increase after treatment was higher in Group 1 than in Group 2. Conclusions: In our study, all stroke patients gained functional benefits regardless of whether they underwent early and late rehabilitation. The fact that the mean corticospinal FA values of the early-rehabilitation patients, was higher than that of the late-treatment patients, might indicate that early rehabilitation might be more effective in recovery of corticospinal tracts.

 Denervation myositis seen in spinal cord injury



Tyler Williamson, Alexander Turfe, Michael Bush-Arnold

Case Diagnosis: Denervation myositis following anterior spinal artery infarct. Case Description: 51 year old female admitted to rehab unit with anterior SCI following anterior vertebral artery infarct of unknown etiology, negative vascular and rheumatologic workup. Admission exam findings included impaired motor function and pain perception, with preservation of proprioception and light touch. During stay, she made mild improvements in muscle function, however was limited by right hip pain, thus requiring workup. X-Ray showed mild osteoarthritic changes to bilateral hips, and bone scan was not typical for heterotopic ossification. MRI demonstrated muscle edema in bilateral gluteus medius and minimus, proximal adductor muscles; as well as left gluteus maximus, right pectineus, quadratus femoris, and obturator externus muscles. CPK was normal, and negative rheumatologic work-up. We discontinued statin, as statin induced myopathy was possible despite normal CPK. Yet, pain persisted, prompting intraarticular corticosteroid hip injection which improved her pain. Follow up during outpatient therapy: she continues to progress, restarted statin, now without pain. Discussions: Denervation myositis, usually seen in peripheral nerve entrapment, consists of acute (within 1 week, MRI normal), subacute ( >3 weeks, MRI: mixed edema and atrophy), and chronic (MRI: only atrophy) phases. With negative labs, positive radiographic findings, and no relief from discontinuing statins, we were able to make subacute denervation myositis a diagnosis of exclusion. Conclusions: If MRI findings show edema and/or atrophy 3 or more weeks post SCI injury, consider the diagnosis of denervation myositis in the context of a negative workup.

 Desempeño funcional de desarticulado de rodilla comparado con niveles transtibial y transfemoral



Diana Guevara, Miguel Gutierrez, Juan Camilo Mendoza Pulido, Thomas Torres, Carolina González Alvarado, Nelson F. Orozco

Case Diagnosis: Comparar el desempeño funcional de tres niveles de amputación por medio de pruebas físicas estandarizadas. Case Description: Estudio retrospectivo a partir de la base de datos del departamento de Amputados y prótesis de un hospital de referencia del país, registrada en el software de captura de datos electrónicos RedCap. Se compararon las medianas de las pruebas funcionales Up and Go Test, L- test, alcance funcional y velocidad de marcha en 2 minutos por medio de estadístico no paramétrico para K grupos, con análisis post hoc. Discussions: Se obtuvo una muestra de 109 amputados de miembro inferior valorados en un hospital de referencia de la ciudad, 76 (69,7%) transtibiales, 12 (11%) desarticulados de rodilla y 18 (16,5%) transfemorales. Se encontraron diferencias significativas para la velocidad de marcha, up and go test y L test entre el nivel de amputación transtibial comparado con los niveles desarticulado de rodilla y transfemoral. No se encontró diferencia significativa para estas pruebas entre transfemorales y desarticulados de rodilla, pero si se observa una tendencia hacia un mejor desempeño entra más distal es la amputación. Para la prueba de alcance funcional no se encontraron diferencias entre los grupos. Conclusions: Los amputados transtibiales tienen un mejor desempeño en pruebas de desplazamiento y movilidad dadas por una mayor velocidad para realizar dichas pruebas. En las pruebas que se relacionan con equilibrio estático como la de alcance funcional no se encuentra diferencia en el desempeño entre los 3 niveles. Es esperable que el nivel transtibial tenga mejor desempeño; no encontrar diferencia significativa entre transfemoral y desarticulado de rodilla implica que no cambia el desempeño al conservar un brazo de palanca de mayor longitud.

 Desipramine withdrawal syndrome complicating recovery from hypoxic-ischemic brain injury: A case study



Mark L. Volker, Jonathan Reisman, Diane Mortimer, Kelli Hall

Case Diagnosis: Desipramine withdrawal in the setting of post-hypoxic myoclonus. Case Description: A 65-year-old male with depression suffered an anaphylactic reaction with loss of airway for approximately ten minutes. Complications included impaired cognition and post-hypoxic myoclonus. His home medication of desipramine was stopped while he was critically ill. He was admitted to the Acute Rehabilitation Unit on day 27. His Nonverbal Orientation Log (N-O-LOG) was 2/10. Myoclonus interfered with cares and therapies. Within 3 weeks, N-O-LOG progressed to 9/10. On levetiracetam and clonazepam, he achieved near-resolution of movements at rest. When he reported feeling depressed, desipramine was restarted. Within 2 weeks, his mood improved but his myoclonus worsened, and he became unsafe for transfers. Desipramine was rapidly weaned, calming his myoclonus. While his IADLs improved, his cognition declined with N-O-LOG of 0/10, and he became paranoid and physically aggressive. He was diagnosed with desipramine withdrawal syndrome. Two weeks into resuming desipramine, his N-O-LOG increased to 7/10. Discussions: An interdisciplinary team represented by physiatry, pharmacy, and psychiatry proved vital in highlighting desipramine withdrawal as the cause of his acute changes. Desipramine is a tricyclic antidepressant whose actions include blocking serotonin and norepinephrine reuptake. For our patient, the abrupt cessation of desipramine resulted in improvement of his myoclonus but worsening of his cognition and mood. Because centrally acting medications, such as desipramine, have intended and unintended effects throughout the body, it is important to consider all previous medication adjustments when establishing a diagnosis. Conclusions: To our knowledge, this is the first reported case of desipramine exacerbating post-hypoxic myoclonus, likely through the effects of one or both of serotonin or norepinephrine. In this complex case, where rehabilitation treatments for cognitive, motor, and mood symptoms were both overlapping and conflicting, identifying and addressing desipramine withdrawal paved the way for a better functional outcome.

 Detection of visual fixation and functional object use through smart phone use in a patient with a disorder of consciousness: A case report



Nicole Diaz-Segarra, Benjamin Seidel

Case Diagnosis: Smart phone use to detect signs of consciousness. Case Description: A 38-year-old male who sustained a severe traumatic brain injury underwent decompressive hemi-craniectomy and was discharged to rehabilitation in an unresponsive state on day 25. The Coma Recovery Scale-Revised (CRS-R) was performed using the patient's smart phone to supplement the protocol. For visual fixation and functional object use, he was unable to consistently fixate on a balloon or use a pen to write as part of the CRS-R. He was, however, able to consistently fixate on his phone with a video of his daughter playing. In addition, when asked to answer an incoming call on his smart phone, he consistently “swiped” to answer, held the phone to his ear, and gave verbal responses including: “Hey”, “How's it going?” “What's up,” and “Talk to you soon”. Discussions: There is currently no literature regarding smart phone use to assess for early signs of consciousness in patients with disorders of consciousness (DOC). Current clinical assessments rely on the observation of behavior responses to a stimulus, with the CRS-R being the most commonly used standardized tools. Standardized tests, however, may overlook certain manifestations of awareness. In this case, technology specific conscious behaviors for visual fixation and functional object use were observed earlier than CRS-R specific behaviors. This approach has the potential to assess for early signs of consciousness and may ultimately be able to assist clinicians in differentiating between unresponsive wakefulness, a minimally conscious state, and emergence into full consciousness. Conclusions: This case highlights the detection of visual fixation and functional object use in a patient with a DOC. While additional research is needed, this shows the utility of integrating smart phone technology into the assessment to detect for early signs of consciousness, particularly in the younger population whose familiarity with technology may reinforce existing cortical pathways.

 Determinants of length of stay and ambulation during rehabilitation of traumatic spinal cord injury patients- insights from Northern India



Mohit K. Srivastava, Anil K. Gupta, Late V.P. Sharma, Dileep Kumar, Sudhir Mishra, Ganesh Yadav

Case Diagnosis: Traumatic spinal cord injury (TSCI) is one of the most devastating injury, and Results in different neurological deficits. A long hospital stay occupies medical and financial resources which leads to substantial social loss and economic burden. To increase efficiency of resource utilization for rehabilitation care centers that treat TSCI patients, it is important to evaluate the determinants of hospitalization length as well as their ambulation. To describe the length of hospital stay and ambulation in patients with traumatic spinal cord injury (TSCI) and identify the associated epidemiological and clinical factors. Case Description: A retrospective study, utilizing a quantitative approach was done. The medical records of 108 patients with TSCI, who fulfilled the inclusion criteria and discharged from the hospital between 1st January 2016 and 31st December 2017 were reviewed with the help of a data collection tool developed for the same to capture relevant information. Sociodemographic and clinical characteristics of the traumatic paraplegics were collected. Rehabilitation Length of stay was defined as the number of days in the hospital or rehabilitation center from the day of the patient's first admission after injury to the date of discharge from the hospital. Discussions: The mean duration of hospital stay was 39.37±8.44 days. 63.6% of age group 15-30 years had hospital stay of ≥30 days. 51.7% patients with AIS grade A and 61.5% patients with pressure ulcers had hospital stay of ≥30 days. Age (AOR 9.88; 95% C.I. [2.33 – 41.81]; 0.002), employment status (AOR 5.57; 95% C.I. [1.09 – 28.37];0.039, location of residence (AOR 0.14 95%C.I. [0.03-0.63];0.01), Pressure Ulcer (AOR 5.81; 95% C.I. [1.77 – 19.06]; 0.004) and history of treatment (AOR 1.98; 95%C.I. [1.76– 14.16]; 0.002) were significant predictors of length of hospital stay in patients with TSCI. Significant factors for ambulation after hospital stay were age, gender, location of residence and neurological category of injury (p< 0.05). Conclusions: The study has observed that age, employment status, pressure ulcers and operation are significant determinants of hospitalization length in TSCI patients and ameliorating these factors can improve their quality of life. Probability of Ambulation was observed to be better in females than in males and age, gender, location of residence and neurological category were affecting ambulation of traumatic paraplegics during the rehabilitation length of stay in hospital.

 Development and reliability analysis of an ICF core set for functioning assessment of adults treated for cancer at hospital discharge



Luz A. Lorca, Cinara A. Sacamori, Paulina A. Benavente

Case Diagnosis: To describe the elaboration process and reliability analysis of a Core Set for functioning assessment of adults treated for cancer at Hospital discharge. Case Description: Descriptive study of the process of developing a Core Set, which included five stages: (1) systematic review; (2) identification and linking of concepts with ICF categories (3) expert's consensus (4) operationalization (5) analysis of inter-rater reliability. Population: 21 experts participated in stage 3; 63 experts in stage 4 and 31 adults treated for cancer in stage 5. The study was approved by the scientific ethics committee (December 15, 2015). Descriptive study of the process of developing a Core Set, which included five stages: (1) systematic review; (2) identification and linking of concepts with ICF categories (3) expert's consensus (4) operationalization (5) analysis of inter-rater reliability. Population: 21 experts participated in stage 3; 63 experts in stage 4 and 31 adults treated for cancer in stage 5. The study was approved by the scientific ethics committee (December 15, 2015). Discussions: 47 articles were included, from them 55 instruments were extracted. 208 concepts were identified from the instruments, of which 204 could be linked to CIF categories. In the expert's consensus 24 categories were selected, which were operationalized. In the reliability analysis, 23 codes obtained a significant correlation that varied between r = .916 and r = 1.0. The code d240 (stress management) did not obtain good inter-rater reliability, which is why it was eliminated. Conclusions: The ICF provides a valuable frame of reference for identifying significant concepts related to the functioning of patients treated for cancer at hospital discharge. After the process of 5 stages we obtained a Core Set with 23 categories, this will soon undergo a validation process in a multicentric study with the participation of 5 health institutions, national and international.

 Development of a quantitative evaluation of motor paralysis using an accelerometer: Reliability and validity



Ren Fujii, Yoshimitsu Hashizume, Shinichiro Tanaka

Objectives: We have developed a new quantitative evaluation system of motor paralysis using an accelerometer. The purpose of this study is to verify the reliability and validity of the evaluation system as a preliminary study. Design: Ten healthy adult volunteers were participated in this study. Measurement tasks were arm elevation movement, hip flexion movement, knee extension movement, ankle dorsi flexion movement, based on Stroke Impairment Assessment Set motor items. We recorded joint movement during each measurement tasks using an accelerometer (AX3, Axivity Inc.) and calculated velocity and distance. The accelerometer was attached to the dorsal center of the wrist joint during the arm elevation task, lateral epicondyle of femur during the hip flexion task, lateral malleolus during the knee extension task and fifth metatarsal bone during the ankle dorsiflexion task. To confirm the concurrent validity, we performed also measurements using a three-dimensional motion capture system (KinemaTracer, KISSEI COMTECH Inc.) at the same time. For the statistics analyses, spearman's rank correlation coefficient was used for validity, and intraclass correlation coefficient (ICC) and 95% confidence interval for minimal detectable change (MDC95) for reliability. Results: The correlation coefficient between the parameters of the accelerometer and the three dimensional motion capture system was r=0.75-0.84 (p< 0.05) at velocity and r=0.71-0.82 at distance for each tasks. In addition, ICC were 0.93-0.95 and MDC95were 4.51-6.89% for each tasks. Conclusions: The reliability and validity of the evaluation system were indicated in the present study. Future studies are required to focus on clinical utility.

 Development of acute onset upper extremity motor paresis following outbreak of herpes zoster rash: A case report



Rebecca Caine, Timothy Foster, Mark Goddard

Case Diagnosis: Herpes zoster infection with subsequent motor paresis: A case of probable brachial neuritis. Case Description: A 60-year-old female with past medical history of hyperlipidemia and fibromyalgia presented with right upper extremity pain followed by development of a characteristic vesicular rash in the C4-C5 dermatomes, for which she was prescribed valacyclovir. The patient had subsequent acute onset of weakness and was prescribed a methylprednisolone dose pack. Strength was graded as 1/5 for shoulder flexion, extension, abduction, external rotation and 3/5 for elbow flexion. Sensation and reflexes were intact. Right shoulder MRI was significant for subtle muscle edema signal involving the supraspinatus, infraspinatus and posterior aspect of the deltoid. Nerve conduction studies were within normal limits. Needle electromyography was significant for active denervation of the deltoid and infraspinatus. The patient underwent physical therapy and regained near full active range of motion three months after initial onset of weakness. Discussions: A leading diagnosis is brachial neuritis given the presentation of pain followed by weakness. There are several reports detailing its association with herpes zoster and the MRI findings are consistent with this diagnosis. Another consideration is mononeuritis multiplex, with involvement of the axillary and suprascapular nerves. This condition can be associated with infection and there are case reports describing an association with herpes simplex virus. A more remote possibility is segmental zoster paresis, a rare and often under recognized complication, in which viral spread from the dorsal root ganglion to the anterior horn cell or ventral root results in motor impairment. There is involvement of the C5 dermatome and myotome, however additional C5 muscles tested on electromyography were within normal limits. Conclusions: The data does not definitively support or exclude any of the above diagnoses. This case is intended to enhance awareness and explore the mechanisms of development of motor paresis following infection with herpes zoster virus.

 Development of a tablet-based participation measure for older patients in outpatient rehabilitation settings



Feng-Hang Chang, Yu Su, Zong-Liang Tseng

Objectives: Tablet technology is recognized as an innovative solution for administering health outcome assessments. However, it is unclear whether adopting tablet technology to measure complex self-reported functional outcomes such as participation is as reliable and acceptable to clients, particularly the older populations. The aims of this study were to (1) develop a tablet-based participation measure; (2) compare the reliability and concordance of this tablet-based measure with the paper-form version; and (3) compare the acceptability to older adults in outpatient rehabilitation settings between these two versions. Design: We programmed a multidimensional participation measure, the Participation Measure--3 Domains, 4 Dimensions (PM-3D4D), into a mobile application software and presented on tablet computers. A two-group design with two administered versions of the PM-3D4D was employed. A convenience sample of 80 adults (mean age: 70.16 years; 52.5% female; 82.5% was diagnosed with musculoskeletal disorders) was recruited from the outpatient rehabilitation clinic of three hospitals in the greater Taipei area. All participants completed the tablet-based and paper-form PM-3D4D at two time points: at the baseline and at 1-week follow-up. Intraclass correlation coefficients (ICCs) were calculated for concordance and test-retest reliability. Participants' ratings and responses as to their preference and perceived difficulty of using the two versions of the measure were summarized and reported. Results: The tablet-based PM-3D4D showed good to excellent test-retest reliability (ICCs=0.79~0.96) and high concordance with the paper-form PM-3D4D (ICCs=0.74-1.00). Approximately 44% participants reported preference for the tablet-based measure, and 20% reported preference for the paper-form measure. Many participants found the tablet-based measure user-friendly, convenient, and environmentally-friendly. Conclusions: The tablet-based PM-3D4D fills a critical void for an efficient and reliable rehabilitation outcome measure tailored to the needs of older adults in rehabilitation settings. Findings of this study provide supportive evidence for administering the tablet-based PM-3D4D to an older Chinese population in rehabilitation settings.

 Development of trismus during locked-in syndrome due to central pontine myelinolysis: A case report



Wiaam Y. Elkhatib, Whitney Pratt

Case Diagnosis: This report describes a case of severe trismus without clear etiology successfully treated with onabotulinum toxin-A bilateral masseter injections following development of central pontine myelinolysis (CPM). Case Description: Patient is a 33-year-old female who presented to the hospital with ascending weakness five days following hyponatremia correction at rates within guideline recommendations. MRI revealed increased signal in the central pons suggestive of CPM. Eighteen days later, she sustained tongue laceration after acute bilateral masseter hypertonic spasticity which was treated with chemo-denervation. Patient gradually regained the functional capacity to voluntarily open jaw for speech and mastication over several weeks. Discussions: Trismus is an upper motor neuron pathology resulting in hypertonic spasticity of masticatory muscles with a broad differential. Cerebrovascular accidents are known culprits as well, although trismus following brainstem lesions is a rarer complication than those in the cerebral hemisphere. No inciting events, past medical history, nor prior imaging findings on further review explained this development. In theory, it may be possible that regional inflammation and edema surrounding the pons secondary to myelinolysis, or less likely an otherwise subclinical microvascular stroke, may have caused sufficient irritation to the trigeminal nerve to induce trismus. Treatment with onabotulinum toxin-A was chosen given severity of the case, the focal nature of her symptoms, the need for oral access to facilitate patient care, and to potentially help relieve pain caused by tonic spasm of the masticatory muscles. Conclusions: Chemo-denervation therapy for this unusual incident of trismus appears to have assisted in alleviating symptoms and improving functionality in speech, swallowing, and facial expression. The significance of this case report centers around the development of trismus in absence of distinctly attributable causation in the context of CPM.

 Diaper UA – A new screen test for urinary occult blood without collecting urine



Hung-Chi Chen, Meng-Chih Lee, Hsin-Ying Chen

Case Diagnosis: A novel catheter-free urine test device is invented and produced by Iding Medical Equipment Company. It is called DiaperUA, urine analysis within patient's diaper. DiaperUA is composed of a wireless enuresis alarm and a stainless steel cage capable of holding wet sensor and test paper stick. In this study, the occult blood (OB) urine test paper is used for its correlation with urinary tract infection. The color change of test paper will happen soon after contact with urine by spreading. Case Description: This study was designed to test the sensitivity and specificity of DiaperUA(OB) to urinary tract infection (UTI). It was consented by the institutional review board of a regional hospital in Taiwan. From 2018 March to June, 10 bedridden patients in respiratory care ward were enrolled. DiaperUA(OB) was applied to every patient once per week. Each time after alarming, the residual urine was obtained by catheterization, and urinalysis was done immediately. Discussions: According to the standard color change of OB test paper, (±) or (±) is defined as negative, (+ to+++) is defined as positive. The normal result of urine sediment WBC is 0 – 5/HPF. The sensitivity and specificity of DiaperUA(OB) to urinary tract infection (UTI) is 80% and 96.3% respectively. Conclusions: The results suggested that DiaperUA(OB) can be a screen test for occult blood phenomenon of urine. Positive result may indicate the possibility of urinary tract infection.

 Differences in long-term functional outcomes by sex: The KOSCO study



Yun Sangmoon, Won Hyuk Chang, Deog Yung Kim, Min Kyun Sohn, Jongmin Lee, Sam-Gyu Lee, Yong-Il Shin, Yang-Soo Lee, Min Cheol Joo, So Young Lee, Jun Hee Han, Jeonghoon Ahn, Gyung-Jae Oh, Young-Hoon Lee, Ji-Yoo Choi, Sung Hyun Kang, Il Yoel Kim, Yun-Hee Kim

Objectives: Previous studies compared the outcome of stroke by sex, but few study focused on functional assessment. The objective of this study was to determine whether there is a difference in functional outcomes according to sex for ischemic or hemorrhagic stroke. Design: This study was an interim analysis of the Korean Stroke Cohort for Functioning and Rehabilitation (KOSCO) designed as 10 years long-term follow-up study. In this study, we analyzed 10,636 stroke patients to investigate differences in demographics and clinical features between male and female stroke patients. Serial data of multi-facet functional assessments up to 24 months by using the Korean-Modified Barthel Index (K-MBI), Fugl-Meyer Assessment (FMA), Functional ambulation classification (FAC), American Speech-Language-Hearing Association-National Outcomes Measurement System (ASHA-NOMS), Korean version of Frenchay Aphasia Screening Test (K-FAST) were analyzed to identify sex differences in functional recovery. Other factors influencing on recovery of stroke such as age, educational level, body mass index (BMI), initial stroke severity, premorbid disability, and degree of comorbidity were adjusted as covariance to analyze the effect of sex. Results: Out of total 10,636 stroke patients (8,210 ischemic strokes and 2,426 hemorrhagic strokes), female patients (43.2% n=4,593) showed significantly older age, lower education level, lower BMI, higher co-morbidity, and severer initial severity. Even after multiple adjustments for these factors, functional outcomes were significantly poorer in female ischemic stroke patients than male in the measures such as FMA, FAC, ASHA-NOMS, K-MMSE, K-FAST, and K-MBI at 24 months after stroke. For hemorrhagic stroke patients, female patients showed significantly lower FMA at 24 months after stroke than male. Conclusions: These results revealed sex-specific differences in functional outcomes of stroke patients and provided information that could be helpful for establishing specific rehabilitation strategies according to sex.

 Different predictive factors for upper and lower extremity motor recovery after ischemic stroke



Jungsoo Lee, Ahee Lee, Heegoo Kim, Jinuk Kim, Won Hyuk Chang, Yun-Hee Kim

Objectives: Stroke patients show diverse recovery patterns. In case of recovery of upper extremity (UE) motor function, diverse clinical and neuroimaging marker were reported as predictive factors. However, a few studies reported factors related to recovery of lower extremity (LE) motor function. In this study, we investigated predictive factors for recovery of UE and LE motor function after stroke using the clinical and neuroimaging characteristics. Design: Forty-two subacute ischemic stroke patients participated. All patients underwent structural and functional MRI data acquisition and cognitive/behavioral assessments at two weeks after stroke onset. Assessments included Fugl-Meyer assessment (FMA), mini-mental state examination (MMSE), and NIH stroke scale (NIHSS). FMA scores was assessed again at three months as outcomes. Important neuroimaging markers were investigated. Corticospinal tract (CST) fractional anisotropy (FA), lesion volume, CST lesion load, and interhemispheric homotopic functional connectivity (IHFC) were extracted from MRI data. A normalized difference between MMSE and FMA scores (diff(MMSE, FMA)) was used as an additional factor. A linear regression model was used to investigate predictive factors. Results: Recovery-related factors and their predictive power were noticeably different between UE and LE motor function. Age, MMSE, diff(MMSE, FMA) and ipsilesional CST FA were predictive factors in both UE and LE recovery. NIHSS score, CST lesion load, lesion volume, and IHFC were related to UE recovery only,, whereas contralesional CST FA was related to LE recovery only. Age and diff(MMSE, FMA) showed higher predictive power in LE recovery compared to UE recovery. Conclusions: Most of predictive markers which were meaningful for UE motor recovery did not show significant relationship with LE motor recovery. On the other hand, age of patient, cognitive function, and integrity of unaffected CST are crucial for LE recovery. These results indicated that different mechanisms might underlie between the UE and LE motor recovery after stroke.

 Differential relationships between physical activity levels and fine motor performance in individuals with and without type II diabetes mellitus



Ali A. Weinstein, Leyla de Avila, Jillian K. Price, Carey Escheik, Pegah Golabi, Naomi Lynn Gerber, Zobair M. Younossi

Objectives: Previous research has demonstrated a decrease in fine motor speed in individuals with Type II diabetes mellitus (T2DM). However, the relationship between physical activity levels and fine motor performance has not been extensively examined in this population. Therefore, the current study examines the relationship between fine motor performance and physical activity in those with and without T2DM. Design: Forty-nine individuals, 24 with T2DM (age: 55.2 ± 11.0 years; 46% female; body-mass index (BMI): 32.8 ± 5.3 kg/m2) and 25 without T2DM (age: 47.2 ± 13.6 years; 56% female; BMI: 28.6 ± 7.3 kg/m2) participated in a cross-sectional study. Fine motor performance was assessed with the Grooved Pegboard task and physical activity levels were examined with the Human Activity Profile, a self-report tool that has two measures of activity: Maximal Activity Score (MAS) and Adjusted Activity Score (AAS). Results: In individuals without T2DM, there were statistically significant correlations between time to complete the grooved pegboard and both MAS (r=-0.49; p=0.01) and AAS (r=-0.43; p=0.03). However, in individuals with T2DM, these correlations between grooved pegboard performance and both MAS (r=0.24; p=0.27) and AAS (r=0.21; p=0.33) were not statistically significant. The fine motor performance was statistically significantly different in comparing individuals with and without T2DM (t(47)=-4.5, p< 0.01) but MAS and AAS were not statistically significantly different between the groups (MAS: t(47)=1.7, p=0.10; t(47)=1.1, p=0.27). Conclusions: Individuals with T2DM were slower in performing a fine motor task than individuals without T2DM, but there wasn't a statistically significant correlation between physical activity levels and fine motor performance, a relationship that did exist in individuals without T2DM. Fine motor performance difference between individuals with/without T2DM might be driven by other factors, such as sensory neuropathy which would preferentially affect fine motor performance rather than overall activity (MAS/AAS).

 Diffuse spontaneous activity after spinal cord injury complicating phrenic nerve evaluation: A case report



Jill C. Penman, Mariko Kubinec, Camilo Castillo, David Haustein

Case Diagnosis: C3 AIS A spinal cord injury with diffuse spontaneous activity on EMG distal to the neurological level of injury. Case Description: A 41-year-old female with a C3 AIS A spinal cord injury secondary to a gunshot wound to the neck was evaluated for diaphragmatic pacing at 3 months post-injury after multiple unsuccessful attempts at ventilator weaning. To assess the integrity of the phrenic nerves for pacing, electromyography (EMG) and nerve conduction studies (NCS) were performed. Routine NCS of peripheral nerves in the limbs were normal, but stimulation of the bilateral phrenic nerves resulted in only volume-conducted responses without consistent compound motor action potentials at the hemidiaphragms. On EMG testing, widespread spontaneous activity was noted throughout the upper and lower limbs distal, but not proximal to, the neurologic level of injury. On ultrasound, the diaphragm appeared atrophic without clear contraction. Discussions: While critical illness myopathy and polyneuropathy may also be considered in the differential diagnosis, diffuse spontaneous activity below the level of the lesion has been documented in the setting of CNS lesions, including spinal cord injuries. The etiology remains unclear but is presumed to be due to transsynaptic degeneration and anterior horn cell depression after diminished trophic input. This case highlights that in the EMG workup of persons with CNS pathology, widespread spontaneous activity below the level of injury may be an expected finding and thus not indicative of peripheral nervous system pathology. Conclusions: Specific to the assessment of phrenic nerve integrity, limiting the needle EMG study to the diaphragm may result in a false positive interpretation of phrenic nerve injury if the only abnormality is spontaneous activity. An analysis of phrenic NCS, other NCS, motor unit recruitment, motor unit action potential morphology, and needle EMG findings in other muscles are essential elements to properly interpret a study in the setting of CNS pathology.

 Diffusion tensor imaging studies on a traumatic spinal cord injury patient: A case report



George S. Chen, Hannah Ovadia, Steven Kirshblum, Bing Yao

Case Diagnosis: Using diffusion tensor imaging (DTI) to evaluate neuro-recovery in an incomplete traumatic spinal cord injury (SCI) patient. Case Description: A 39-year-old male with no significant past medical history was admitted to an acute inpatient rehabilitation hospital after suffering a fall at a construction site. Imaging in the emergency room showed a C4-6 fracture with cord compression and a small anterior hematoma at C5-6. He underwent C4-6 ACDF and C5 corpectomy. ISNCSCI exam on initial presentation showed C2 ASIA D. The patient successfully completed a course of inpatient rehabilitation. He was then followed over the course of 6 months, and repeat ISNCSCI exams along with DTI studies were performed. Correlations were noted between the various DTI indices and overall neuro-recovery. ISNCSCI exam at 6 months showed C7 ASIA D. Discussions: Clinically, the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) is the best classification and prognostic tool for patients with SCI. However, this measure is subjective and can be insensitive to incremental neurophysiological and functional changes during recovery. DTI is a powerful tool that can measure the diffusion of water molecules within nerve fibers and fiber tracts, and can potentially be used to study pathology that are undetectable with conventional imaging and electrodiagnostic techniques. In our case, we examined 4 different DTI indices (axial diffusivity, fractional anisotropy, mean diffusivity, and radial diffusivity) both above and below the level of injury and found that not only do the indices change during the 6-month period, but there is also a significant correlation between the DTI indices and the patient's sensory and motor function recovery. Conclusions: Our case demonstrates that DTI can not only serve as a tool to evaluate structural changes after SCI, but it can also potentially be used to predict motor and sensory recovery over time. Further studies are currently on going.

 Disability and quality of life under and over 60 years, 12 months after a traffic accident: Cohort study



Luz H. Lugo-Agudelo, Julian A. Silva-Alzate, Alvaro E. Pinto-García, Héctor I. Gracía-García, Fabio A. Salinas, Blanca C. Cano-Restrepo, Gilma N. Hernández-Herrera, Claudia Y. Vera-Giraldo

Objectives: To compare 12 months later functioning, quality of life (CV), pain, anxiety and depression among adults under and over 60 years who had moderate and severe injuries in traffic accidents (TA) in Medellín and its metropolitan area. Design: Secondary analysis of two prospective cohorts 2009-2010 (18 to 60 years) and 2015-2016 (over 60 years). They were evaluated at baseline and 12 months with functioning (WHO-DASII), QoL (SF-36), pain (EAV), anxiety (STAI-R and STAI-E) and depression (PHQ-9). The differences between groups were compared 12 months later by means of the t-Student test. A multiple linear regression analysis was done to determine factors related to disability and QoL. Results: 837 patients were included, (590 of 18-60 years and 247 > 60 years), 84.8% completed the follow-up. The motorcycle was the main vehicle involved (86.1% vs. 60.7%.). Personal Care scores were significantly better in >60 years but greater commitment in the domestic and outside activities, and global work scale. The QoL twelve months later was significantly better in < 60 years in the Emotional Role, Physical Role, and Physical functioning. Pain in both groups was mild 12 months later. Anxiety and depression with greater commitment in > 60 years. In the multivariate analysis age > 60, pain, severity of trauma, anxiety, depression and being a woman were associated with worse outcomes. Conclusions: The global disability score, the ER, PR, PF at twelve months was more compromised at > 60 years.It is necessary to develop preventive AT policies of greater impact to reduce road accidents that affect the population, mainly motorcycle users and the vulnerable population of roads such as pedestrians, bicycle users and motorcycle or motorcycle occupants.

 Does marijuana smoking increase the risk of atrial fibrillation and stroke?



Yusik Cho, Mery Elashvili, Lawrence G. Chang

Case Diagnosis: Left temporal stroke. Case Description: A 45 year-old female daily marijuana smoker (has a medical card) presented to the emergency room with delirium and bizarre and aggressive behavior. She had a history of atrial fibrillation (AF) status post ablation two years ago, substance abuse (quit alcohol three years ago), and depression. She was found to have a left temporal infarct confirmed on MRI of brain and developed rapid AF treated with cardizem and heparin. MRA did not show any arterial stenosis. Carotid doppler and echocardiogram were normal. Urine toxicology was positive for marijuana. While she was treated at our acute rehabilitation facility, her tachycardia was well controlled with cardizem. Patient made marked progress in all language domains and was discharged home with supervision. Discussions: To date, marijuana is the most widely used illicit drug and has been shown to be a precipitating factor for AF especially in young patients without any risk factor. A range of arrhythmias occur from acutely smoking marijuana: sinus tachycardia to ectopic atrial or ventricular rhythms to atrial or ventricular fibrillations. Smoking marijuana is associated with adrenergic stimulation in atrial coronary or microvascular flow and may facilitate AF development due to increased pulmonary vein ectopy, enhanced atrial electrical remodeling, and increased dispersion of refractoriness. Marijuana use also increases risk of myocardial infarction and ischemic strokes directly through reversible cerebrovascular spasm. Conclusions: Acute marijuana smoking can increase risk of AF to stroke development. At this time, the purity or chronicity of marijuana smoking as risk factors for AF to stroke is inconclusive. Marijuana smokers, however, with cryptogenic tachycardia should be evaluated by a cardiologist. The significance of this study is to educate and advise for cessation of smoking marijuana to prevent any future occurrences of life threatening cardiac disturbances and possible subsequent strokes, especially among the younger population.

 Does olfactory functioning relate to outcome from inpatient rehabilitation in stroke patients?



Lakshmi A. Nerusu, Amanda Reyes, Rizwan Alvi, Johnathan Ho, P. Tyler Roskos

Case Diagnosis: Case reports suggest stroke patients are at risk for altered olfaction, which affects nutrition, dietary intake, and quality of life. However, relationships between olfaction and rehabilitation outcomes are poorly understood. This study aimed to examine the incidence of olfactory dysfunction in individuals with stroke compared to a control group. We also explored relationships between olfaction and rehabilitation outcome measures. We hypothesized that impaired olfaction may be an indicator of more severe stroke and poorer outcome from inpatient rehabilitation. Case Description: This study included participants admitted to the inpatient rehabilitation service with a diagnosis of stroke (n=20) or musculoskeletal injury/debility (n=20). The following inclusion criteria were used: age 18 or older; cognitively intact based on orientation assessment; and ability to provide informed consent. Patients were excluded if they had prior stroke or neurological disease affecting olfaction; had history of anosmia; or had smoked tobacco products within the past month. Participants were administered an olfactory test rating their sense of smell as normal, decreased, or absent. Functional independence measure and NIH stroke scale scores were used as outcome variables. Discussions: Results showed no difference between groups on demographic variables. Incidence of olfactory dysfunction was higher in the stroke group (89%) compared to controls (65%). The groups did not show significant differences on admission or discharge FIM scores or the olfactory test. We did not see significant differences on outcome measures as a function of olfactory ratings. Correlations between olfactory ratings and outcome measures were low-to-moderate, but non-significant. Conclusions: Although incidence of abnormal olfaction was higher in participants with stroke, results demonstrated no direct relationship between olfactory ratings, severity of stroke, and rehabilitation outcome. Future research may utilize a more sensitive tool to evaluate olfaction to better understand how impaired olfaction may impact functioning in a rehabilitation setting.

 Does the pulmonary function affect the dietary levels of subacute stroke patients?



Yoon Ghil Park, Myung Eun Yoo, Hyo Jung Lee

Objectives: Previous studies have reported that there is a relationship between the pulmonary function and deglutition. However, there is a lack of study identifying specific correlations between pulmonary function and dysphagia in patients with stroke. To efficiently treat and prevent dysphagia, this study aimed to clarify the correlation between the pulmonary function tests and parameters of videofluoroscopy. Design: 36 stroke in-patients with dysphagia were retrospectively analyzed. We evaluated pulmonary function tests in sitting position, including vital capacity (VC) measured by spirometry and peak cough flow (PCF) measured by a cough flow meter. For assessment of dysphagia, we used videofluoroscopic swallowing study (VFSS). At admission and discharge, the patients were divided into 3 groups by dietary levels (G1, tube feeding; G2, dysphagia diet; G3, general diet). Results: The optimal cutoff values of VC and PCF for presence of aspiration were analyzed (Figure 1. cutoff point of VC = 47.8 %, cutoff point of PCF = 155 mL/min).The correlation between VC or PCF and parameters of VFSS was analyzed by the chi-square test. It showed only one element of VFSS with liquid, 'Food propelling posteriorly', was significant difference of presence of aspiration at discharge by using the cutoff value of VC (p=0.02). The dietary levels at admission had significant positive correlation coefficients with VC (r=0.57, P=0.0003) and PCF (r=0.35, P=0.03). The one-way ANOVA of VC among groups divided by three diet levels at admission showed statistically significant difference (p=0.001; Table 1). The independent t-test of VC between G1 and G3 dietary groups at discharge showed a significant difference (p=0.02; Table 2). Conclusions: Based on our research, pulmonary function can affect the dietary levels. The pulmonary function in dysphagia patients with stroke should be clinically emphasized. In addition, large scale study is needed to correlate pulmonary function with swallowing difficulty.

 Drug reaction with eosinophilia and systemic symptoms, a serious reaction from levetiracetam seizure prophylaxis in traumatic brain injury



Jennifer Horng, Emily Ryan-Michailidis, Malaka Badri, Shailaja Kalva

Case Diagnosis: Drug reaction with eosinophilia and systemic symptoms (DRESS). Case Description: 41 year old man with traumatic brain injury (TBI) with subdural hematoma after a motorcycle accident was placed on levetiracetam for seizure prophylaxis. Two months afterward, patient presented with a pruritic maculopapular rash on the face, trunk and extremities, mucosal lip erosions, fever, transaminitis and eosinophilia. Biopsy was consistent with drug reaction with eosinophilia and systemic symptoms (DRESS) and patient was treated in the burn unit with solumedrol, topical triamcinolone and emollients. He received erythromycin and tears for eye involvement, nasogastric tube for nutrition, and foley for urethral meatal involvement. He continued to have cardiac and thyroid monitoring for organ involvement. Patient initially presented to acute rehab with impaired cognition, problem solving and insight. Eventually the patient met goals for cognition using compensatory strategies and acknowledging functional implications of deficits. Discussions: After severe TBI, many patients receive an antiepileptic to prevent early posttraumatic seizure. More recently, levetiracetam has been used because of an improved side effect profile compared with phenytoin. This patient demonstrates that serious complications, such as DRESS syndrome may occur with levetiracetam within 8 weeks of initiation. Conclusions: Physiatrists should be aware of DRESS syndrome as a severe drug induced reaction of levetiracetam and be mindful in using antiepileptics to prevent early posttraumatic seizures.

 Drug use and disability in trauma events captured by the national trauma data bank, 2016



Katherine D. Goss, Margaret K. Formica, Margaret A. Turk

Objectives: People with disability and those who misuse/abuse drugs both demonstrate increased emergency department (ED) utilization. However, little research explores the potential relationship between these variables. This study assessed drug use across disability status in events captured by the National Trauma Data Bank (NTDB), the largest aggregate of United States trauma data. Design: Trauma events among adults captured by the NTDB in 2016 were analyzed. Data items included: patient information, drug use (pre-existing drug use disorder (DUD) and current illegal/prescription drug use), and disability comparison group status (DCG-1: pre-existing functionally dependent health status; DCG-2: a pre-existing qualifying disability condition). Descriptive statistics and adjusted logistic regression Results are reported. Results: A total of 782,241 trauma events among adults were included for analysis. Of all included events, 4.7% (N=49,459) involved patients with pre-existing DUD, 15.8% tested positive for current drug use (N=120,029), 5% were in DCG-1 (N=39,011), and 24.7% were in DCG-2 (N=193,513). Patients in DCG-1 were 23.5% less likely to have a pre-existing DUD (AOR= 0.765; 95% CI: 0.71, 0.83; p< .001), and were also less likely to have current drug usage (AOR=0.568; 95% CI: 0.54, 0.60; p< 0.001). Contrastingly, patients in DCG-2 were 17% more likely to have a pre-existing DUD (AOR=1.171; 95% CI: 1.15, 1.20; p< 0.001) and also more likely to have current drug usage (AOR=1.285; 95% CI: 1.26, 1.31; p< .001). Conclusions: While individuals in DCG-1 were less likely to be diagnosed with DUD or have current drug use in recorded trauma events, individuals in DCG-2 were more likely to have DUD and current drug use. These findings indicate a relationship between disability, drug use, and trauma which may be complex and varied, and warrants further analysis. While registry data has inherent limitations, this work provides a novel assessment of drug use and disability using a large and diverse trauma population.

 Drug-induced sweet's syndrome initially presenting as Stevens-Johnson syndrome in the acute rehabilitation setting



Eugene Palatulan, Nasim Chowdhury

Case Diagnosis: Drug-induced Sweet's syndrome. Case Description: A 28-year-old female with Asthma underwent sub-occipital craniectomy and telovelar approach for fenestration and decompression of dorsal medullary cyst, Chiari 1 malformation and syringobulbia. She was admitted to acute inpatient rehabilitation (AIR) with mobility impairments including a Trendelenburg gait, decreased foot clearance and excessive lateral trunk sway. One week into AIR course, we noted rashes in the posterior neck, which progressed into diffuse urticaria in the face, abdomen, and extremities. Concomitant dyspnea and progressive painful rash became a significant barrier to therapy. We suspected drug-induced delayed-hypersensitivity potentially from Celecoxib, Tizanidine and Cyclobenzaprine, new medications started postoperatively. Benadryl, hydrocortisone cream, and on-standby epinephrine were provided. Dermatology performed a punch biopsy and recommended Etanercept for a suspected Stevens-Johnson syndrome. Final pathology revealed ichythyosis vulgaris suggestive of drug-induced Sweet's syndrome. Cessation of offending agents and switch to triamcinolone-camphor cream controlled the hypersensitivity. Patient completed AIR course and discharged at modified independence. Discussions: Drug-induced Sweet's syndrome is a rare illness characterized by neutrophilic dermatosis characterized by appearance of edematous and erythematous papules, plaques, or nodules two weeks after starting new medication. In a type-IV hypersensitivity reaction, it is vitally important to review medications naïve to patient. Cessation of offending agents and initiation of corticosteroid agent is key. Of the three offending agents suspected, Celecoxib is known to cause drug-induced Sweet's syndrome. Conclusions: Drug-induced Sweet's syndrome is a rare illness that may initially present as Stevens-Johnson syndrome and can be caused by various drugs such as Celecoxib which was the presumptive etiology in this case. Early detection, prompt withdrawal of offending agent and corticosteroid treatment is vital as pain/discomfort poses a barrier to a patient's acute rehabilitation course.

 DTRAX cage movement with subsequent hemiplegia and allodynia: A case report



Anthony L. Cooper, Raymund Millan

Case Diagnosis: Allodynia. Case Description: A 77 year old female presented to acute hospital 5 days after C4-C7 arthrodesis and fusion for cervical spondylosis and multiple herniated discs. After surgery she experienced progressive left arm pain and eventually hemiplegia. CT revealed facet fixation cage was anterior and medial in position encroaching on the left left C4-5 neural foramen, compromising the left C5 nerve root. She underwent hemi-laminotomy, foraminotomy, and removal of displaced DTRAX cage. After surgery patient had residual hemiparesis and new onset allodynia. On physical exam light touch of her arm provoked 10/10 pain. Patient's pregabalin 150mg twice daily was increased to three times daily and diclofenac gel was added. Massage therapy, fluidotherapy, and anodyne therapy were utilized one hour per day. As patient's hypersensitivity to pain decreased, she began to have gains in upper extremity strength. The patient subsequently experienced resolution of allodynia and had 4/5 strength throughout the affected extremity at discharge. Discussions: Allodynia is often associated with cervical radiculopathic pain. Since the mechanisms underlying cervical radiculopathic pain-associated allodynia are unclear, adequate treatment remains elusive. A multimodal approach incorporating a neuropathic pain medication such as pregabalin, anti-inflammatory medication such as diclofenac gel along with desensitization modalities like fluidotherapy and anyodyne therapy may serve as a good treatment regimen. As a result of decreased pain, functional gains can be made during therapy. Conclusions: A multimodal approach to allodynia treatment including medications and intense desensitization therapy may be helpful in cervical radiculopathic pain-associated allodynia.

 Dual-task elicits decreased balance performance in adolescents following sport-related concussion



Abdulaziz A. Alkathiry, Anthony Kontos, Joseph Furman, Susan Whitney, Patrick Sparto, Saud F. Alsubaie

Objectives: Sports activities require high performance on cognitive tasks and balance function simultaneously. In individuals with concussion, postural instability and imbalance are evident in the first 72 hours post-injury and usually return to normal within a week of injury. However, some studies have reported persistent, sub-clinical balance deficits months after injury when patients were tested using dual-task assessments. The primary goal was to assess changes in dual-task balance performance over time in adolescents with sport-related concussion (SRC). Design: Twenty-three adolescents (female (n= 9)) aged 12 to 19 years with a recent, currently symptomatic SRC were assessed within 10 days, 4-17 days after the first visit, and at clearance. Body sway was measured during the single-task conditions while participants stood quietly on firm and compliant surfaces. For the dual-task condition, participants concurrently performed either a simple spatial-discrimination or complex perceptual-inhibition visual feedback task. Body sway was estimated using the root mean square (RMS) of the center of pressure (COP) recorded with a portable force plate. A linear-mixed-model was performed to investigate the effects of visit, surface, and task on RMS COP in the anterio-posterior (AP) and medio-lateral (ML) directions. Results: A significant increase in AP sway was observed in the dual-task condition (p < 0.001), and the perceptual-inhibition-task resulted in more sway than the spatial-discrimination-task in both directions (p < 0.006). There was a significant increase in sway at the second compared with the first visit (p = 0.036 in AP, p = 0.028 in ML). Conclusions: The results demonstrated that a cognitive visual dual task elicits balance perturbations in adolescents following SRC. The increase in sway during recovery from the SRC was unexpected and warrants further examination.

 Dysphagia after anterior cervical discectomy and fusion: A case report



Mohammad Islam, Kasandra Erazo

Case Diagnosis: Dysphagia after Anterior Cervical Discectomy and Fusion. Case Description: 73 old was admitted due to a mechanical fall down 7-8 flights of stairs. she was found to have significant damage to her spinal cord secondary to long standing cervical stenosis and arthritis of C3-C5 vertebrate. Neurosurgery performed a C4 corpectomy with cage placement and fusion. She was transferred to acute rehabilitation at Metropolitan hospital for expected benefit from therapies. Speech and swallow evaluation revealed aspiration of fluids and particulate matter on modified barium swallow. The patient was made NPO and further aspiration precautions were in effect. After lengthy therapy by speech and swallow team, patient was to resume feedings by mouth. Discussions: The anterior approach is thought to be the best method to relieve pain and recover the function of patients (4). However a variety of complications have been reported, dysphagia is the most common complication after this procedure (4). Dysphagia rates can reach as high as 83% most of which are self-limited and typically resolve in 3 months (4). The incidence of prolonged dysphagia can range between 3% and 35% of cases and can cause significant health and nutritional risks for patients. Conclusions: Dysphagia is a common complication after anterior cervical decompression and fusion that can cause a decreased quality of life for a patient. To prevent such an event from occurring there are certain intraoperative and postoperative techniques after ACSS. 1. Modifying diet and controlling the size of the bolus given 2. Heightening sensory input prior to or during swallowing, 3. Applying voluntary control to the swallow (breath holding, effortful swallow); 4. Protecting the airway with postural adjustments to reduce risks of aspiration ( ie chin. Tuck, head tilt, head rotation, head lift); and 5. Performing exercises to strengthen weak facial muscles to improve coordination.

 Dysphagia is related to bone mass and fat free mass in adults with cerebral palsy



Se Hee Jung

Objectives: One of common disability of cerebral palsy (CP) is dysphagia which frequently Results in long-standing inadequate dietary intake. Inadequate dietary intake can affect body weight, bone mass, bone mineral density, muscle mass, and fat mass in general population. However, there is no study to investigate the relationship between the severity of dysphagia and the body composition in adults with CP. We aimed to determine whether the severity of dysphagia is associated with the body composition of adults with CP. Design: This is a cross-sectional study in university hospitals and communities for persons with disabilities in South Korea. A total of 99 adults with CP (58 men, mean age of 41.8±9.0 years) were included. The severity of dysphagia was assessed as no, mild, moderate, and severe. The body composition was analyzed using dual-energy x-ray absorptiometry. The correlation between the dysphagia severity and body weight, waist circumference, body mass index, percent body fat, trunk percent fat, android-to-gynoid fat ratio, bone mass, bone mineral density, T-score, Z-score, fat mass, and fat free mass was investigated using the Spearman correlation analysis. Results: The dysphagia severity was not related to age or the Gross Motor Function Classification System level. The severity of dysphagia was related to 1) bone mass (trunk and legs), 2) fat free mass (total and legs), 3) lean mass (total and legs), 4) bone mineral density (lumbar spine, femur neck and total femur), and 5) T-score (lumbar spine, femur neck and total femur). However, the severity of dysphagia was not related to body weight, waist circumference, body mass index, fat mass, percent body fat, trunk percent fat, and android-to-gynoid fat ratio. Conclusions: Dysphagia in adults with CP is related to bone mass, fat free mass and bone mineral density. Dysphagia does not show relationship with well-known parameters of obesity or underweight in adults with CP.

 Early diagnosis of iatrogenic inferior trunk plexopathy



Andrew Lai, Kyaw Lin, Marc Eivind Evensen

Case Diagnosis: 69-year-old male presents with left forearm and hand weakness, tingling, and numbness shortly after coronary artery bypass grafting. Case Description: 69-year-old right handed male presents to our electrodiagnostic clinic with left forearm and hand weakness, tingling, and numbness, after a coronary artery bypass grafting 6 weeks prior. Symptoms began the very next day after the surgery, and has been gradually worsening. There is also pain in the left 4th and 5th digit and medial palm with numbness in the medial-posterior forearm that wakes him up at night. No past medical history of arm or wrist problems prior to the surgery. Physical examination revealed mild atrophy noted in left first dorsal interosseous, flexor carpi ulnaris, thenar and hypothenar eminences compared to contralateral side. Strength intact in bilateral upper extremities except for 3/5 left thumb abduction and 4/5 left finger flexion. Sensation intact bilateral upper extremities to light touch, except decreased sensation to left medial forearm, medial hand, 4th and 5th fingers. Discussions: Electrodiagnostic evaluation revealed left medial motor axonal neuropathy, left ulnar sensorimotor neuropathy, left medial antebrachial cutaneous neuropathy, and acute denervation at the left extensor digitorum communis, left abductor pollicis brevis, and left first dorsal interosseous muscles. Our final impression was a left inferior trunk plexopathy which correlates with his physical examination findings. Conclusions: Brachial plexus injury is an uncommon complication of coronary artery bypass grafting (CABG). Mechanism of injury includes sternal retraction which results in compression of the brachial plexus. Often the condition is transient, however may be permanent and create life-long disability for patients. Physiatrists and cardiothoracic surgeons should always have plexopathy in their differential diagnosis after CABG. This case illustrates how a comprehensive physical examination of a post-op CABG patient and expedited electrodiagnostic study can lead to early identification and treatment of iatrogenic plexopathy.

 Early mobilization in intensive care for severe acquired brain injury patients: Current practices in France



François Feuvrier, Olivier Barber, Claire Jourdan, Karolina Griffiths, Margrit Ascher, Frédérique Pavillard, Kevin Chalard, Paul Bory, Pierre-François Perrigault, Isabelle Laffont

Objectives: Early mobilisation (EM) in intensive care units (ICU) is safe, feasible and beneficial for patients. Little is known about the current practices of EM for patients with acquired brain injury (ABI) in ICU in France. The aim of the study was to evaluate the current mobilisation practices and its barriers in ICUs for patients with ABI. Design: A cross sectional survey on EM practices was conducted online with two questionnaires in July 2017, August 2018 and a follow up in July-August 2019. Questionnaires were distributed to physicians and physiotherapists working in 130 ICUs across France. Results: The survey was completed by 48 physiotherapists (PTs) and 54 physicians in 39 different wards. Responses from one physician and one physiotherapist for each ward were analysed. The mean number of inpatients/wards were 21 (range 9-50), with a mean length of stay of 11 days (5-22). PRM physicians were involved in care according to 82% of ICU physicians responses. EM was most frequently started within 24-48 hours after admission. Most physiotherapists (87%) stated that 75%-100% of patients received positioning and passive range of motion therapy. Standing exercises were less frequently performed, reported by 29% of PT and concerning less than 25% of the patients. Walking therapy was reported by 46% of PT (< 25% of patients) and electrostimulation was mostly never proposed (82% of PTs). The most common medical barriers to EM were high intracranial pressure and hemodynamic instability. Pre-established protocol criteria to initiate EM was poorly reported. Conclusions: Early mobilisation in various forms is being practiced in the ICUs of France. Main Results demonstrate a good willingness and enthusiasm amongst physicians and physiotherapists, but a lack of medical support and not enough personnel to attain EM objectives.

 Early mobilization and rehabilitation after spinal cord injury-critical care perspective



Be Kim Leong

Case Diagnosis: We share a case of rehabilitation for a patient who sustained spinal cord injury which resulted in tetraplegia, neurogenic shock, autonomic dysfunctions and other medical complications. Case Description: He received acute resuscitation in emergency department and followed by spinal stabilization surgery with post-operative care at intensive care unit (ICU). In ICU, this patient was managed for persistent hypotension, ventilator dependent issue, optimal analgesic control, venous thromboembolism prophylaxis and nosocomial infection. Some of the rehabilitation medical issues in this patient include tracheostomy care, hyponatraemia, dysphagia, neurogenic bladder, neurogenic bowel and skin pressure injury. He had received active functional training to improve sitting tolerance, transfer technique, respiratory muscles strength and swallowing efforts. Patient achieved safe oral intake, decannulation of tracheostomy tube, good sitting tolerance up to 2 hours with 1 person assisted transfer technique prior to discharge from inpatient care. Psychosocial interventions were also done to ensure safe integration back to community. Discussions: Scientific evidences have demonstrated benefits of early mobilization and rehabilitation in critical care patients. However this process is more complicated in spinal cord injury (SCI) patients due to multiple systems dysfunction. Early mobilization may be harmful, result in oxygen desaturation and hypotension in tetraplegic spinal cord injury patients. Therefore, the proper techniques should be emphasized to improve safety and feasibility of early mobilization in spinal cord injury patients. We had established functional training for this patient to allow him on wheelchair ambulation. Career education, equipment prescription and home assessment were also completed to ensure suitable environment after discharge from hospital. Conclusions: Assessment, medical care, functional training and psychosocial intervention are the core components of spinal rehabilitation management. Multidisciplinary approach in early mobilization and rehabilitation following spinal cord injury will improve the functional status and outcomes of patients.

 Early surgery and rehabilitation of tuberculosis spondylitis with spinal cord injury, promote better functional outcomes? A case report from Indonesia



Nita T. Reyne, Ahmad Ramdan, Ellyana Sungkar, Farida Arisanti

Case Diagnosis: Extrapulmonary tuberculosis (EPTB) is associated with high morbidity and mortality rates. Skeletal tuberculosis accounts for 10–35% of EPTB, with tuberculosis spondylitis (TS) represent 50% of the cases. Magnetic resonance imaging (MRI) is an excellent diagnostic procedure for TS. Case Description: A 46-years-old homemaker with four children was referred to the Rehabilitation Department in the acute setting on her fourth-day admission with T8 Spinal Cord Injury AIS C due to TS with lung tuberculosis. She was presented with paraparesis, bedridden, bowel bladder problems, adjustment disorder, and fully dependent ADL. Thoracic spine MRI showed compression fracture forming gibbous deformity and suppressing the posterior fragments; paravertebral abscess extended into the epidural space causing spinal canal stenosis with signs of myelopathy. She underwent internal stabilization after two weeks receiving anti-tuberculosis therapy or five weeks since her first complaint. Her immediate family became her complete facilitator and her toddler child was the main motivator for her recovery. She showed very good progress on the medical, psychological, and functional outcomes within two weeks after surgery. She could walk without an assistive device three months later and became AIS E in six months. Discussions: TS management in developing countries often encounters some problems which limit the provision of adequate management. The economic issue, bureaucratic health services, systems and policies in Indonesia can delay surgery for months. Theoretically, delayed surgery affects rehabilitation and functional outcomes. Even worse, while waiting for the surgery, complications of TS-related-SCI may arise, which make surgery is contraindicated. We tried to perform early surgery and rehabilitation for a better medical and functional outcome, and it was proven effective. Conclusions: The early surgery and rehabilitation promote better functional outcome and affect the quality of life. They are worth fighting for although more supporting evidences are required. Improvement in health services, systems and policies are expected in the future.

 EEG alpha characteristics in eyes-closed and eyes-open resting-states in adult males with traumatic spinal cord injury



Jinhui Peng, Lijuan Ao, Wenli Wang, Xia He

Case Diagnosis: Alpha brainwaves change with external stimuli and different physical conditions. To study alpha changes after traumatic spinal cord injury, power spectral density, amplitude and frequencies of peak amplitudes representing activities of cortical cells, information processing efficiency of central nerve system and neural activation levels, respectively, were investigated in both eyes-closed and eyes-open resting-states. Case Description: 19 male adults with paraplegia due to traumatic spinal cord injury and 15 healthy controls were recruited. Both eyes-closed and eyes-open EEG data of subjects in sitting position were collected for 3 minutes with wireless dry electrode cap and analyzed by EEGLAB software. Power spectral density, amplitude as well as frequencies of peak amplitudes in eyes-closed and eyes-open states were calculated and compared with independent t test and paired sample t test. Discussions: Power spectral density, amplitude and frequencies of peak amplitudes in alpha brainwaves were higher in male adults with paraplegia due to traumatic spinal cord injury. Conclusions: Activities of cortical cells, information processing efficiency of central nerve system and neural activation levels were enhanced in male patients with paraplegia due to traumatic spinal cord injury. This study reveals that compensatory functions of central nerve system occur after spinal cord injury, providing new ideas for objective assessment and rehabilitation in patients with spinal cord injury.

 Effect of exercise and niacinamide ribose on the aging in mice



Zhiguan Huang, Qing Mei Wang, Xun Luo

Objectives: This study aimed to investigate the effect of exercise and nicotinamide riboside (NR) on cognition and muscle strength of the senescence-accelerated prone (SAMP8) mice during aging. Design: Male SAMR1 mice were used as healthy group (A), while SAMP8 used as abnormally aging group and randomly divided into control group (B), exercise ( C), NR supplement ( D), exercise + NR (E). Each group had 1tenmice. At age of 7 month, exercise program using rotary training instrument were as following: in the first week, rotary speed was 12 RPM for 10 min and ran for 5 times per week. Speed gradually increased to 22 RPM for 30 min/time, 5 times/week for 10 weeks. At 7th week, NR was administrated by i.p at the dose of 200mg/kg/day after 2 hours of exercise. Cognition was measured with Morris water maze experiment. Body weight and grip force were measured every week. Max contraction force of gastrocnemius was measured under anesthesia with isoflurane. Results: At the age of 7 months, the baseline body weight of SAMP8 was significantly lower than that of the SAMR1. The incubation period of group E was significantly lower than those of B, C, and D, and the number of platform crossing of C, D and E was higher than that of B. The body weight of mice in groups of exercise, NR and combination treatment, body weight, muscle force and level of fatigue were significantly better than that of control group. Combination treatment group has apparent improved efficacy, showing Max and average swimming speed faster than those of B , while other indexes better than others groups (p< 0.05). Conclusions: Exercise and NR intervention in mice may have the potential to increase the weight and the quality of the skeletal muscle, improve muscle strength, memory and learning, may have anti-fatigue effect.

 Effect of one session of pendular articular decompression on chest expansion



Christophe Bensoussan, Antoine Champclou, Cedric Corneil, Abderrahmane Rahmani

Objectives: Aging induces a regression of the respiratory system, in particular by impacting chest expansion which leads to many complications in terms of the person's well-being. Our study was designed to show the effectiveness of pendular articular decompression (PDA Satisform) on chest expansion in a mixed population, ages 18 to 62. Design: 42 participants were divided into four groups (three DPA groups and a control group) and evaluated using two tests (ribbon-meter chest expansion and ground Finger-Distance-Test) before and at the end of the session. A third evaluation was conducted two weeks after the session for eight participants. The three DPA groups, of different age groups (n = 34), performed a 10 minutes DPA Satisform session, while the control group (n = 8) performed a 10 minutes lower limb elevation. Results: After the DPA session, a statistically significant improvement in all three parameters (lower thoracic level, upper thoracic level and ground finger distance test) was observed in all three groups with DPA. These improvements were maintained during the two weeks following the DPA procedure. Concerned the control group, no significant improvement has been observed between the pre-test and post-test phases. Conclusions: In conclusion, this study shows the effectiveness of one DPA Satisform session on the chest expansion of healthy people. We observed a significant effect laying for two weeks after the protocol. DPA therefore appears to be a valid approach against the harmful effects of aging on the respiratory system. Now it is important to continue this work on people with respiratory diseases with severe repercussions on thoracic expansion.

 Effect of stroke recurrence on the predictive value of serum BDNF level for motor recovery



Xiao Xi, Qianfeng Li, Xun Luo, Yuling Zhang, Xi Zeng, Liang Zhou, Qing Mei Wang

Objectives: Brain-derived neurotrophic factor (BDNF) plays an important role in neuroplasticity after stroke. Our pervious study suggests that serum BDNF levels on admission were not clinically correlated with motor function at discharge. This study was to investigate if stroke recurrence may affect the correlation between the serum BDNF and the motor outcome. Design: Three hundred and fifty eight post-acute stroke patients were enrolled in this retrospective study. Serum BDNF levels were measured on admission to the rehabilitation hospital, and motor outcome was measured with Functional independence measure (FIM) on admission and discharge. Demographic and clinical characteristics including stroke site, stroke size, interval between blood sample and onset of stroke, medications, comorbidities were collected from electrical medical records. Pearson correlation was used to evaluate the correlation between serum BDNF level and FIM motor score at discharge. Results: In patients with one time prior stroke the serum BDNF level was moderately related with FIM motor score at discharge (r=0.427, P=0.001). In patients with first ever-stroke and more than one time prior stroke there were no association between serum BDNF level and FIM motor score at discharge, (r=0.178, P=0.003) and (r=-0.282, p=0.400) respectively. There was no difference between demographic and baseline clinical characteristics between the three groups. Further subgroup analysis revealed that in the patients with one time prior stroke and CAD but without AF, serum BDNF had strong correlation with FIM motor score at discharge (r=0.738, P= 0.002). Conclusions: Stroke recurrence and CAD may influence the predictive value of serum BDNF on motor outcome. The result provides insight into biological mechanism of stroke recovery and potential therapeutic target in responsive subgroup.

 Effectiveness and complications of sodium oxybate administration for treatment of posthypoxic myoclonus: A case report



Jennifer Yu, Emily Ryan-Michailidis, Forrest A. Brooks

Case Diagnosis: A 68-year-old male presented with recent organizing pneumonia resulting in hypoxic arrest and tracheostomy dependence with subsequent severe post-hypoxic myoclonus. After optimization of his multiple medical issues, including tracheostomy decannulation, the patient remained with fluctuations in cognition and arousal. Additionally, myoclonus severely limited functional abilities. He was trialed on multiple antiepileptics for myoclonus. All medications resulted in modest alleviation of his symptoms, but increased sedation and worsened activity tolerance. Case Description: The patient was admitted to acute inpatient neurorehabilitation for treatment of his functional deficits. He initially required moderate-to-maximum assistance for mobility due to myoclonic activity in all limbs. With intensive therapies, he progressed to minimum-to-moderate assistance level. Balance, endurance, and fine motor movements remained limited by diffuse myoclonic activity. Treatment with sodium oxybate was then initiated at 0.75g daily. He demonstrated global reduction in myoclonus for several hours after administration with improved arousal and verbal output; ambulation progressed to contact guard level. Improved motor control led to independent feeding and writing tasks, which was never achieved prior. The trial was terminated after four doses as the patient was consistently noted to have confusion, irritability, emesis, and somnolence several hours after administration. Downtitration to 0.5g did not alleviate side effects. Discussions: Sodium oxybate is a salt of gamma-hydroxybutyrate (GHB). It has been previously reported to improve refractory myoclonus, although side effects of the medication are rarely reported. Here we present a case of poor patient tolerance to sodium oxybate despite modest treatment dose. Other authors have described dosage up to 9g per day without increased somnolence. Side effects of the medication were likely amplified by patient's underlying impaired arousal from anoxic encephalopathy and history of upper airway obstruction. Conclusions: This case highlights that although sodium oxybate can reduce myoclonus, its use should be considered cautiously in patients with baseline impairments in arousal.

 Effectiveness of a community based rehabilitation center dealing with physical disability in Quetta, Pakistan



Hameed ul Mehdi, Muhammad Raza

Objectives: The objective of this project is to work in rehabilitation, physical deformities and provide advocacy in health sector. Design: Humanitarian Organization Providing Effective Services, HOPES Quetta, Pakistan started its operation in 1996 with medical professionals well qualified in physiotherapy, rehabilitation and training sectors. Besides its rehabilitation, referral and health services, it successfully integrated an intensive collaboration among line organizations for exchange of knowledge through meetings, seminars, by e-mails locally, nationally and internationally. It trains key youth medical professionals regarding all forms of physical deformities, health, hygiene, HIV/AIDs, and rehabilitation. It conducts workshops for females on health issues such pre-post pregnancy deformity, child health deformities and effective prevention. HOPES provide treatment by physiotherapy techniques. It provides information to women health, child health in meeting with medical professionals around the province. Results: HOPES have been very successful in its rehab services, health, social, charity and awareness campaigns. The project has covered entire province in rehabilitation of all physical deformities. It received excellent empathy from the society and from the Government. A strong accountability, capacity building, commitment, contribution, sharing of the knowledge and experience is the main essence and success of our programs. Conclusions: We successfully labored in all kinds of physical disabilities, its rehabilitation. Our programs are effective increasing level of understanding about physical deformities, concept of physiotherapy, child disability, its prevention, pregnancy deformities, health awareness among the general public at large.

 Effects of an exercise program on cardiac function and quality of life of patients with stroke



Josiela C. S. Rodrigues, Gustavo J. Luvizutto, Tais R. Silva, Robson A. Prudente, Rafael D. M. Costa, Fernanda C. Winckler, Juli T. Souza, Estefânia A. T. Franco, Caroline F. S. M. P. Silveira, Tainá F. C. Valadão, Daniele A. A. Rossi, Leticia C. O. Antunes, Gabriel P. Pinheiro Modolo, Luis C. Martin, Rodrigo Bazan, Silmeia G. Z. Bazan

Objectives: To evaluate the effect of an exercise program on the morphological and functional echocardiographic variables, evaluate the quality of life of patients after ischemic stroke. Design: A longitudinal, randomized clinical trial consisting of patients with clinically stable chronic ischemic stroke is being performed. Patients are being randomized into two groups: Control Group (CG): physical therapy intervention according to the National Institute for Health and Care Excellence protocol; and Intervention Group (IG): cardiovascular rehabilitation on a treadmill programmed at speed and inclination compatible with individual capacity for 45 minutes, three times a week for 16 weeks. Patients in both groups are undergoing transthoracic echocardiography and quality of life assessment (EuroQol) at the beginning and end of the protocol. Comparisons between groups were performed by Student's t-test, and between the moments, before and after intervention, were made by paired t-test. Significance level: p< 0.05. To date, the participations in the study of 17 patients (CG=7 and IG=10) were completed and analyzed and the participation of other patients is ongoing. Results: There was a significant improvement in morphofunctional echocardiographic variables: left ventricular systolic diameter (LVSD, p=0.02), left ventricular mass (LVM, p< 0.01), LVM index (LVMI, p< 0.01), left atrium diameter (LA, p< 0.01); ejection fraction (EF, p< 0.01), systolic excursion velocity of the mitral annulus to the tissue Doppler (Wave S, p=0.04); left atrial volume index (LAVI, p < 0.01) and E/e' ratio (p=0.02) in the intervention group patients when compared to the control group at the end of the research protocol. There was an improvement in GI compared to CG in the pain and discomfort domain of the EUROQUOL questionnaire (p=0.02) at the end of the protocol. Conclusions: Improvement of morphofunctional echocardiographic parameters and pain after the cardiovascular rehabilitation program suggests a favorable impact on cardiac function and quality of life after stroke.

 Effects of lower thoracic spinal cord stimulation on bowel management in tetraplegics



Anthony F. DiMarco, Robert T. Geertman, Kutaiba Tabbaa, Gregory A. Nemunaitis, Krzysztof E. Kowalski

Objectives: Spinal cord injury (SCI) has serious adverse consequences for bowel function in a majority of subjects. Some of the challenges relate to their dependence on caregiver support, need for medications, and the extensive time requirements associated with bowel management (BM). Lower thoracic spinal cord stimulation (SCS) has been shown to restore an effective cough and some patients have reported improvement in bowel function, as well. To determine whether usage of SCS to restore cough may improve BM in individuals with SCI. Design: In five consecutive tetraplegics, SCS was applied at home, 2-3 times/day, on a chronic basis and also as needed for secretion management. Stimulus parameters were set at values resulting in near maximum airway pressure generation (Paw) (30-40V, 50Hz, 0.2ms). Paw was measured as an index of expiratory muscle strength. Questionnaires related to BM, were also administered. Results: Mean Paw during spontaneous efforts was 39±7cmH2O. Following a period of reconditioning over a 20-week period, SCS resulted in Paw of 139±20cmH2O. The time required for BM routines was reduced from 118±34 min to 18±2 min (p< 0.05). Mechanical methods for BM (digital rectal stimulation and/or manual evacuation) were completely eliminated in 2 patients. The number of medications required for BM was also reduced. No patients experienced fecal incontinence as result of SCS. Each patient and caregiver also reported marked overall improvement and reduction in the daily stress level associated with BM. Conclusions: Our results suggest that SCS to restore cough may be a useful method to improve BM and life quality for both SCI patients and their caregivers.

 Effects of mechanical insufflation-exsufflation on compartmental chest wall volume in patients with chronic cervical spinal cord injury



Kozo Hanayama, Takefumi Sugiyama, Hiromichi Metani, Kazunari Furusawa, Masaki Hyodo

Objectives: The objective of this study was to evaluate the effects of mechanical insufflation-exsufflation (MI-E) on volume change of the chest wall and each compartment of the chest wall in patients with cervical spinal cord injury using optoelectronic plethysmography (OEP). Design: Fourteen male patients with chronic cervical spinal cord injuries were included. Each subject was instructed to lie on a bed in the supine position and 45 reflective markers were placed on predetermined locations on the chest wall. The respiratory movements were recorded by a 3D optoelectronic motion analysis system (Vicon MX; Vicon Motion Systems, Oxford, UK) with 6 infrared cameras placed around the subject. The subjects were asked to take deep breath (vital capacity measurement maneuver).Then, we applied MI-E through face mask at the pressure of ±30, 40, 50 cmH2O. The following parameters were calculated from the saved 3D coordinate data of the reflective markers; change of the total volume of the chest wall and the compartmental volume of the upper thorax, lower thorax and abdomen. Results: The change of chest wall volume was significantly greater during MI-E of ≥±30 cmH2O than when taking a deep breath. The volume change in the upper and lower thorax compartment was significantly greater during MI-E of ≥±30 cmH2O than when taking a deep breath. However, MI-E made no significant difference to the volume of the upper and lower thorax compartment between pressures of ±30 cmH2O and ±50 cmH2O. The volume change in the abdomen compartment was slightly greater during MI-E than when taking a deep breath, but this was not statistically significant. Conclusions: The findings of this study indicate the possibility of maintenance or improvement of the compliance of the chest wall, especially the ribcage in patients with spinal cord injuries, using MI-E. In turn, these findings could lead to the prevention of pulmonary complications.

 Effects of pendular articular decompression satisform on lumbar and hip mobility



Christophe Bensoussan, Antoine Champclou, Cedric Corneil, Anthony Dardillac, Paul Delamarche

Objectives: Effect of a Pendular Articular Decompression Satisform device's practice on lumbar mobility. This experiment concern subjects who are exposed to a prolonged sitting position during their professional activity. Design: 48 subjects participated to the study, [age : 38 ± 10.2 years ; height 169.2 ± 8.6 cm and weight : 66.6 kg ± 13.5 kg]. We examined effects of practice or detraining: the effect of one session, of three weeks of regular use, of 3-weeks-practice on one session effect or 3 weeks of rest. The mobility was evaluated by 4 mobility tests (6 measures) performed in three different anatomical plans: finger-to-floor test, lateral flexion test, rotation test and Schöber's test. Results: A single session significantly improves the mobility in the frontal plane weheras 3 weeks of regular use leads to a gain in anterior flexion, in lateral flexion and in rotation of non-dominant side. 3-weeks-pratice reduce the session effect and the detraining result in lower mobility. Conclusions: The practice of DPA Satisform device seems to be benefic for mobility improvement in subjects who are exposed to a prolonged sitting position. In conclusion, the examination of a more extend population could give a definitive response on the mobility device effect.

 Effects of quadriceps fatigue on spastic cocontractions between quadriceps and hamstrings and gait in stroke patients



Charline Duchossoy, Thomas Wacquez, Hervé Devanne, Etienne Allart

Objectives: Despite spastic cocontractions' frequency in stroke patients, the influence of muscle fatigue on their appareance stays misunderstood. The main aim of this study was to assess the effects of an isokinetic fatigue protocol on knee extensors cocontractions (rectus femoris, vasti lateralis and medialis) during knee flexion in chronic post-stroke patients presenting a stiff-knee gait (SKG) pattern. We also evaluated the effects of this protocol on quadriceps spasticity, gait spatiotemporal parameters, gait velocity, endurance and perceived exertion. Design: Thirty hemiparetic patients with SKG were evaluated before and after the isokinetic protocol, which consisted in alternately maximal isokinetic concentric knee extensions and passive knee flexions until effective quadriceps fatigue. The cocontraction index (CCI) between the three quadriceps heads and the semi-tendinosous (ST) was registered, as well as the agonist recruitment index (ARI) of the ST. Quadriceps spasticity (Tardieu scale), spatiotemporal parameters (Gaitrite®), maximal gait velocity (10 meters walk test), gait endurance (2 minutes walk test) and perceived exertion (Borg Rating of Perceived Exertion) were assessed too. Results: Results showed an effective quadriceps fatigue after the isokinetic protocol (p=0.014) and a significant decrease of quadriceps spasticity (p=0.022), but no significant effect on the CCI (upward trend) or the ST ARI (downward trend). Moreover, the Gaitrite® performances highlighted a significant improvement of spatiotemporal gait paremeters, such as gait cadence (p=0.001), healthy and paretic step length (p=0.001), FAP score (p=0.025), and walking endurance (p=0.006) and velocity (p=0.006). Lastly, walking tasks were a little more exhausting after the fatigue protocol (BRPE:9,3 versus 10,5). Conclusions: These results indicate that quadriceps fatigue may have positive effects on quadriceps spasticity and gait in hemiparetic patients, but no effect on the degree of spastic cocontractions. Thus, quadriceps fatigue protocol could be use in current practice as a complement to botulinum toxin injections to reduce spasticity and improve gait performances in stroke patients.

 Effects of repetitive transcranial magnetic stimulation on cognition and functional connectivity in subacute stroke patients



Yeong Wook Kim, Min Kyun Sohn

Objectives: To determine the mechanisms on cognitive improvement with repetitive transcranial magnetic stimulation (rTMS) over the left dorsolateral prefrontal cortex (L-DLPFC) in subacute stroke patients. Design: Twenty-eight first-ever stroke patients with cognitive impairment were recruited. All subjects were randomly assigned to real or sham stimulation group and completed 10 sessions of rTMS for 2 weeks. High frequency rTMS were on the L-DLPFC at 80% of resting motor threshold (rMT). At the time of baseline, 1 month and 3 months after stroke onset, all subjects were evaluated; the several clinical scales, motor evoked potentials (MEP), event-related potentials (ERPs), resting state functional magnetic resonance imaging (RS fMRI) and diffusion tensor imaging (DTI). Results: After the intervention period, the real stimulation group improved significantly in the K-MMSE, K-MOCA, K-MBI and K-GDS compared with sham stimulation group. And these effects lasted after three months in MOCA. There was no significant timexgroup effect among the U-FMA, EQ-5D, and CPT. Among the VCIHS parameters, Z- scores of executive and memory function showed higher delta value between baseline and 3months timepoints in rTMS group. The MEP showed higher TIME x GROUP interaction in the intracortical inhibition value on right hand. It suggests that there is beneficial effect on premotor cortical excitability of rTMS. The change of P300 amplitude on F3 and C3 was increased in real stimulation group significantly only in the auditory Oddball paradigm. The RS fMRI analysis Results showed more increased functional connectivity of Cingulate Gyrus, Supramarginal Gyrus, Cerebellum Crus, Precentral gyrus, Middle temporal gyrus and Inferior temporal gyrus after stimulation compare with the sham group. Conclusions: These results suggest that high frequency rTMS on the L-DLPFC improves cognitive function and functional network activity in subacute stroke. The rTMS seems to be a recommendable treatment in stroke patients with cognitive impairment.

 Effects of spasticity and related posture on median nerve and carpal tunnel in stroke patients with upper extremity spasticity: ultrasonographic and electrophysiologic evaluation



Seçilay Güneş, Aysun Genç, Derya Gökmen, Haydar Gök, Şehim Kutlay

Objectives: Spasticity induced flexed wrist posture is a common problem in stroke patients. The aim of this study was to evaluate whether there is an effect of upper extremity flexor spasticity on carpal tunnel (CT) and median nerve by using ultrasonographic and electrophysiological evaluation in patients with stroke. Design: A total 76 (46 stroke/30 healthy) individuals enrolled in the study. Demographics (age, gender, time since stroke etc..) were recorded. Individuals with diseases that could affect peripheral nerves (diabetes mellitus, hypothyroidism etc..) were excluded. Clinical evaluations included Brunnstrom Motor Recovery Stages (BMRS), Modified Ashworth Scale (MAS) and the Barthel Index (BI). The cross-sectional area (CSA) of the CT and median nerve (wrist/mid-arm levels) was measured by ultrasound (US). Motor nerve conduction studies of the median, ulnar, fibular and tibial nerves and sensory nerve conduction studies of the median, ulnar, and sural nerves were performed. After electrophysiologic evaluation, individuals diagnosed with polyneuropathy were also excluded. Results: The mean age of stroke and control group was 55,6± 13,5, 56±12,1 respectively. The mean time since stroke was 47,7± 67,7 month. 52,2 % of the patients were moderate dependent in activities of daily living. Compound muscle action potential amplitudes (CMAP) of median nerve was significantly reduced in hemi-paretic side compared to non-paretic side (p:0,02). The CSA of the CT was significantly smaller compared to non-paretic side (p:0,03) and there was a weak but significant inverse correlation between time since stroke and CSA of the CT (r:-326, p:0,03). The CSA of the median nerve at wrist was significantly thicker in patients with wrist flexor spasticity is MAS 2 and above (p:0,032). Conclusions: Our result showed that time since stroke have an impact on CSA of CT and also the severity of wrist flexor spasticity is associated with thickening in median nerve. Spasticity related chronic wrist posture may cause entrapment of the median nerve.

 Efficacy of local corticosteroid injection in carpal tunnel syndrome, a randomized clinical trial



Shahidur Rahman

Objectives: Carpal tunnel syndrome is a clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the wrist. This study was done to see the efficacy of local corticosteroid injection in CTS and compare this with conservative treatment. Design: / Recorded data of 70 patients were analyzed. All the patients were diagnosed as idiopathic carpal tunnel syndrome by nerve conduction study NCS). Mild to moderate cases of conduction delay were included. 35 patients were enrolled in group A and were provided with local injection triamcinolone 40 mg just proximal to the wrist crease in more symptomatic hand . 35 patients in group B were given naproxen 500mg twice daily and night splint. Patients were followed up at one month. 10 patients in group B were lost The outcome measure was based on rating the severity of three symptoms pain, paresthesia, on Visual analogue scale (VAS) of 0 – 10 and nocturnal awakening. Results: /27% patients were male. Age ranges were 44.647 +_ 5.02 in group A and 46.371 +_ 5.725 in group B . Pretreatment pain in group A and B were 5.914+_ 1.41 and 7.0+_1. 37 respectively. Pretreatment paresthesia in group A & B were 6.0+_1.3 B and 7.0+_1.21 respectively. 84% patients had moderate conduction delay in NCS study. Only 4 patients in each group had nocturnal awakening. Post treatment follow up at one month in group A shows significant improvement wth reduction of pain and paresthesia to 0. Group B also shows improvement with reduction of pain and paresthesia to 1+_ .621 and 2+_3.13 respectively. No nocturnal awakening were reported in either group. Follow up NCS study were not done in any patient. Conclusions: / Local corticosteroid injections were found to be effective in idiopathic CTS and were better than conservative treatment with night splint and NSAIDs.

 Efficacy of low level laser therapy in carpal tunnel syndrome: Experience of 49 cases in Bangladesh



Farida K. Chhobi, Abdullah Yusuf, Mohammad E. Hussain, Rafiqul Islam, Mohammad Hasib, Khurshid Mahmood

Objectives: To assess the outcome of Low level laser therapy in Carpal Tunnel Syndrome in term of symptoms severity and functional status. Design: This single centered, parallel, double blinded randomized control trial was conducted in the Department of Physical Medicine and Rehabilitation at a specialized hospital in Bangladesh from January 2019 to June 2019. CTS cases above the age of 18 years, confirmed by nerve conduction study, were selected as study population based on inclusion and exclusion criteria. Patients were randomly assigned into two groups designed as group A and group B. The assignment was done with double blind method. Group A underwent laser therapy (3 Joules/cm2, 2 min, 50 Hz) over the carpal tunnel area. Group B were treated with conventional method (wrist splint each night, therapeutic exercises, ADL advices). All patients received therapy for a total of 14 sessions, first 7 sessions on consecutive 7 days and last 7 sessions on alternate days. Patients were assessed according to Boston Carpal Tunnel Questionnaire (BCTQ). Results: The mean age of the patients (89.8% female, 10.2% male) was 40.61±8.70 (range, 22-60 years). Both the study and control group separately showed improvement after 6 weeks, but comparison of BCTQ score between study and control showed significant difference in improvement in both the Symptom Severity Scale (p=0.000) and Functional Status Scale (p=0.005). The pain (p=0.000), numbness (p=0.000) and paresthesia (p=0.000) were also significantly changed after 6 weeks follow up in laser therapy group. No adverse events were reported. Conclusions: Low intensity laser therapy is effective compared with night-resting splints in CTS.

 Electrical stimulation in combination with heat induces neurite outgrowth in PC12m3 cells via the p38 mitogen-activated protein kinase pathway



Kenji Kawamura, Yoshio Kano

Objectives: Electrical stimulation of the nervous system is a technique that is frequently used in physical therapy. In patients who are unable or unwilling to perform whole-body exercise, neuromuscular electrical stimulation (NMES) may be an alternative treatment to enhance lower limb muscle strength. Electrical stimulation is a promising technique for axonal regeneration of peripheral nerve injuries. However, the molecular mechanisms underlying these effects of electrical stimulation remain under investigation. To clarify the mechanisms of nerve regeneration by electrical stimulation, we investigated differentiation and cellular damage of PC12 mutant (PC12m3) cells caused by electrical stimulation. In addition, we investigated stimulation conditions that are gentle to the human body by combining electrical stimulation with heat. Design: We investigated the role of the p38 mitogen-activated protein kinase (MAPK) pathway in electrical stimulation-induced neurite outgrowth of PC12m3cells in which nerve growth factor (NGF)-induced neurite outgrowth is impaired. For experiments on neuritogenesis, the cells were treated with NGF and/or exposed to electrical stimulation in a cell electrical stimulation culture apparatus for 5 to 60 min. The electrical stimulation was applied with 10 Hz constant current square-wave pulses of 1 ms in duration and intensity of 100 mA using a Nicolet Viking IV programmable signal conditioner. As another independent experiment, we investigated stimulation conditions that are gentle to the human body by combining electrical stimulation with heat. The PC12m3 cells were exposed to15 min electrical stimulation using a 10 to 100 mA intensity in hot water at 40 degrees. After 7 days of incubation, the lengths of neurites were measured and the numbers of neurites were counted. In addition, MAPK activity was determined. Results: When cultures of the PC12m3 cells were exposed to electrical stimulation at 100 mA for 30 min, activity of p38 MAPK increased and neurite outgrowth was greatly enhanced. The frequency of neurite outgrowth induced by electrical stimulation was approximately 10-fold greater than that of neurite outgrowth induced by NGF alone. The neurite outgrowth induced by electrical stimulation was inhibited by a specific p38 MAPK inhibitor, SB203580. The activation of p38 MAPK induces activation of the transcription factor CREB. The activation of CREB induced by electrical stimulation was inhibited by SB203580.Longer electrical stimulation of PC12m3 cells provoked cell death, which was enhanced by SB203580. When cultures of the PC12m3 cells were exposed to 15 min electrical stimulationusing a 10-mA electric current in warm water at 40 degrees, neurite outgrowth was enhanced. Conclusions: These findings suggest that electrical stimulation-induced activation of the p38 MAPK/CREB pathway is responsible for the neurite outgrowth and survival of PC12m3 cells. When applying this technology to human, it is painful and unbearable to be exposed to electrical stimulation at 100 mA for 30 min. However, in combination with electrical stimulation and heat, 10-mA intensity electric current in warm water at 40 degrees may be applied for 15 minutes comfortably.

 Electroacupuncture decreases inflammatory pain through peripheral annexin A1-formyl peptide receptor 2/ALX-opioid receptor pathway



Daniel Fernandes Martins, Cintia Vieira, Daiana Cristina Salm, Verônica Horewics, Daniela Ludtke, Aline Emer, Júlia Koerich, Gustavo Mazzardo, Sayron Elias, Anna Paula, Lisandro Ceci, Afonso Salgado, Francisco J. Cidral Filho, Leidiane Martins, Ari Moré

Objectives: The present study evaluated the involvement of the Annexin 1/FPR2/ALX receptor in the antihyperalgesic effect induced by electroacupuncture (EA) in an animal model of persistent peripheral inflammation. Design: Swiss male mice underwent intraplantar (i.pl.) injection with complete Freund's adjuvant (CFA). Mechanical hyperalgesia was assessed by the von Frey test. Animals were treated with EA (2-10Hz, ST36-SP6) or subcutaneous BML-111 injection (FPR2/ALX an analog of lipoxin A4) for 5 consecutive days. In another set of experiments, on the first and fifth days after CFA injection, animals received i.pl. WRW4 (FPR2/ALX antagonist) or naloxone (non-selective opioid receptor antagonist) before EA or BML-111 treatment. Expression of the FPR2/ALX and Annexin 1 (AnxA1) in the paw was performed on the second day after CFA injection by the Western Blotting technique. Results: EA and BML-111 reduced mechanical hyperalgesia. i.pl. pre-treatment with naloxone or WRW4 prevented the antihyperalgesic effect induced either by EA or BML-111. EA treatment increased AnxA1 but did not alter FPR2/ALX receptor expression in the paw. Furthermore, i.pl. pretreatment with WRW4 prevented the increase of AnxA1 expression induced by the EA. On the other hand, pretreatment with BML-111 did not change the expression of FPR2/ALX receptor or AnxA1. Conclusions: Endogenous increase of FPR2/ALX and decrease of AnxA1 expression at the inflammation site are involved in CFA-induced inflammatory pain. EA treatment produces its antihyperalgesic effect through AnxA1/FPR2/ALX pathway. This seems to be triggered by the activation of FPR2 and a cross-talk with the opioid system.

 Electromyographic findings in patients with postpoliomyelitis syndrome and application in rehabilitation



Mark A. Lissens

Objectives: Thanks to vaccination programs worldwide, acute poliomyelitis nowadays is rarely seen anymore. However, 12.5 million polio survivors can several decades later be contracted with new symptoms due to so-called post poliomyelitis syndrome (PPS), resulting in fatigue, pain, weakness, new muscle atrophy and difficulties in activities of daily life (ADL) or functional loss. The objective of this study was to explain the major symptoms in PPS electrodiagnostically and how to apply our findings in rehabilitation. Design: We evaluated 30 PPS patients, 11 males and 19 females, mean age 53,2 years. We performed concentric needle electromyography (EMG) of the rectus femoris muscle, in 25 of them bilaterally, and in 5 of them unilaterally, because their other side was completely atrophic. Results: In all 55 examined muscles we found neurogenic motor unit action potentials and giant motor units, with mean maximal amplitude of 7.4 mV. When taking into account only the normal appearing muscles, excluding severely atrophic muscles, the mean amplitude of these 32 muscles was 7.9 mV, compared to a normal value of 1.2 ± 0.6 mV. Conclusions: Our findings can be explained by the fact that normal anterior horn cells can adopt hundreds of “orphaned” muscle fibres. In an average polio infection 50 to 80% of motor neurons are affected, with a 50% neuronal fatality. However, over 50% of motor units of a muscle may be lost without symptoms and without visible muscle atrophy. This is the reason why in such muscles giant motor units can be found and why PPS patients feel after decades of almost normal functioning new symptoms such as weakness, fatigue and new muscle atrophy. In rehabilitation medicine it is important to investigate musculature in PPS patients accurately in order to set up adequate rehabilitation programs in which affected muscles are not overloaded, leading to new muscle atrophy.

 Electromyographic studies in fecal incontinence



Ana Margarita Chong Medina, Jorge Luis González Roig, Yaima Almanza Díaz

Objectives: Fecal incontinence can be cause important disorders in people's quality of life. The diagnostic keys to these disorders and the therapeutic options are poorly systematized. The neurophysiology of defecation is still under study and depend on the integrity of the anatomical and neuronal structures, as well as on the correction of the coordination of mechanical, muscular and nervous systems. In this study, we evaluate the usefulness of anal electromyography in the diagnosis of patients with fecal incontinence. Design: A descriptive, cross-sectional and prospective study was conducted in female patients with incontinence, treated in the Clinical Neurophysiology Department of the “Julio Díaz” Hospital, National of Rehabilitation Center. The patients were evaluated by external anal sphincter electromyography and Wexner score. To characterize the patients, from the clinical and epidemiological point of view, an exploratory data analysis was applied, the relationships between sociodemographic and clinical variables were evaluated with the result of the electromyographic study and the severity of fecal incontinence. Contrast of non-parametric hypothesis was performed, with respect to the positivity of the electromyographic study. Results: Predominate patients between 41 and 60 years, average of 58 years, with obstetric history of more than 2 births and evolution of the disease over 5 years. Moderate incontinence was the most prevalent with the most frequent electromyography alteration: isolated pattern to contraction and signs of denervation. Wexner's score and classification had a relationship of medium strength, with statistical significance, in relation to the time of evolution of the disease and the electromyographic pattern, respectively. The positivity of the study was 97.7%. Conclusions: The structural examination of the anal canal must be combined with a neurophysiological study that allows us to deepen our knowledge of these disorders, as well as, better classify patients, indicate therapeutic more effectively, and evaluate the prognosis of patients with fecal incontinence.

 Electromyography of scalene and rectus abdominis during the respiratory cycle in healthy subjects



Rola Tout, Joseph Maarrawi

Objectives: Expose the electromyography and spirometry relationship and the chronology of the contraction of Scalene and Rectus abdominis in physiological breathing and understand the physiology of respiratory muscles by analysis of EMG signals of inspiratory and expiratory muscles. Design: Methods: 128 electromyographic tests were performed during the respiratory cycle on 43 healthy adults. EMG signals of Scalene (inspiratory muscle), Rectus abdominis (forced expiratory muscle) were recorded by using LabView system. The breathing was recorded by using a spirometer (vernier®). the test of 15 seconds was repeated 3 times for each subject. Results: The duration of the contraction of Scalene are superior to Rectus abdominis 82% p-value = 0.000058, the amplitude of Scalene is superior of Rectus abdominis, p-value = 0.000000073. 109 tests of Scalene contraction begin before that of Rectus abdominis (63.74%), p-value = 0.000012. RMS is 0.02 ± 0.011 μv for Rectus abdominis and 0.04 ± 0.021 μv for Scalene, p-value = 6.76591E-06. Duration of inspiration is 1.25 s ± 0.19, the expiration is 1.04 s ± 0.19. The mean frequency of Rectus abdominis is 54.19 Hz ± 6.35, it is 57.21 Hz ± 7.08 for Scalene, p-value is 9.84081E-08. The median frequency of Rectus abdominis is 51.05 Hz ± 6.51, it is 52.72 Hz ± 6.94 for Scalene, p-value is 0.0098. The muscle fatigue of Rectus abdominis decreased from 60.40 ± 0.45 to 19.98 ± 4.32. For Scalene it decreased from 60.41 ± 0.4 to 23.52 ± 4.41. Conclusions: There is a synergistic - antagonism relationship between the Scalene (inspiratory muscle) and Rectus abdominis (forced expiratory muscle) during respiration. Scalene is a main inspiratory muscle, its contraction is important in amplitude, duration and frequency. the Rectus abdominis participate to the inspiration phases and it's contraction is less important in duration, amplitude and frequency. Both muscles are fatigable during the inspiratory cycle.

 Electrostimulation therapy on upper limb motor dysfunction in patients with ischemic stroke: A functional magnetic resonance imaging study



Yi'shuang Zhao, YuMei Zhang

Objectives: To explore the mechanism of functional electrical stimulation combined with rehabilitation training in patients with hemiplegia after ischemic stroke by functional magnetic resonance imaging (fMRI). Design: Twenty ischemic stroke patients with upper limb motor dysfunction for 2 to 3 weeks ,and 20 normal subjects in the control group were selected. Both groups received functional electrical stimulation and routine rehabilitation training. Fugl-Meyer scores, ARAT and motor task-related fMRI were assessed before and after intervention. The task of fMRI scan was designed using wrist flexion movement. All fMRI data were processed and analyzed with PPM5, REST and XJVIEW software. The number of activated voxel and the lateralization index (L1), functional connections with primary motor cortex (M1) were calculated in the different areas of interest. To compare the difference between the two groups of patients in the change of motor network function connection and its correlation with the improvement of motor function. Results: Compared with control group, L1 of primary motor cortex (PMA) and sensorimotor cortex (SMC) were significantly decreased. After intervention, L1 in the area of interest increased significantly, which was correlated with Fugl-Meyer score on the affected side of the upper limb, but had no statistical significance with ARAT score. The functional connections between ipsilateral SMC, contralateral M1, contralateral SMC, bilateral supplementary motor area (SMA), bilateral PMA and M1 were significantly improved. Conclusions: In patients with ischemic stroke, motor function of the affected side is maintained by compensation of a large range of motor related areas on both sides. The movement activation of the affected side showed a tendency towards M1 or SMC, and the lateralization index was significantly increased. The degree of lateralization may be correlated with the upper limb motor function. Functional connections between M1 and brain regions associated with bilateral motor areas were enhanced.

 Emergence from vegetative state following intrathecal baclofen pump placement



Priyanca Shah, Stephen Hampton

Case Diagnosis: Anoxic brain injury secondary to opioid overdose. Case Description: A 27-year-old male with a history of childhood epilepsy, chronic pain, and opioid abuse with cardiac arrest and anoxic brain injury in the setting of opioid overdose and initially in a vegetative state. Hospital course complicated by persistent fevers, posturing including, rigidity, facial grimacing, and hemodynamic changes concerning for paroxysmal autonomic instability with dystonia or PAID syndrome which was refractory to management with baclofen, propranolol, bromocriptine, dantrolene, clonidine, gabapentin, antipyretics, opioids, and benzodiazepines. The patient underwent an intrathecal baclofen trial with improvement in lower limb posturing, improved tachycardia, and hyperthermia hours after the initial bolus. Additionally, the patient was weaned off of benzodiazepines and opioids. Three weeks after intrathecal baclofen placement patient demonstrated emergence from a vegetative state. Discussions: Intrathecal baclofen pump trial and placement showed improvement in this patient's refractory autonomic storming and posturing which improved after trial and continued to improve after intrathecal baclofen pump placement and titration. Additionally, three weeks after placement, the patient emerged from a vegetative state. Placement of an intrathecal baclofen pump allows the patient to be weaned off of sedating medications and reduce autonomic instability promoting emergence. Conclusions: Implantation of an intrathecal baclofen pump reduces autonomic storming, dystonic posturing, and may help with emergence from a vegetative state.

 Encephalopathy of unknown etiology with cognitive and functional improvement after adjustment of psychotropic medication regimen



Joshua Levin, Mithra Maneyapanda, Jeffrey Boyd

Case Diagnosis: Encephalopathy due to underlying psychiatric condition. Case Description: 45 year old female with history of bipolar disorder who was hospitalized after experiencing a “seizure”. On admission she was awake, but minimally responsive. An extensive neurological workup was unremarkable. Medication interventions, including Lorazepam challenge, solumedrol course, and IVIG did not improve her condition. She was diagnosed with encephalopathy of unclear etiology and one month after admission she was transferred to inpatient rehabilitation. While in rehabilitation she initially made limited functional improvements, had multiple medical setbacks, and continued to be minimally responsive beyond moaning with continued restlessness. Her behavior was regulated with clonazepam, valproic acid, propranolol, escitalopram, mirtazapine and quetiapine. Eventually, with psychiatric input, her medication was adjusted by switching her SSRI to venlafaxine, and neuroleptic to olanzapine. With additional dose titration she made significant cognitive and functional improvement and was eventually discharged home with her parents. Discussions: Patient's diagnosis of encephalopathy of uncertain etiology was initially thought to be autoimmune or secondary to medication overdose. She had multiple treatment regimens with little improvement. Her underlying psychiatric condition was found to be the presumed cause of her condition, likely a combination of bipolar disorder with major depression. With modification of her psychotropic regimen she went from near catatonia on admission to being discharged three months later at a supervision level. Conclusions: This case highlights the importance of considering psychiatric causes of patients presenting with neurologic deficits. This patient was discharged to inpatient rehabilitation without a clear diagnosis making management of her care much more difficult. After modification to her medication regimen with psychiatry's input she was able to achieve significant cognitive and functional improvement. She met most of her functional goals and was discharged at a supervision level. The patient's functional outcome may have been negatively affected had her underlying psychiatric condition not been adequately addressed.

 Endovascular thrombectomy 37 h after acute ischemic middle cerebral artery stroke: A case report



Conan So, Naveed Chaudhry, Dheeraj Gandhi, John Cole, Melissa Motta

Case Diagnosis: We present a case of delayed thrombectomy in a 43-year-old man with acute dysarthria, left-sided weakness, and visual neglect. Initial MRI/A demonstrated a small completed stroke and a thrombus in the right middle cerebral artery. Case Description: Thirty-seven hours after symptom onset his weakness acutely worsened. A repeat MRI revealed an unchanged core infarct volume and a cerebral angiogram suggested an abrupt occlusion of the right distal M1. Thrombectomy was performed with complete reperfusion and the patient's strength recovered following the procedure. He had a modified Rankin Scale (mRS) of 1 at six-months post-thrombectomy with minimal residual deficits. Discussions: Endovascular thrombectomy following an acute ischemic stroke can lead to improved functional outcome when performed early. Current guidelines suggest treatment within six hours after symptom onset. Recent studies including the DEFUSE-3 and DAWN trials demonstrate that some patients may benefit from thrombectomy up to 16 and 24 hours, respectively. Our case demonstrates that the relationships between the key parameters including clinical presentation, imaging mismatch, and the upper time limit for endovascular thrombectomy treatment remain uncertain. It may be reasonable to consider a lower threshold to proceed with thrombectomy in younger patients who have clinical presentations different than the ones used in the DEFUSE-3 and DAWN trials. Conclusions: We conclude there is a subset of patients that may safely benefit from thrombectomy in later time windows beyond the trial criteria, especially in the setting of clinical exam to imaging mismatch.

 Epidemio-clinical profile of patients who presented low back pain in the rehabilitation center of Chu-Jra madagasacar retrospective study, descriptive



Andréa Holiarisoa Raharinantenaina

Objectives: Chronic low back pain is a common pathology and the third cause of functional disability leading to progressive physical deconditioning and desocialization. Rehabilitation plays a major role in the care of these patients. Our study aims to determine the epidemiological and therapeutic aspect of patients with chronic low back pain seen in Rehabilitation Center of CHU-JRA Antananarivo Madagascar. Design: This was a retrospective study, descriptive over a period of 1 year from 01 January to 31 December 2018 including all patients who came for a consultation for chronic low back pain greater than 3 months of progression in the Rehabilitation Center of CHU-JRA. All patients with acute low back pain are excluded from our study. Results: Of the 1237 patients collected, 338 patients were retained. The incidence of chronic low back pain was 27.32% with female predominance with a sex ratio of 1.7. The average age was 49.29 years. The 73.66% were working. We noted that 77.06% are referred by Doctors. A history of at least one episode of low back pain is found in 44.37%. Scoliosis was reported in 31.36%, scoliotic attitude in 18.93%, osteoarthritis in 15.08%. Radiography was the most accessible supplementary investigation for patients. We were able to estimate that 95.79% received at least 10 rehabilitation sessions and 47.63% would have had a clinical improvement according to EVA scale. Conclusions: Chronic low back pain is common, affecting young people in employment. Rehabilitation appears to be effective in reducing pain and improving the functional capacity of these patients. Further research is needed to help us understand more about the long-term course and broader outcomes and impacts from low back pain.

 Evaluating different sources of information for individuals with and caregivers of individuals with spinal cord injuries



Sejean Yang, Jessica Pope, Alaanah Bhanji, Ali A. Weinstein

Objectives: With the increase in the availability of health-relevant information, it has become more difficult for individuals to identify sources that are relevant and reliable. The study's objective was to compare the benefits and shortcomings of information sources. Design: Sixteen individuals with SCI (spinal cord injury) and 17 caregivers of individuals with SCI participated in semi-structured telephone interviews that were qualitatively analyzed. Results: Three main sources of information were identified: internet, social, and health care providers (HCP). The consensus about the internet was that there was a plethora of SCI-related information, but often information was not reliable, not specific enough, not well-organized, or the amount of information was too overwhelming. A popular social resource was online support groups (OSG). OSG are easily accessible and give individuals the chance to interact with individuals with comparable situations. Many individuals with SCI and caregivers participated in-person support groups/group activities, where they can meet similar individuals. Though social resources can be helpful and convenient, the information obtained was not always reliable. HCP was a preferred resource for individuals with SCI and caregivers. HCP were viewed as reliable, and their willingness to listen was appreciated. Challenges with HCP included lack of appointment availability, lack of knowledge in alternative treatments, and a tendency to treat individuals with SCI impersonally. Conclusions: There is not a singular source of information that can provide all of the necessary health-related information. A resource that combines the strengths of the different sources would be beneficial for both individuals with SCI and caregivers of individuals with SCI. For example, a website (internet resource) containing reliable resources and instructions from both peers (social resource) and HCP would take advantage of the strengths of each type of resource.

 Evaluation of physical activity practice in people living with HIV on antiretroviral therapy in Burundi



Eric Havyarimana, Alexis Sinzakaraye, Ella C. Ininahazwe

Objectives: In sub-Saharan Africa, the level of practice of physical activities (PA) is not known among people living with HIV / AIDS (PLHIV). A significant proportion of PLHIV has difficulty practicing PA. The purpose is to evaluate the level of PA and investigate barriers and motivations to PA practice among PLHIV in Burundi. Design: The study included PLHIV between 14 and 64 years old. PA level was assessed with the Global Physical Activity Questionnaire (GPAQ). Quantifying an individual's total activity takes into account the total amount of time spent on physical exercise per week, the intensity of PA and the MET-minute energy expenditure involved in the activities: at leisure, at work or when traveling on foot or by bike. The combination of these factors classifies each respondent into one of three categories of physical activity level: intense, moderate and low. Results: A sample of 383 PLHIV responded to the questionnaire. The majority were active for an average of 294.51 (SD: 226.10) minutes per day resulting in an average energy expenditure of 490.15 (SD: 387.88) MET-minutes. 40.99 % reported practicing intense PA, 41.78 % practiced moderate PA and 17.23 % were sedentary. Levels of PA practice were slightly correlated with patient's occupation (r = - 0.21; p = 0,03), while correlations with other sociodemographic factors were negligible, r ranging from - 0.08 to 0.03. results suggested that increase in viral load rate was associated with sedentary lifestyle (r= 0, 54). PLHIV reported they would practice PA in order to improve their health (50.39%) but lack of time is a major obstacle (40.73%). Conclusions: The study showed that people living with HIV in Burundi are not sedentary. These results can be used by caregivers and PLHIV associations to promote physical activity practice in sedentary PLHIV and to encourage those already active to keep practicing.

 Exercise-induced spinal epidural hematoma in a pediatric patient with hemophilia A: A case report



Ady M. Correa-Mendoza, Edwardo Ramos

Case Diagnosis: Spinal epidural hematoma. Case Description: 13-year-old-male with medical history of hemophilia-A presented to the Emergency Room with 6-hours onset of severe non traumatic lumbar pain after playing recreational basketball. Initially, oral analgesics were provided due to suspicion for muscle spasms. However, lumbar pain persisted and patient developed progressive bilateral lower extremity weakness and urinary retention 24 hours later. On examination, he was found with L2 incomplete paraplegia, lower extremities areflexia and neurogenic bladder/bowel. An MRI study was performed, revealing an anterior T10-T11 spinal epidural hematoma causing cord compression. Patient underwent emergency laminectomy 12 hours later and received Factor-VIII replacement therapy afterwards. He is participating from inpatient rehabilitation with gradual improvement in lower extremity strength, proprioception and overall functionality. Discussions: Neurologic complications in hemophiliac patients are rare, but most commonly reported in the pediatric population. There is an incidence of 7.5% of central nervous system bleeding compared to 0.001-1.9% of spinal epidural hematomas. Although the pathogenesis is unknown, it has been proposed that epidural hematomas occur due to ruptured valveless epidural veins as they provide an alternate route for venous return when there is increased intra-thoracic/intra-abdominal pressure. In our patient, the combination of a vulnerable endothelium of the epidural veins along with physical activity involving back flexion and forced expiration mechanisms (Valsalva maneuver) most likely increased his intrathoracic pressure while playing basketball, precipitating a spinal cord injury. Conclusions: Besides prompt diagnosis of spinal epidural hematoma, timely intervention is crucial so that patient could recover his neurologic and functional capacity. Due to vulnerable vascular structures in hemophiliac patients, physical activities should be performed taking into account that some forces may increase intra-thoracic/intra-abdominal pressure, predisposing to neurologic complications such as epidural hematomas. Further research is needed on this population to prevent these injuries by possibly modifying exercises and respiration techniques while performing sports/physical activity.

 Experimental evidences for functional changes in cortical blood flow by transcranial direct current stimulation



Eun-Ho Yu, Jihong Min, Ju Hyun Son, Ho Koo, Min Sun Kim, Yong-Il Shin

Objectives: Several clinical studies have demonstrated that Transcranial direct current stimulation (tDCS) can change cerebral blood flow with a polarity - specific manner. However, there is a little information about possible underlying mechanisms for modulation of cerebral blood flow by tDCS. The purpose of this study was to evaluate changes in functional or structural changes in cortical blood vessel by tDCS. Design: tDCS was applied bilaterally on the skull with intensity of 150 uA and duration of 20 min from Sprague - Dawley rats. Structural changes in cortical blood vessel were evaluated by imaging cortical blood vessel stained with Evans-blue dye or by direct visualization of cortical vessels stained with fluorescent dye with a confocal microscope. Functional changes was monitored by direct measurement of cortical blood flow with a Laser-Doppler and by direct recording of oxygen and nitric oxide concentration from the cortex using a voltammetric technique. Results: Anodal tDCS resulted in increase in diameter of blood vessels in the cortex and also upregulation of oxygen and nitric oxide concentrations in the cortex. In contrast to, cathodal tDCS cause the reduction of size of cortical blood vessels and of oxygen concentration. But there is a little changes in concentration of nitric oxide in the cortex under cathodal tDCS. Conclusions: This results suggest that tDCS may modulate functional changes in blood flow by changes in release of nitric oxide in the cortex.

 Exploring patients' and caregivers' experiences and perceptions on the strengths and limitations of the early supported discharge program postacute stroke: A qualitative study



Odessa S. Nuez, Gerald Choon Huat Koh

Objectives: Post-acute stroke rehabilitation has been provided as inpatient, extending hospitalization. This has been challenged by providing other options such as Early Supported Discharge (ESD). ESD provides home-based rehabilitation by an interdisciplinary team. The main objectives of this study are to explore the experiences of patients and caregivers under the ESD post-acute stroke program and to understand their perceptions on its strengths and limitations. Design: This is a qualitative study using an inductive approach. The participants were 11 patients with mild to moderate stroke and 8 caregivers. Purposive sampling was done. Semi-structured in-depth interviews were done for all participants. Thematic analysis was performed to elicit recurrent themes. Results: The 3 key themes were patient-caregiver partnership, patient-centered care and team support. Caregiver support was vital in the patient's recovery. Caregivers acted as “therapists” by assisting the patient with the exercises and providing encouragement. Caregiver stress was evident in some of the participants. Lack of stroke education was shown to contribute to caregivers' stress. Patient-centered care was an interplay between patient empowerment, individualized rehabilitation and good patient-clinician partnership. Shared decision making in rehabilitation goal setting was an important aspect of patient-centered care. Team support encompassed communication, education and cost. Two-way communication provided easy access to a healthcare professional. Stroke education was an important aspect that must be adequately provided. Fees for the therapy visits were offset by government subsidies and were reasonable given the amount of time spent by the therapists and the quality of the sessions which included trips in the community. Conclusions: Knowing patients' and caregivers' experiences and perceptions provide insight on the strengths and gaps in the ESD program. Identifying these would help to improve quality in healthcare service delivery.

 Extracorporal shock wave treatment of spasticity: A systematic review



Karsten Knobloch, Henning Lohse-Busch, Andreas Gohritz

Objectives: Extracorporeal shock wave therapy (ESWT) has evolved in various clinical disciplines since its first clinical for urological kidney stone destruction on February 7, 1980. The impetus for the treatment of spastic symptoms with ESWT was given in 1994 by clinical observations during the treatment of painful gonarthroses. Already during the session with ESWT, the painful muscular flexion contracture of the knee joints decreased because of the greatly increased visco-elasticity and tonicity of the muscles. Muscles are subject to reciprocal antagonist inhibition and consequent contracture formation in pain paralysis as well as spastic paresis. Therefore, it was obvious to apply ESWT also for spastic contractures. In neurology, shock wave therapy was used clinically in 1996 in children with cerebral palsy. Aim: Systemic review to assess the efficacy of extracorporeal shock wave therapy (ESWT) in spasticity in both, children and adults in a standardized way. Design: On April 15, 2019, the keyword search was carried out in the databases of MEDLINE, EMBASE, PubMed, and the Cochrane Library. In addition, for all results considered relevant, the reference lists of the included publications were probed manually for further potential studies. The following keywords have been reviewed (sample information for PubMed): Shock wave therapy #6496 hits; Extracorporeal shock wave therapy #4397 hits; ESWT #705 hits; Spasticity #13949 hits; spasticity shock wave #42 hits; Shock wave nerve #179 hits; Extracorporeal shock wave therapy nerve #78 hits; Extracorporeal shock wave therapy stroke #31hits. All abstracts are assessed for relevance and the full-text analysis was correspondingly included for the relevant articles. In addition to the respective level of evidence, the patient characteristics as well as different shock wave parameters were analyzed. Results: This review included 888 patients from 10 randomized-controlled trials (RCTs, n=488) and 14 non-RCTs (n=400). Children were studied in six studies (3 RCTs n=57, 3 non-RCTs n=141) with 2 radial and 4 focused ESWT devices. Adults were analyzed in 18 studies (7RCTs n=431, 11 non-RCTs, n=259). Regarding ESWT technology used, four RCTs used radial ESWT and five RCTs focused. Both, radial and focused ESWT improved function and reduced spasticity significantly. On average 3-5 ESWT sessions (1500 shots, 4-5Hz) were applied, while two studies did 12 ESWT sessions. Adverse effects were not noted with the applied device parameters neither among children nor in adults. Radial ESWT was used with treatment pressures between 1.5-3.5bar with 1500-4500 pulses per session and a treatment rate of 4-5Hz slow. Focused ESWT is successfully used in spasticity therapy with rather low energy flux densities of up to 0.1mJ / mm2 with 1500 pulses per affected muscle. Conclusions: Following evidence-based criteria both radial and focused extracorporeal shockwave therapy (ESWT) reduce spasticity and improve function without adverse effects among children and adults affected from spasticity.

 Extremely rare presentation and complicated rehabilitation course of patient with external hydrocephalus following epidermoid tumor resection: A case report



Jennifer M. Cushman, Yulia Rivelis, Mery Elashvili

Case Diagnosis: A 69 yo M patient admitted for rehabilitation s/p craniotomy with resection of suprasellar epidermoid cyst. Surgery was complicated by post-operative right thalamic, left caudate stroke, left frontal hemorrhage, persistent encephalopathy, seizures, and hyponatremia due to SIADH. Rehabilitation was recommended to improve functional endurance, cognitive status, and prevent muscle atrophy. Patient was found to have mixed language and bilateral visual field deficits, mixed oral-pharyngeal dysphagia, and right hemiparesis. Patient was initially unarousable s/p craniotomy and not progressing during rehab. CT scan revealed external hydrocephalus complicated with midline shift leading to neurosurgery consult. Patient was started on Decadron, but still showed functional regression. Due to severe clinical decline, rehab was emergently halted in order to transfer patient for neurosurgical intervention for surgical implantation of a VP shunt. Case Description: A 69 yo M presented with complications following elective neurosurgical resection of epidermoid cyst. Discussions: Epidermoid cysts, congenital in origin, account for roughly 1% of intracranial tumors. They arise from epithelial cells retained during neural tube closure. Because of the growth along cranial nerves and tissue planes, symptoms are usually present and gross total resection is near impossible. These tumors arise from inclusion of ectodermal epithelial elements with a benign course and slow progression. It may present as an extra-cerebral intradural lesion in about 40% of cases with most tumors located in the cerebellopontine angle. Tumor is avascular in nature, comprised of cholesterol and keratin in a solid crystalline state. Conclusions: This case highlights a patient's post-operative resection complications, including external hydrocephalus with midline shift, discovered and closely managed by the multidisciplinary rehabilitation team. This rare presentation stresses the importance of the multidisciplinary team management in rehabilitation medicine and close monitoring of post-operative neurosurgical patients undergoing inpatient rehabilitation.

 Eye can't feel my feet when I'm with you: A case of Miller Fischer syndrome presenting during posttreatment rehabilitation



Amy Park, Lisa Hu, Chanel Davidoff

Case Diagnosis: Guillain-Barré Syndrome, Miller Fischer Syndrome. Case Description: A 28-year-old healthy male presents after with progressively worsening bilateral lower extremity pain and weakness for 2 weeks. Pain was a sharp, shooting, and burning sensation. Initial workup included a lumbar puncture, which was consistent with Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP). Patient completed a 5-day course of intravenous immunoglobulin (IVIG) and was discharged to acute inpatient rehabilitation. Patient initially showed improvements in balance and gait. He then developed teary eyes, fluctuating lower extremity weakness, worsening balance and new grip weakness. Patient was transferred back to the acute care service, where further neurological work up suggested Miller Fischer Syndrome. Patient was treated with plasmapheresis and returned to acute inpatient rehabilitation. Discussions: Guillain-Barré Syndrome (GBS) is a general classification that includes several variants of acute immune-mediated polyneuropathies. Patients typically present with worsening bilateral lower extremity weakness and areflexia. Less commonly, patients develop upper extremity weakness, respiratory muscle weakness, and oculomotor weakness. The Miller Fisher Syndrome (MFS) is a rare variant of GBS which is defined by a triad of ophthalmoplegia, areflexia and ataxia. Treatment includes plasma exchange or IVIG. About 10% of patients experience relapses after treatment. Medical complications that develop due to prolonged immobilization may interfere with rehabilitation progress. Supportive care and aggressive rehabilitation should be carried out concurrently when indicated. Conclusions: Higher intensity, multidisciplinary therapy programs available in the acute inpatient rehabilitation setting have been shown to reduce disability and improve quality of life in patients suffering from GBS. This case of Miller Fischer Syndrome demonstrates the importance of the multidisciplinary rehabilitation approach in determining whether it is appropriate to maintain the course of supportive care in a patient who has completed treatment for GBS, and is on the course for recovery, versus requiring physiatric re-evaluation and further treatment in the setting of possible relapse.

 Factors associated with social participation among people with disabilities: A nationwide disability registration analysis



Tzu-Herng Hsu, Tsan-Hon Liou, Kwang-Hwa Chang

Case Diagnosis: According to estimates by the World Health Organization (WHO), one billion or more people globally are disabled. Disability refers to a person's activity limitations and participation restrictions. Disability is related to an illness or health condition and is accompanied by various types and degrees of body function impairment, creating different patterns of difficulty in daily living. Social participation is associated with health and subjective quality of life in person having spinal cord injury, stroke or other disabilities. In addition, it is shown to be positively associated with psychological and physical functioning. Furthermore, social participation is linked to relevant and pivotal outcomes of a successful rehabilitation in person with disability. The aim of this study is to explore factors associated with limitation in social participation among people with disabilities based on the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Case Description: Participants - We recruited people who experienced a single type of disability from the Taiwan Data bank of Persons with Disability (TDPD) based on the International Classification of Functioning, Disability, and Health (ICF) framework from July 11, 2012 to November 30, 2017. We excluded persons whose disability type or any of the domain scores was missed in the database. Measurements - We calculated standardized scores (ranged between 0-100 points) of each domains, and the 32-item index on the basis of item-response theory and the WHODAS 2.0 manual. Each domain score and the 32-item index can be converted into a percentage of rank (ranged between 0-100%). Data analysis - We used nonparametric logistic regression analyses to estimate the participants' likelihood of participation restrictions. Those variables found to have significant association with domain 6 (social participation of WHODAS 2.0) in the univariate analyses were entered into the models for multivariate analyses. Discussions: This study recruited 344,367 participants (49.23% ≧ 65 years old; 55.5% males) having a single type of disability between July 11, 2012 and November 30, 2017 from the TDPD. In nonparmetric regression, participants with ICF chapter 3, 5, 7 or 8 were positively significantly associated with restriction of social participation compared to chapter 1 disability. Participants who had lower income, higher education level (aged ≧ 65 years), higher degrees of disability or lived in institutions or rural area showed positive correlation with participation restriction. As for WHODAS 2.0, female, education years, incomes level, urbanization level and severity of disability were included into multivariate model, and participants who had higher percentage of rank in domains cognition, mobility, self-care, getting along, life activities had positively significantly associated with restriction of social participation in nonparametric regression. Furthermore, poor mobility and getting along with others showed the highest positive correlation with participation restriction. Conclusions: People who have lower income, higher education level (in group of aged ≧ 65 years), higher degrees of disability or lived in lower urbanization area have greater risk of restrictions in social participation. Compared to people with mental function impairment, those having impairment in speech, digestive, movement-related, and skin-related functions are likely to be difficult to participate social activities. In WHODAS 2.0, people who have difficulty in mobility and getting along with people are more likely to experience participation restrictions.

 Factors influencing the assiduity of patients followed in rehabilitation for orthopedic and traumatological pathologies



Randrianasolo Ruth Pascale, Solofomalala Gaëtan Duval

Case Diagnosis: To determine risk factors associated with “lost to follow-up” patients and to determine the possible causes. Case Description: A case-control study based on 31 cases of “lost to follow-up”, for 36 controls matched by frequency to cases. Discussions: Low socioeconomic level, oprning hours , session rate, sufficient explanations of costs were protective factors. Use of expensive transportation, non-compliance with sitting appointments and length of sessions were risk factors. The most common causes were pecuniary problems and patients availability. Conclusions: Lost to follow-up is multifactorial and nonspecific. A complex and harmful phenomenon requiring action to overcome in order to reduce its impact.

 Familial hemiplegic migraine with concurrent meningioma: A case report



Elizabeth Lin, Jack Mensch, Caroline Lee, Sanjeev Agarwal

Case Diagnosis: Familial Hemiplegic Migraine with Concurrent Meningioma. Case Description: 69-year-old female with FHM complicated by ataxia and dysarthria who presented with worsening migraines and ataxia associated with left sided numbness. A diagnosis of FHM was made in her teens, with multiple negative head CTs throughout her lifetime, the last one being 10 years prior. From her family history of FMH, our patient knew that attacks usually decrease with age, but her attacks were increasing in frequency and magnitude. MRI revealed a right-sided parasagittal meningioma, which was surgically resected. She was subsequently admitted to acute rehabilitation. Discussions: Our patient symptoms quickly resolved after surgery, suggesting her recent symptoms were caused by her meningioma rather than her FMH. After 4 weeks of inpatient rehabilitation, she returned to her baseline functional status. She had mild residual ataxia and dysarthria with resting tremor but was independent with ambulation and ADLs. Hemiplegic migraine (HM) is a rare subtype of migraine, which presents with a motor aura. Motor auras consist of reversible unilateral motor weakness that occurs concurrently or prior to a headache. In severe forms, patients suffer from prolonged hemiparesis, permanent cerebellar ataxia, epilepsy or mental retardation. HM can occur in families or sporadically. Approximately 75% of FHM cases are linked to a mutation in CACNA1A, ATP1A2 or SCN1A. Treatment of HM includes avoiding triggers, such as stress and bright lights. Preventative treatment with sodium valproate, lamotrigine, verapamil or acetazolamide may be indicated in patients with frequent attacks. Conclusions: FHM aura can mimic TIA, epilepsy, brain tumors and stroke. CFS analysis, MRI or EEG may be indicated based on presentation. A throughout history can prompt quicker diagnosis and treatment, thus improving morbidity and mortality. Conversely, HM should be kept in the differential of patients who present with persistent attacks of motor weakness and a negative neurological workup.

 Fatigue syndrome in the subacute stroke rehabilitation



Marcela Lippert-Grüner, Stephan Grüner

Objectives: 60 stroke patients in the subacute phase of illness were analyzed concerning the degree and changes of post-stroke fatigue (PSF) before and after at mean 15 days of rehabilitation with 4 hours/day including 60 minutes of moderate physical training of strength and endurance. Design: PSF was measured with the fatigue severity scale FSS and tested with a two-sample t-test for dependent samples (both-sided, one-sided after Bonferroni-correction). Results: 66,7% of the patients had a PSF (FSS >=4) at admission and discharge. 40% of the patients had an average score of 5 or higher at admission and 30 % at discharge. The values of the total scores showed only slight fluctuations, 16,7% of the patients improved 3 or more points at a maximum score of 63 points, 83,3 % remained approximately equal (range -2 to +2), no case of deterioration of 3 or more points. The average score reduced from 4,3 +-1,7 to 4,2+-1,4, statistical analysis revealed no significant differences. Conclusions: We saw 2/3 of the patients with a proven PSF (average score >= 4) at admission and at discharge. FSS remained approximately equal in 5/6 of the patients, statistics showed no significant difference. In many PSF-cases, rehabilitation intensity of training in the rehabilitation in the subacute phase must be reduced, with potentially negative consequences for the outcome. Initiation of prolonged physical training after the discharge is necessary. Some studies reported a reduction of the post stroke fatigue, but it is not known if the reduction of fatigue was a result of the physical training alone or a combination effect of physical training and cognitive behavioral therapy. It is may be necessary to initiate some ongoing trials that compare the effects of physical training, cognitive training, or both. Evidence is insufficient to recommend the use of a specific treatment to treat or prevent post-stroke fatigue.

 Favorable rehabilitation course of a patient with status post resection fungal brain mass



He Meng, Anusha Lekshminarayanan, Eric L. Altschuler

Case Diagnosis: 57-year-old male with past medical history of Type 2 diabetes mellitus, hypertension, initially presented with seizures. Neuroimaging (computed tomography and magnetic resonance imaging head) revealed a destructive mass in the right nasal cavity, destruction of the cribriform plate and mass (6 x 2 x 3 cm) in the right inferior frontal lobe. Sinus biopsy showed fungal mass which was extensively debrided and resected. In order to prevent cerebral herniation, the airway was secured with a tracheostomy, nutrition provided with gastrostomy tube. Based on culture-sensitivity, intravenous azole antifungals were begun (Isovuconazole). Case Description: He was admitted to acute inpatient rehabilitation for deconditioning caused by the traumatic brain injury (TBI) caused by fungal infection and mass resection. Despite refusal to perform therapy consistently, he progressed to performing activities of daily living (ADLs) and transfers with modified independence, speech and dysphagia improved; the tracheostomy tube removed. The patient's diet was modified to mechanical soft with honey thick liquids. Infectious disease team advised to continue the azole antifungal orally for total 6-month duration. Discussions: The incidence of central nervous system (CNS) fungal infection is increasing, recently, in neurosurgical patients. Characterized with high mortality and morbidity rate, early aggressive surgical intervention is required. CNS fungal infections with aggressive neurosurgery and antifungal use resulted in 70% survival rate. However, since there's no discussion or guidelines for rehabilitation course in the literature, identifying and characterizing issues could reduce morbidity. Conclusions: Post-surgical CNS infection can be managed using current TBI protocol and antifungal therapy to achieve the rehabilitation goals. However, further meta-analysis or randomized controlled trials might help to characterize the rehabilitation of CNS fungal infection post-resection and optimize guidelines.

 Feasibility of using a smartphone-based mobile application for weight management in obese minority stroke survivors with cognitive impairments: Pilot comparative effectiveness trial



Nneka Ifejika, Minal Bhadane, Chunyan Cai, Elizabeth A. Noser, James C. Grotta

Case Diagnosis: To test the feasibility and preliminary efficacy of using a mHealth weight loss intervention versus food journals to monitor dietary patterns in minority acute stroke patients with cognitive impairments (Swipe out Stroke). Case Description: Swipe out Stroke (SOS) is a Phase I Prospective Randomized Controlled Trial with Open Blinded Endpoint (PROBE). Adaptive randomization was used for assignment to one of two groups – 1) SmartPhone based self monitoring, 2) food journal self monitoring. The SmartPhone group used the app Lose it! to record meals, document physical activity and communicate with the study team. Reminder messages were sent daily during the first 30 days. Weekly summaries and reminder messages for missed entries were sent between 31 and 90 days; weekly summaries only were sent between 91 and 180 days. The food journal group used paper diaries to document daily dietary intake. Both the SmartPhone and food journal groups received four face-to-face visits (baseline, 30, 90 and 180 days), culturally competent counseling by a minority research coordinator, cookbooks, measuring cups and educational materials. The primary outcome was a reduction in total body weight at 180 days. Discussions: Thirty-six participants (63.9% African-American, 36.1% Hispanic) were enrolled, 17 in the SmartPhone group, 19 in food journal. Mean age 54.1 (SD 9.4), BMI 35.7 (SD 5.7) education, employment & family history of stroke or obesity did not differ between the groups. Rates of depression [median Patient Health Questionnaire-9 (PHQ-9) 5.5; IQR 3.0 – 9.5) and cognitive impairment [median Montreal Cognitive Assessment (MOCA) 23.5; IQR 21 – 26] were similar in both groups. Sixty-nine percent of stroke survivors completed SOS (n=25); one participant died (SmartPhone group). Depression was higher at 30 days in the food journal group (PHQ-9 of 8 vs 2; P=0.03). At 180 days, the SmartPhone group had more cognitive impairments (MOCA 23 vs 27; P=0.04). Median weight change was 5.7 pounds in the SmartPhone group versus 6.4 pounds in the food journal group (P=0.77). In depressed participants, the median weight change was 3.9 pounds compared to 6.4 pounds (P=0.45). Conclusions: In this study of minority stroke survivors, there was no significant difference in weight loss between the SmartPhone and food journal groups. While feasible, the use of SmartPhone based self-monitoring in this vulnerable population has a unique set of challenges, including concomitant depression and cognitive impairments. Future studies that include pharmacologic and behavioral treatment of post-stroke depression, post-stroke cognitive therapy and mHealth interventions over a shorter duration, may positively influence intervention efficacy.

 Femoral neuropathy as a unique presentation of heterotopic ossification in anoxic brain injury



David Oh, Esther Yoon, Chad Metzger, Paul Chan, Miriam Segal, Channarayapatn Sridhara

Case Diagnosis: Femoral Neuropathy due to Heterotopic Ossification in the Iliopsoas. Case Description: 65-year-old male with anoxic brain injury due to cardiac arrest who presented for acute rehabilitation. On admission, he was found to have left lower extremity pain and weakness with 1/5 strength in hip flexors and knee extensors. An electrodiagnostic study revealed active denervation of left femoral nerve innervated muscles and no voluntary motor unit potentials in the rectus femoris and iliopsoas. Findings were suggestive of localized peripheral neuropathy of left femoral nerve. Imaging revealed potential heterotopic ossification (HO) in the left iliopsoas muscle and was confirmed with a triple phase bone scan. He was treated with IV pamidronate, vitamin D supplementation and calcium level monitoring. Discussions: HO is a common complication of trauma, spinal cord injury, or traumatic brain injury. This is an unusual case where HO affected the iliopsoas in the area of the femoral nerve, resulting in a focal neuropathy with active denervation. During inpatient rehabilitation, the patient had prompt diagnostic workup and treatment with intravenous bisphosphonates. His therapy regimen was modified to focus on physiological functional activities along with avoidance of resistance exercises and electrical stimulation, so as not to interfere with axonal regeneration and peripheral sprouting. Outpatient evaluation three months post-radiological diagnosis revealed improvement to 3/5 left hip flexion and 1/5 knee extension strength. The patient was able to ambulate at close supervision level with a dual channel MAFO and an anterior floor reaction component to prevent buckling. Repeat electrodiagnostic studies are pending. Conclusions: This case highlights an unusual presentation of heterotopic ossification in the region of the iliopsoas as a cause of focal femoral neuropathy in the setting of anoxic brain injury. It is important for providers to recognize the value of prompt diagnostic workup as well as appropriate pharmacologic and therapeutic treatment in an interdisciplinary setting.

 Fluctuating mental status and new paradoxical left hemispatial neglect during inpatient rehabilitation for left temporo-occipital intracerebral hemorrhage with intraventricular hemorrhage



Justin L. Weppner, Jenna Meriggi, Kevin Franzese

Case Diagnosis: Cerebral vasospasm in the setting of intracerebral hemorrhage (ICH) with intraventricular hemorrhage (IVH). Case Description: 61-year-old man admitted to inpatient rehabilitation (IPR) following a spontaneous left temporo-occipital ICH with IVH. On acute hospital day (HD) 2 the patent underwent an angiography that did not reveal a source of bleeding. His external ventricular drain (EVD) was removed on acute HD 12. The patient was discharged on HD 13 to IPR. On IPR HD 3, during interdisciplinary conference, the therapy team noted the patient was exhibiting new paradoxical left hemispatial neglect which did not anatomically correspond with the diagnosis of left ICH. Physical examination revealed a drowsy patient with a new left hemispatial neglect with a right gaze preference. CT angiogram revealed diminutive caliber of the bilateral proximal A1 and M1 segments which was consistent with cerebral vasospasm. Discussions: When physical examination findings are conflicting with the expected findings based on radiographical anatomy further evaluation is warranted and a broad differential diagnosis should be considered. Strong interdisciplinary teamwork is a hallmark of effective rehabilitation management and encouraging all members of the team to feel comfortable reporting concerns noted on therapy or nursing evaluations is vital. Active listening and addressing therapy team concerns improves the effectiveness of medical care provided on the rehabilitation unit. While ICH is not commonly associated with cerebral vasospasm, practitioners treating patients with ICH should be aware of the risk of cerebral vasospasm associated with IVH. While the true incidence of cerebral vasospasm secondary to ICH with IVH is not well described one study reported cerebral vasospasm in 5.6% of patients. Conclusions: Physical exam findings should be correlated to radiographic anatomy and if discordant further evaluation should be conducted. If a patient with ICH with IVH experiences a clinic deterioration during IPR cerebral vasospasm should be considered in the differential diagnosis.

 Focal enoxaparin-related hematomas causing thigh swelling in a spinal cord injury patient: A case report



Theodora Wong, Shane Davis, Sujin Lee, Jay Han

Case Diagnosis: Hematomas associated with low-molecular-weight heparin are usually described as developing spontaneously, especially retroperitoneal. Few studies reported thigh hematomas, and none showed small, localized hematomas leading to persistent swelling. We report an unusual presentation of thigh swelling as a manifestation of enoxaparin-related focal hematomas. A 40-year-old male presented with progressive ascending paresthesias secondary to a non-traumatic T7 AIS A spinal cord injury (SCI). He underwent T10-T11 laminoplasties with intramedullary spinal cord lesion resection. Case Description: After admission to inpatient rehabilitation, the patient developed mild fever and bilateral thigh swelling, greater on the left. Compression and elevation provided minimal improvement. Doppler ultrasound was negative for deep vein thrombosis (DVT) and pelvis/femur X-rays did not reveal bony abnormalities. CT and MRI scans of the femur showed diffuse hypodensity in bilateral thigh musculature and thick rim-enhancing multifocal fluid collections up to 1.8 cm in the left vastus intermedius, suggestive of hematomas, myonecrosis with ossification, or myositis ossificans. It was found that the subcutaneous enoxaparin used for post-op DVT prophylaxis was administered in alternating thighs due to patient preference. Injections were moved to the abdomen, and indomethacin was initiated as myositis ossificans/heterotopic ossification prophylaxis with gradual resolution of symptoms. Cephalexin was used for prophylaxis given the rim-enhancing fluid collections on imaging and fever. Discussions: This is a case of enoxaparin-induced hematomas causing thigh swelling in a new SCI patient. A likely contributing factor involved the location of enoxaparin injections, since symptoms gradually improved after site was moved from thigh to abdomen. Early development of heterotopic ossification may also be a concern, although imaging was inconclusive. Conclusions: Caution should be exercised when administering subcutaneous DVT chemoprophylaxis to an alternative area with less sensation and less subcutaneous fat. Unexpected complications such as intramuscular hematoma or infection may occur.

 Focal sustained facial seizure following an arteriovenous malformation, Todd's paralysis with a twitch: A case report



Joseph M. Seldin, Madhavan Elangovan, Sarah Khan

Case Diagnosis: Our report details the case of a 68-year-old man who presented to our acute inpatient rehabilitation facility after suffering a seizure associated with prolonged left-sided arm and facial weakness due to Todd's paralysis. The patient later suffered a focal facial seizure requiring transfer to neurology service. Case Description: A 68-year-old man with a history of intracerebral hemorrhage secondary to arteriovenous malformation in 2010, treated with surgical clipping and ventriculoperitoneal shunting. Since then the patient suffered recurrent seizures which were well controlled with anti-epileptic drugs. However, June 2019 he presented to the ER with a tonic-clonic seizure followed by left-sided facial/arm paralysis. The patient had a negative stroke work up and was diagnosed with Todd's paralysis. He was discharged to acute rehabilitation once medically stable. On his third day of rehabilitation, the patient was noted to have sustained facial twitching, refractory to his anti-epileptic medication regimen including STAT doses of Ativan. He was transferred back to the neurology, where administration of benzodiazepines resulted in over-sedation and did not address his facial motor symptoms. Phenobarbital was added to his medication regimen, which improved his symptoms. Discussions: Although arteriovenous malformations can be treated surgically, decreasing the risk of further intracranial hemorrhage and hypertension, the presence of a long-standing seizure focus can be debilitating many year later. As we see in this patient who presented with intractable seizures and Todd's paralysis. It is important however to be able to identify a sustained facial twitch as a focal seizure which may require transferring to neurology service for further management. Conclusions: We thus present a case of Todd's Paralysis secondary to a seizure originating from a surgically clipped arteriovenous malformation. Although seizures are a common sequela of this type of malformation, proper diagnosis and management of all medical and functional complications in these patients are important.

 Follicular helper T-cell lymphoma with secondary EBV diffuse large B-cell lymphoma presenting as spinal cord compression syndrome: A case report



Mothi Babu Ramalingam, Soo Ting Kong

Case Diagnosis: Follicular Helper T cell Lymphoma with secondary EBV Diffuse Large B Cell Lymphoma. Case Description: A 57-year-old female with history of schizophrenia presented with progressive bilateral lower limbs weakness and urinary incontinence. MRI Spine showed an intra medullary enhancing mass in the thoracic region. Patient underwent T9 to T 11 laminectomy with biopsy which showed inflammatory and necrotic changes with no evidence of malignancy. CT imaging showed heterogeneously enhancing hypo dense lesions in the right adrenal gland and biopsy of the lesion showed necrotizing lymphohistiocytic inflammation. She was empirically treated as disseminated tuberculosis but the TB work up was negative . She was transferred under inpatient rehabilitation unit for spinal cord injury rehabilitation. Her stay under rehabilitation was complicated by recurrent fevers , postural hypotension episodes and pulmonary embolism. Discussions: Patient developed massive saddle pulmonary embolism during her inpatient stay, In view of persistent fever and thrombotic event she underwent imaging which revealed worsening bilateral adrenal masses. In view of high suspicion for hematological malignancy bone marrow aspiration and trephine biopsy was performed , the results of which were inconclusive. After multi-disciplinary discussion, patient underwent laparoscopic right adrenalectomy. The histopathology results confirmed T Cell Lymphoma with secondary Diffuse Large B Cell Lymphoma. Patient was started on chemotherapy but her lower limb tone remained flaccid and sensory motor deficit did not improve over the stay . She is on regular physical therapy to prevent chemotherapy related impairments such as fatigue. Conclusions: Early treatment of underlying hematological malignancy is crucial for neurological and functional recovery in metastatic spinal cord dysfunction. This case illustrated that there is a possibility that early disease modifying treatment combined with appropriate surgical intervention may improve the overall outcome of patients with metastatic spinal cord compression.

 Foot drop following proximal tibia intraosseous cannulation: A case report



Charnette Lercara, Susan Stickevers

Case Diagnosis: Foot drop following intraosseous cannulation. Case Description: An 81-year-old diabetic female presented with cardiac arrest. During resuscitation, intraosseous access was obtained via the proximal anterior tibia after multiple failed attempts at lower extremity intravenous access. Subsequently, she was noted to have new-onset foot drop. Exam revealed a small punctate scab at the anterior tibia along the tibial spine, with no palpable collection or drainage appreciated. Ankle dorsiflexion, eversion, inversion and plantar flexion was 1/5, 1/5, 2/5 and 5/5 respectively. She also reported hyperesthesias in the distribution of the superficial peroneal nerve. Upon discharge two weeks later, she continued to experience hyperesthesias but showed mild improvement in her muscle strength (ankle dorsiflexion, eversion and inversion was 2/5, 2/5 and 3/5 respectively) and was fitted with a posterior leaf spring AFO. Discussions: This case illustrates an unexpected outcome following CPR via intraosseous cannulation - an otherwise safe method of obtaining vascular access. Our patient's foot drop may have occurred secondary to poor intraosseous needle placement as the deep peroneal nerve runs lateral to the tibial spine. However, she also had superficial peroneal nerve involvement suggesting either an additional proximal insult to the common peroneal nerve or an anatomical variant of the common peroneal nerve, branching more distally and anteriorly than expected, allowing both nerves to be affected simultaneously. Another possibility is that the common peroneal nerve was injured by the tourniquet placed on the distal thigh during the attempted placement of the lower extremity intravenous line. Two months later, the patient didn't have any further motor recovery and declined electrodiagnostic testing. As a result, we can only presume that there is a link between the intraosseous catheter placement and her clinical presentation. Conclusions: This is the first reported case, to our knowledge, of peroneal nerve injury following intraosseous cannulation at the tibia resulting in foot drop.

 Foot drop in an 80-year-old tennis player: A case report



Michael J. Andrews

Case Diagnosis: Left Common Peroneal Neuropathy. Case Description: 80-year-old female was referred for evaluation of progressive left foot drop of three months duration. Physical exam demonstrated trace muscle activation left ankle dorsiflexion and extensor hallicus longus where the left hip and plantar flexors was normal. Sensation was reduced over dorsum of left foot. Further history revealed that the patient had been wearing a neoprene sleeve over her left knee while playing tennis three to four times per week. NCS: Left common peroneal nerve demonstrated prolonged latencies, significantly decreased amplitudes and slowed conduction velocities. Left tibial, right tibial and common peroneal nerves were normal. Sensory responses were unresponsive at left sural and superficial peroneal nerves. Left common peroneal nerve “F” wave was absent. EMG: Left tibialis anterior, extensor hallicus longus, and extensor digitorum brevis muscles showed positive sharp waves, fibrillation and long duration polyphasic potentials. Tibial and femoral nerve muscles were normal. Discussions: Common peroneal neuropathy is the most common compression neuropathy of the lower extremities resulting from trauma or more chronic external compression (mass lesion) or prolonged immobilization. Leach et al reported seven runners and one soccer player with this condition secondary to exercise who were treated surgically. Nerve conduction studies and needle EMG evaluate the severity of nerve compression and extent of axonal injury, which can guide in treatment and prognosis. Predictors of poorer outcome include evidence of denervation injury on electromyography, severe weakness at onset, and age (Bsteh G. et al). Unfortunately, this elderly patient endured months of symptoms before diagnosis and appropriate intervention. Conclusions: Common peroneal compression neuropathy secondary to wearing below-knee compression stockings (Malhotra et al.) and wearing KBM prosthesis (Reinders MF et al. ) have been described. The case presented above demonstrates a unique cause of common peroneal nerve entrapment resulting from chronic use of an over-the-counter neoprene knee sleeve.

 Foot pressure distribution characteristics during walking of flat foot students aged 7-14 years old



Zhiguan Huang

Objectives: Flat foot greatly increases injury risk and with a high incidence of flat feet in adolescence. This study compares the distribution characteristics of plantar pressure between the flat foot and normal arch foot in Guangzhou students. Design: Six hundred fifty-eight students aged 7-14 years old in Guangzhou were investigated, with 341 males and 327 females. The arch foot type was evaluated by the foot mark of the subject on Footdisc foot measurement board (Taiwan), which by the principle of thermal imaging. Foot pressure distribution characteristics during walking were tested by the pressure plate (Sensor Medica, Italy, with 50hz frequency and resolution of 2.5dpi and 8bit). All data are conducted by SPSS21.0 and analyzed by independent sample t-test, with P< 0.05 for a significant difference. Results: Flat feet incidence accounted for 35%, with a significantly higher rate in boys than that in girls. During walking at self-choose speed, compared to normal arch teenagers, there was different foot-ground contact area ratio under the areas of both MF (7-9 years old), right foot MF (11-13 years old) and right foot MF-L (15 years old) in flat feet teenagers (P < 0.05), while showing significantly higher pressure peak value under some areas of both feet (P< 0.05). Conclusions: Foot-contact area and pressure are two major factors affecting the pressure distraction, the lower arches with the larger archer-ground contact area will lead to less pressure. During walking, the difference in plantar impulse is mainly manifested in the internal and external lateral area of the arch, where with higher injury risk.

 From cold sore to encephalitis: A case report



Stephen W. Peirce, Alexandru Dinu

Case Diagnosis: Herpes Simplex Virus 1 Encephalitis. Case Description: 54-year-old female, previously healthy and active with no past medical history, presented with flu-like symptoms and new-onset seizures. Admitted to the ICU for status epilepticus in the setting of HSV1 encephalitis, confirmed with lumbar puncture and consistent with findings on MRI brain. She was placed in a medically-induced coma and started on Keppra and Acyclovir. Acute hospitalization was complicated by tracheostomy placement due to respiratory failure and PEG tube placement. She became more responsive with persistent left sided weakness and left hemianopsia. Physiatry was consulted and she was admitted to inpatient rehabilitation after 21 days of acute care. On admission to rehab, she was fully oriented however answered only to yes/no questions and was minimally responsive to commands. She worked intensively with physical, occupational, and speech therapy for three weeks. Discussions: HSV1 encephalitis is the most common cause of fatal sporadic encephalitis in the US. Even when treated, mortality approaches 30% with most survivors having serious neurologic deficits. This patient's case is uncommon especially in the setting of an otherwise healthy individual. An inpatient rehabilitation setting was imperative to her remarkable recovery with the numerous resources available. By discharge, she was ambulatory over 150 feet with supervision and able to perform functional ADLs. FIM scores were 6, 5, and 7 for PT, OT, and ST respectively upon discharge; up from 1-2 throughout at time of admission. Various other therapies were beneficial including; Aquatic, Recreational, and Family Therapy. Thereafter, treatment consisted of 6 weeks of intravenous Acyclovir with two additional weeks of oral Valacyclovir. Conclusions: The clinical course of HSV1 encephalitis secondary to a recent “cold sore” in an otherwise healthy patient has a sudden onset and usually a poor prognosis. However, with the correct treatment followed by aggressive rehabilitation; the prognosis is very favorable.

 Functional and socioprofessional consequences of trauma to limbs seen in physical medicine and readapatation at Chu-Anosiala Madagascar: A prospective descriptive study



Andréa Holiarisoa Raharinantenaina

Objectives: The goal of the rehabilitation of limbs' post-traumatic patients is to restore functional independence in order to allow reintegration into their socio-professional context. The Objectives of our study are to describe the functional consequences and the socio-professional future of patients suffering from trauma of the limbs followed in Physical Medicine and Rehabilitation. Design: This was a prospective descriptive study of trauma-affected patients of limbs admitted to the Physical Medicine and Rehabilitation (M.P.R) department of the CHU - Anosiala during the period from 01 November 2018 to 01 February 2019. During this period, 21 patient records were collected. Results: Males (52.38%) to a majority of youth with an average age of 44 years were the most affected. The professional groups were dominated by the professional profession (42.85%). The top causes were road accidents (52.38%). The PRM management time was generally within 3 months of initial treatment. On admission we noted 61.90% joint stiffness in patients. Edema and pain were associated in 57.14% and 66.66% of cases, respectively. The 71.42% had an evolutionary partial recovery. There were 71.42% of return to work cases with 2 cases of workstation layout and 28.57% of patients were not yet able to return to work. Conclusions: Injuries to the limbs are very frequent and constitute a real obstacle to the functions of the musculoskeletal system which can be re-established by an early rehabilitation or a satisfactory functional autonomy of the patient. This requires an honest collaboration between a rehabilitation specialist and a trauma and orthopedic surgeon.

 Functional impact of radiation-induced fibrosis of the neck in head and neck cancer survivors: Preliminary results



Diana Molinares, Stuart Samuels, Laura Huang

Objectives: Determine the incidence of radiation-induced fibrosis (RF) in head and neck cancer (H&NC) survivors. Determine the optimal physical exam (PE) and clinical tools Determine the impact of radiation on the musculoskeletal system. Understand potential post-radiation impairments. Design: This is a cross-sectional study to evaluate the effects of RF on H&NC survivors' function and QoL. Our Physiatry team developed a comprehensive physical and functional exam to quantitatively evaluate H&NC patients. To participate, the patient must be in remission and have received radiation >1 year prior to enrollment as treatment for a primary H&N mucosal squamous cell carcinoma or a salivary gland cancer. Subjects with traumatic neck or shoulder musculoskeletal pathology within 2 years of the treatment were excluded. Participants attended a Cancer Rehabilitation appointment, where a Board-Certified Physiatrist performed a standardized PE, with emphasis on a comprehensive neuromusculoskeletal exam. Results: To date, 25 patients have met inclusion and exclusion criteria and have undergone a Physiatric evaluation. On PE, 52% were found to have an abnormal posture of the neck. Anterocollis was the most common position (32%), followed by rotational torticollis (24%) and laterocollis (20%). 40% of participants have evidence of H&N lymphedema and 32% have moderate-severe superficial soft tissue fibrosis. 24% presented an oral cavity opening < 4cm. 100% of the participants had impaired range of motion of the cervical spine: 68% decreased neck flexion, 84% decreased neck lateral bending, 92% decreased neck extension and 92% decreased neck rotation. Conclusions: There are no data for the benefit of physiatry services in H&NC patients. Our findings demonstrate the disease and treatment related morbidity on the musculoskeletal system in H&NC patients. Post-radiotherapy evaluation, treatment and management by a physiatrist is instrumental to optimize function and QoL. This study represents the first step in creating a comprehensive, collaborative and multidisciplinary program to diagnose, treat and manage RF in H&NC patients.

 Functional outcomes and neuropsychiatric management of patient with autoimmune chorea: A case report



Susan Samuel, Calvin R. Chen, Sarah Khan

Case Diagnosis: This report details the rehab course of an 86 year old female with autoimmune chorea. She was admitted for altered mental status likely multifactorial in etiology due to an underlying autoimmune disorder and a urinary tract infection. Her rehab course was complicated by agitation requiring psychiatric medications. Case Description: The patient was recently diagnosed with autoimmune chorea and had been treated with intravenous immunoglobulins for the last 2 months every three weeks prior to admission to the acute care hospital. She returned with worsening confusion and agitation. MRI, lumbar puncture and EEG were completed with no acute findings. Infectious workup demonstrated an UTI and she was treated with antibiotics. She was also treated with a course of high dose steroids and IVIG. She was medically optimized and admitted for comprehensive acute inpatient rehabilitation. The patient's rehab course was complicated by increased confusion and agitation. Psychiatry was consulted and patient's symptoms were managed with Seroquel and Depakote. She was also found to have another UTI and successfully treated with antibiotics. Patient progressed to the level of supervision/min assist and successfully discharged to the community. Discussions: Autoimmune chorea is a rare form of movement disorder that affects a patient's functionality including ADLs and mobility. Patients can present with unexpected neuropsychiatric symptoms that often hinder their functional progress with therapies. In this case report, we will discuss the utility and benefits of an acute inpatient rehabilitation and pharmacological regimen for patients with this rare disorder in order to be able to achieve functional gains for discharge home. Conclusions: We present a rare case of autoimmune chorea with associated neuropsychiatric symptoms affecting their function and quality of life. An acute inpatient rehabilitation environment allows for proper neuropsychiatric medication management and a comprehensive therapy program for patients to safely return to their community.

 Functional profile of oncologic outpatient at instituto nacional de cancerología according to international classification of functioning, disability and health



Anamaria Hernandez-Rivera, Miguel Moreno, Angela Suarez

Case Diagnosis: The objective of the study is to describe the functioning profiles of adult cancer patients treated in the outpatient rehabilitation service, in accordance with the nomenclature proposed by the CIF, taking into account sociodemographic and clinical variables. Case Description: Descriptive cross-sectional study, including patients diagnosed with cancer valorated for first time at outpatient rehabilitation. Population was made by random sampling. The definition of the functional profiles was carried out through multiple correspondence analysis. Discussions: 1.We included 260 from 1907 patients assessed at outpatient rehabilitation consultation. 2.The most frequent cancer groups referred to rehabilitation were; breast cancer, head and neck cancer, hematolymphoid malignancies, genitourinary tumors and musculoskeletal tumors. 3.Functional profiles complexity is related with; age of patient, advanced oncological diseases, poor symptomatic control and the requirement of multimodal oncologic treatment (chemotherapy, radiotherapy and surgery). 4.Body structural alterations were related with the cancer location, and the treatment required if it was surgery or radiotherapy. In other hand body functional alterations are more frequently related with the cancer behavior, comorbidities and the impact of treatment, becoming more frequently presented the neuropathy related with cancer and the movement alterations. Conclusions: The findings of the present study are relevant in the definition of short lists of the international classification of functionality for cancer patients, in addition to the availability for breast cancer and head and neck tumors. The functional profiles in cancer patients are a needed for focus the attention on relevant topics required in the functional surveillance of the cancer patient in the rehabilitation scenario, in face of disability high risk. This vision strengthening the need for early and appropriate rehabilitation intervention strategies, with clinical well oriented measures supported by standardized functional tests.

 Functional profile of stroke survivors according to Brazilian functioning index



Marcelo Riberto, Juliana Coelho, Thabata Soeira, Patricia Vianna, Rafael Rocci

Objectives: Background: The Brazilian Functioning Index (IF-Br) was developed and published by an interministerial task force at the request of the Presidency of the Republic of Brazil, aiming to standardize and quantify the functioning assessment of people with disabilities aiming for specific social policies. Aims: To analyze psychometric properties and the functional profile of stroke survivors using the IF-Br. Design: Methods: An observational, longitudinal, prospective, and descriptive study. In order to ascertain intra and inter-examiner concordance two evaluations were conducted, with a six-month interval between them, in which the IF-Br was applied and compared with another evaluation instrument, the Functional Independence Measure (FIM)™, in 53 individuals (men 56.6%, mean age: 62.7±13.5) that had a history of Stroke from December 2016 to May 2019. Results: The Spearman correlation between the IF-Br and the FIM™ was performed (0.86; p < 0.001), after which a strong, positive relationship was observed, indicating that the functional assessment instruments are directly proportional. When comparing the inter-examiner data, all of the correlations were identified as positive among the Stroke individuals. In turn, when analyzing the intra-examiner data during the six-month interval, both evaluation instruments displayed positive associations, and all of the Stroke individuals were observed to be more functional. Among the seven domains that compose the IF-Br, the sensorial, domestic life and education, work, and economic life domains did not exhibit any correlation with FIM™. Conclusions: The IF-Br is considered a complete evaluation instrument to assess functional profiles since it analyzes aspects that are not contemplated in other tools, such as Environmental Factors.

 Functional questionnarie about people with spinal cord injury



Daniela M. Utiyama, Fabio M. Alfieri, Artur Aquino, Linamara R. Battistella

Objectives: The objective is available the function capacity with spinal cord injury. Design: Application of international questionnaire by telephone, in person and internet. Results: We have 200 questionnaries. The Results will be analyzed and the correlations will be between function condition and time of injury and education. Conclusions: The conclusion is people with spinal injury in Brazil need more support to do the daily activities.

 Functionally impairing hyperreflexia and its clinical significance in brain injured patients



Darshan I. Shah, Jacob Rohrs, Reed C. Williams

Case Diagnosis: Spasticity and clonus result from upper motor neuron (UMN) pathology that disinhibits a tendon stretch reflex. While spasticity often occurs with clonus, the two are clinically different. Spasticity is velocity-dependent increased resistance to passive stretch whereas clonus is rapidly alternating involuntary muscular contraction and relaxation. Because subtypes of hypertonia are difficult to distinguish by patients, the symptoms are reported as “spasms.” Completing a thorough neurological examination can clarify type, and help focus treatment. Case Description: 21-year-old female with a history of right insular arteriovenous malformation and rupture at age 12, with subsequent recurrent seizures and residual left functional hemiparesis, presents to multiple providers complaining of a “trembling left foot” and falls; prompting an extensive, negative, seizure workup. The progressive “trembling” has deleterious effect on her baseline, chronically stabilized, hemiplegic-gait and is contributing to instability. Examination in physiatry clinic revealed increased left-sided spasticity with new-onset ankle clonus, which the patient confirms as the “foot tremble” instrumental to her falls. Protecting the functional use of spasticity at her hip/knee, she was referred for chemodenervation of the plantar-flexors and a stabilizing ankle-foot orthosis. Discussions: The patient benefitted from a comprehensive evaluation by rehabilitation medicine and a multimodal approach to management. One pattern of brain injury recovery can be extensor synergy. Her quick gait speed and rapid dorsiflexion after initial contact activates a self-sustained stretch reflex activating her ankle clonus. A focal botulinum-toxin injection in the gastroc-soleus complex can reduce spasticity and avoid the cognitive impairment and potential global weakness associated with oral agents. Prescription of an ankle-foot orthosis and gait training will decrease her fall risk. Conclusions: A thorough neurologic examination is essential in uncovering the functionally impairing sequelae of brain-injured patients. Uncovered exam findings also prompted evaluation by the neurosurgical team to address the worsening UMN signs as a possible marker of neural hyper-excitability.

 Gait intention detection for transfemoral amputees



Junghwa Hong, Hunhee Kim, Taekyeong Lee

Case Diagnosis: Recently advent power knee prostheses for assisting transfemoral amputees' gait require capabilities in ascending and descending stairs and slopes. As a result, the power knees should adapt or change powered mechanisms for depending on the level, stair, and slope. Therefore, the knee prostheses should know the gait intentions of transfemoral amputees. Since EMG activities of transfemoral residual muscles such as the rectus and bicep femoris have correlations with the hip moments of the transfemoral amputees, it could be closely related to the user's gait intention. Thus, EMG activities of the residual rectus and bicep femoris could be utilized for detecting gait intentions of the above-knee amputees. However, the EMG activities in the thigh stump of transfemoral amputees have significantly different depending on individuality. As a result, a detecting gait intention requires intelligence for training each individual EMG patterns. Case Description: The purpose of this study is to develop a detection method using an adaptive filter and a time-delayed neural network (TDNN) to detect gait intentions based on the surface EMG (sEMG) from the residual rectus and bicep femoris of transfemoral amputees' gait. Two transfemoral amputee subjects participated in the experiment. 3D kinematics and kinetics were acquired at normal walking speed. Discussions: A gait state was predicted using sEMG signal that was adjusted the adaptive filter and then applied to TDNN. The estimated sEMG signals using the adaptive filter were fitted well to the real or measured sEMG signals without amplitude losses. After applying TDNN, the time delay was 24ms. However, the trained sEMG predicted a gait state by the predictive accuracy of 92.3%. Conclusions: The prediction was successful, but more accuracy for the prediction is required for a practical application. To do that, more measured sEMG from the other residual muscles would be required for future research.

 Getting over the wall of wallenberg: A case report about a multidisciplinary rehabilitation team approach



Yulia Rivelis, Jennifer M. Cushman, Mery Elashvili

Case Diagnosis: A 59 year old female with Wallenberg Syndrome presented to acute inpatient rehabilitation with a past medical history significant for hypertension and fibromyalgia complained of acute onset of headaches, left facial numbness, right-sided weakness, ataxia, dizziness, and vomiting, which led her to call EMS. Imaging revealed a left medullary infarct and 24 hours later, she began to exhibit hoarseness, hiccups, and dysphagia as well as left sided facial droop with decreased sensation and left tongue deviation. Case Description: This patient showed great improvement throughout her rehabilitation course. She initially presented with complaints of acute onset of headaches, left facial numbness, right-sided weakness, hoarseness, ataxia, dizziness, and vomiting. Truncal ataxia and ambulation showed significant improvement with physical therapy, and sensory deficits slowly recovered with therapeutic modalities such as electrical stimulation. With the aid of speech therapy, her diet was gradually advanced until she no longer required PEG tube feedings and tolerated an oral diet. Patient will still require ENT outpatient follow-up to evaluate her vocal cord weakness as one of the sequelae resulting from Wallenberg syndrome. Discussions: Lateral medullary syndrome, also known as Wallenberg syndrome or posterior inferior cerebellar artery (PICA) syndrome, is a rare presentation causing a variety of symptoms due to ischemia in the lateral portion of the medulla within the brainstem. Symptoms include sensory deficits to the contralateral trunk and extremities, while affecting the ipsilateral face and cranial nerves. Dysphagia, dysphonia, and Horner syndrome are also common clinical findings. Wallenberg syndrome affects many anatomical structures, including the nucleus ambiguous, trigeminal nucleus, spinothalamic tract, cerebellum, and vestibular nuclei. Conclusions: This case highlights the many complications of Wallenberg syndrome and the subsequent need for a multidisciplinary rehabilitation treatment approach to manage the sequelae and manifestations resulting from a medullary stroke.

 Glasgow Coma Scale-age prognosis score as a tool to predict functional outcomes in geriatric patients with traumatic brain injury



Xin Yi Yap

Case Diagnosis: The wave of “silver tsunami” around the world has also brought about an increasing incidence of traumatic brain injury in geriatric patients. Falls are a leading cause of TBI in the elderly, followed by motor vehicle accidents. There is a need for a simple tool to gauge the effects of the injury on patients. The Glasgow Coma Scale (GCS) - age prognosis (GAP) score, calculated as age/initial GCS, was proposed as a means to reliably predict inpatient outcomes in the acute setting. We look at how it applies to functional outcomes for patient a few months later. Case Description: We performed a retrospective analysis of patients who were discharged from a brain injury rehab facility over a 24 month period from February 2016-February 2018, over the age of 65 years old. The GAP score was calculated for all patients. Primary outcome measures include duration of PTA , length of stay in a subacute rehabilitation unit, and GOS-E scores in 6 months. Secondary outcomes include discharge destination. Discussions: A total of 106 patients were included. Mean age was 72.28, and there were 66 (62.26%) males and 40 (37.74%) females. There was a significant correlation between the GAP score and PTA duration (p=0.017) as well as length of stay. (p=0.041) The trend observed was also that for patients with a higher GAP score, they are more likely to be discharged to a care facility. There was no statistical association between the GAP score and GOS-E at 6 months. Conclusions: For geriatric patients with TBI, the GAP score can be a simple and effective tool to predict functional outcomes 6 months later. However, a prospective study with bigger sample size should be performed to further validate this.

 Greater occipital nerve block as treatment for persistent headache in cerebellar stroke with hemorrhagic transformation



Bari A. Madureira, Kevin Sperber

Case Diagnosis: Persistent headache after cerebellar stroke with hemorrhagic transformation. Case Description: 86yo M with PMHx hypertension, hyperlipidemia, BPH, atrial fibrillation (not on anticoagulant) presented to the ED with new onset headache associated with diaphoresis & tinnitus. Found to have left cerebellar infarct on MRI with noted deficits in balance and gait on exam. Once stabilized, patient transferred to acute rehab. Headache/dizziness persistent during admission. Dizziness unresponsive to trial of meclizine/reglan which was discontinued due to concern over urinary retention/confusion; headache unresponsive to tylenol. Repeat imaging obtained two weeks post-admission revealed hemorrhagic transformation. Due to headache persistence, pain management consulted who recommended consideration of greater occipital nerve block. Hemorrhagic transformation stable on multiple repeat CT scans and patient brought to outpatient clinic for recommended injection with combination of lidocaine, bupivicane & depomedrol. Patient had significant improvement in headache symptoms with only mild tenderness at injection sites in the days following. He was discharged from rehab to home the week following injection. Discussions: Occipital nerve blocks are considered a treatment option in various etiologies of headache including chronic cluster headaches, migraines, occipital neuralgia & post-dural puncture. However, there is limited data in regards to occipital nerve blocks in patients with persistent headache after stroke. The incidence of headache after stroke varies among studies and is recorded to occur in somewhere between 9% & 38% of patients. It is more common in those with intracranial hemorrhage due to irritation of surrounding structures. Other means of treatment (ie. NSAIDs) are frequently avoided in these patients particularly during the acute period after hemorrhage due to increased risk of bleed. Thus other methods should be considered. Conclusions: Greater occipital nerve block may be a treatment option in patients with persistent headache after hemorrhagic transformation particularly in those in whom other options are not viable or in whom conservative management has failed.

 Hair cutter's palsy – A new occupational focal dystonia: A case report



Eric L. Altschuler, Kasandra Erazo

Case Diagnosis: Focal right hand occupational dystonia associated with cutting hair. Case Description: A 39 year-old right handed without significant past medical history working as a hairdresser—up to 20 cuts a day—with chief complaint of right hand pain, numbness, and tingling for over a year was seen for electrodiagnostic study. There was no pain at the time of presentation. Numbness and tingling worsened at night. She reported occasional neck pain; no right shoulder pain. On physical exam, right abductor pollicus brevis and hand intrinsic with 5/5 motor strength with full range. Light touch was intact and the same as the left hand. Tinel's of the right wrist was negative. Right median and ulnar motor and sensory conduction studies showed normal latencies, amplitudes, and conduction velocities. The right median-radial comparison study showed normal right radial nerve and no slowing of the median nerve compared with the radial nerve. Further history revealed significant pain, not numbness, as the work day progressed. Discussions: Given the patient's normal exam and negative electrodiagnostic studies, carpal tunnel syndrome is unlikely. Instead, we think she has a focal vocational hand dystonia. Along with reassurance and referral to occupational therapy, we suggested the patient try cutting hair with her left hand. The first occupational focal hand dystonia, writer's cramp, was described by Bernardino Ramazzinni in a Supplementum to the 1713 second edition of his classic De Morbis Artificum (”Diseases of Workers”). Writer's cramp has nearly become extinct as a diagnosis due to copy machines and computer word processing. New diseases can arise. Conclusions: Hair cutting as a vocation may be a risk factor to develop an occupationally associated focal hand dystonia. Barriers to cutting with the non-dominant hand are numerous, however, but could be worth teaching in hair cutting schools. Ways to prevent, ameliorate or treat this focal dystonia are worthy of further study.

 Hand dexterity in cervical stenosis



Jeremy Lou, Tiffany Su, Ken Makovsky, Anne Nastasi, Resa Oshiro, Agnes Wallbom

Objectives: Cervical spondylytic myelopathy (CSM) may negatively impact upper extremity function and fine motor control. There are several validated tools for measuring dexterity in neurologic diseases. The nine-hole peg test (9-HPT) is one such test that was validated in patients with multiple sclerosis. The gold standard for evaluating neurologic function in patients with CSM is the Japanese Orthopaedic Association (JOA) score, which was later adapted into the Modified Japanese Orthopaedic Association (mJOA) since the JOA had poor external validity in Western populations. The mJOA assesses upper limb motor dysfunction, lower limb motor dysfunction, upper limb sensory dysfunction, and bladder dysfunction. It has demonstrated a significant correlation with recovery rate in patients receiving surgery for CSM. Our aim is to establish a correlation between the 9-HPT and mJOA in patients with CSM. Design: This is a prospective, single-blinded observational pilot trial. We aim to study 64 patients referred for cervical stenosis at the West Los Angeles Veteran's Healthcare Center Outpatient Spine Clinic. Subjects will complete the mJOA questionnaire, followed by the 9-HPT, which will be recorded. The main outcome measures are the mJOA score and timed 9-HPT results. Results: 11 participants have been enrolled in the study, all male and right-handed. The average age was 62. The mean 9-HPT score was 28.7 seconds (range 20.4-38.7). Nine of 11 patients with CSM had a prolonged preoperative 9-HPT score, above the normal level for age-and sex-matched individuals. There was a strong negative correlation between the 9 HPT and upper limb mJOA score (r=-0.7, p=0.022) and between the 9-HPT and total mJOA score (r=-0.6, p=0.049). Conclusions: The 9 HPT scores were prolonged in CSM and showed a correlation with the upper limb and total mJOA scores.

 Head trauma triggering acute functional decline in adrenomyeloneuropathy: A case report



Miguel E. Velez, Jeffrey C. Schneider

Case Diagnosis: Adrenomyeloneuropathy (AMN). Case Description: 36yo male with extensive first-degree family history as well as a possible childhood diagnosis of Adrenomyeloneuropathy (AMN) who presented for evaluation following prolonged functional decline over last months. Patient remained asymptomatic from his disease until mid-20's when he developed impaired gait, calf atrophy and hand and foot paresthesias. His disease did not progress further in the following decade until some months prior to presentation when he suffered a fall off an All-Terrain Vehicle (ATV) resulting in head trauma. Following event patient noted a precipitous decline in his function over the coming months with worsening gait instability, new urinary and fecal incontinence and frequent falls. Imaging revealed spinal cord atrophy which extended through his internal capsule via the corticospinal tract into subcortical white matter which had contrast enhancement. Physical exam and imaging findings together with symptom progression supported the diagnosis AMN of which was discussed in childhood but not confirmed. Discussions: This case exemplifies typical presentation of a patient with AMN given his positive personal and family history as well as symptoms progression including impaired gait, spasticity, weakness, numbness with bowel and bladder incontinence. His overall decline in function coincided with a reported episode of head trauma which has been reported in the literature. This is thought to be secondary to an immune response subsequently triggering a change from a primarily AMN phenotype to cerebral Adrenoleukodystrophy predominant phenotype. Conclusions: AMN is a form of X-linked adrenoleukodystrophy caused by mutations in the ABCD1 gene resulting in failure of fatty acid oxidation affecting myelin in primarily in the spinal cord where exacerbation of symptoms may be seen following head trauma.

 Health maintenance tool for people with spinal cord injury: A tool for consumers from consumers



Mohit Arora, Melissa McCormick, Dimity O'Leary, Selina Rowe, Anne Sinnott Jerram, Gerard Weber, James W. Middleton

Objectives: Previous research has demonstrated that there is a clear need for a Health Maintenance Tool, which can support people with SCI with different levels of health literacy and self-management capacity, particularly after discharge into the community. The tool should also support people with SCI to manage their five key areas related to bladder, bowel, skin, autonomic dysreflexia and pain, as well as provide strategies to their caregivers and primary health care providers. Design: A mixed methods design including rapid reviews, interviews, focus-group discussions and a Delphi approach for building consensus (for bladder, bowel and skin) was undertaken. The study involved consumer group, primary care group (GPs), as well as expert group (SCI and other relevant experts). Interviews (involving consumers and GPs) and focus group discussions (involving consumers) data were analyzed using thematic analysis approach using NVivo software. Delphi surveys (involving expert group) data were analyzed using a consensus process and consensus were built on the management recommendations, red flags condition, referrals and clinical pathways. Results: Overall, 19 people with SCI, four GPs and 65 discipline and SCI-specific specialists participated in the study. The 6 key themes derived from the qualitative analysis of the interviews and focus group discussion were (1) Where do I start? (2) Best counsel? (3) Sharing knowledge (4) Timely access for help (5) Shared decisions and (7) Promoting self-management. A total of 42, 36 and 61 statements were written for bladder, bowel and skin, respectively. Two rounds of the Delphi surveys were employed to achieve complete agreement. Conclusions: The promotion and maintenance of optimal health and quality of life over the life span of an individual with SCI involves ongoing surveillance and prevention of secondary complications. This tool aids in supporting the self-management, provides essential knowledge and self-management strategies. A digitalized version of the tool is also being proposed.

 Hemiparetic shoulder and hemiparetic hand-serious problems in the neurorehabilitation clinical practice of poststroke patients (impact of mirror therapy and functional electrostimulations on autonomy)



Ivet B. Koleva, Radoslav R. Yoshinov, Borislav R. Yoshinov

Objectives: Stroke is a socially important disease in industrialized countries, with a high level of prevalence and mortality. Motor weakness and spasticity provoke pathokinesiological dysbalance in the upper extremity, with severe difficulty in everyday activities of stroke survivors. Our goal was to evaluate the impact of mirror therapy and functional electrostimulations in the complex neurorehabilitation algorithm in patients with post-stroke hemiparesis, hemiparetic shoulder and hemiparetic hand. Design: A total of 171 post-stroke patients with hemiparetic shoulder and hemiparetic hand were observed. Patients were randomized into four therapeutic groups (57 per group). The control was done before, during and at the end of the NR course (of 20 treatment days), and one month after its end - using a battery of clinical methods and functional scales. In all patients we applied a complex neurorehabilitation (NR) program of physiotherapy, cryotherapy and ergotherapy; including proprioceptive neuromuscular facilitation (Kabath), strength and endurance exercises for shoulder abductors and rotators (rotator cuff muscles), wrist and fingers extensors and flexors, lateral trunk and scapular muscles; grip and grasp training and goal-oriented activities. Group (gr) 1 received only this NR program. In gr 2 we added mirror therapy for the hemiparetic hand. In the next group (gr 3) we added functional electrostimulations for the deltoid muscle, for extensors of the wrist and fingers. Results: The comparative analysis of results demonstrates significant pain reduction (Visual analogue scale); diminution of spasticity and contracture (Aschworth scale); increase of the range of motion (ROM) of the humero-scapular joint, of the wrist and fingers (goniometry); recovery of the humero-scapular rhythm and the grasp kinesiology; improvement of functional capacity (Brunnstrom), grasp capacity (Box and Block test) and autonomy (FIM – Self-care subscale; Barthel index - – subscales Grooming, Eating, Getting dressed, Bathing). Conclusions: Neurorehabilitation improves patients' autonomy and quality of life.

 Hemiparetic upper limb impairment is determined by distinct lateralized motor networks



Shay Ofir, Isaac Meilijson, Silvi Frenkel-Toledo, Nachum Soroker

Objectives: Motor impairment of the hemiparetic upper limb (HUL) is a leading cause for disability following stroke. In clinical practice left and right hemiparesis are usually treated as identical syndromes. Yet, research points to important differences in the role played by the left and right hemispheres in motor control, e.g., voluntary, goal-directed control mode (left hemisphere (LH) dominance) vs. reactive control towards unexpected external stimuli (right hemisphere (RH) dominance). Given the limited success of current therapies in ameliorating HUL function, a better understanding of the neuroanatomical correlates underlying the above differences is important for the development of more effective HUL rehabilitation. Recently, a voxel-based lesion-symptom mapping (VLSM) study has shown striking differences in the impact of lesion location on left and right hemiparesis. We aimed to investigate these differences from a network perspective. Design: 107 first-ever stroke patients (58 – LH damage, 49 – RH damage) were examined (Fugl-Meyer test) during the late sub-acute period (1-3 months post-onset. The impact of lesion location on proximal (FM-A) and distal (FM-B+C) HUL function was assessed separately for each hemisphere side, using a multivariate game-theoretical approach (multi-perturbation Shapley-value analysis; MSA). Results: In the LH (right hemiparesis), damage involving motor-planning parts of the cerebral cortex exerted a major impact on HUL residual function. In contrast, in the RH (left hemiparesis), damage involving motor-execution parts played a key role. HUL function was affected differently by damage to white matter association fibers in each hemisphere. Damage to the cortico-spinal tract in its passage in the ventral brainstem, and damage affecting the primary somatosensory cortex contributed equally to right and left HUL function. Conclusions: Hemiparesis is an asymmetric phenomenon determined by damage to a distinct set of regions in each hemisphere. The current findings may help dictate target regions for stimulation in rehabilitation treatments incorporating non-invasive brain stimulation.

 Hemiplegic migraines: Identifying zebras amongst horses



Amara Nasir, Ketevan Amirkhanashvili, Ratnakar P. Veeramachaneni

Case Diagnosis: Hemiplegic migraines (HM). Case Description: A 22-year-old female with a history of migraines with aura, presented with right-sided tingling in her arms and legs that progressed to weakness and inability to walk. Patient reported two similar episodes three and four years ago. Her first episode of HM was at the age of eighteen, when she experienced a headache with right-sided hemiplegia. CT, MRI, MRAs, EEG and CSF studies were unremarkable. In acute rehabilitation (AR), she regained strength and function after a few weeks. Similar to prior episodes, her workup was inconclusive, and she was admitted to AR again. Medical Management alleviated the acute episode and she is gradually recovering her motor function with physical/occupational therapy (PT/OT). Discussions: HM are a rare subset of migraines with a prevalence of only 0.01%. They are often described as headaches with an associated aura that not only includes unilateral motor symptoms, but also other symptoms such as visual field defects, tingling, numbness, or ataxia. Once other possible etiologies have been ruled out, PT/OT plays an important role in decreasing the duration/intensity of the episodes with manual therapy, stretching, strengthening, specific exercise training, modalities, self-distraction and education. To decrease the frequency/intensity of the episodes, massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy have been reported to be as effective as propranolol and topiramate. Conclusions: Though rare, this case reminds us of the importance of recognizing the possibility of hemiplegic migraines in a patient who has the appropriate clinical presentation, and the possibility of a delay in diagnosis due to symptoms that can be confused with other disorders. The recognition of this entity will help prevent the disabling impact of suboptimal treatments on an individual's quality of life. PT/OT may play a significant role in the acute management and prophylaxis of HM.

 Heterotopic ossification due to ischemic stroke



Saoussen Layouni, Sonia Jemni, Sahbi Elmtawa, Rihab Moncer, Emna Toulgui, Khaled Maaref, Fayçal Khachnaoui, Walid Ouannes

Case Diagnosis: Heterotopic ossification (HO) is frequently seen after spinal cord injury, traumatic brain injury. It is considered rare with hemiplegia following stroke. Case Description: A case of a 48-year-old patient with right hemiplegia related to an ischemic stroke was admitted to our department on the 3th month after the event. He developed right hip pain, especially during passive range of motion (ROM) exercises. The patient had not previously attended a physical medicine and rehabilitation program. Right hip flexion, and abduction, adduction, internal–external rotation and were limited at the beginning of range of motion (ROM) due to pain. X-ray and pelvic computed tomography revealed HO around the hip joints. After 6 weeks of inpatient rehabilitation, the ranges of hip joint motion are not improved. He was treated by surgical intervention. Discussions: HO is the formation of bone in an abnormal site occurs in post-stroke hemiplegia in 0.5–1.2%. It is not common after stroke, but should be considered in the differential diagnosis when, range of motion limitation inflammation, swelling or effusion, palpable mass and pain are present. Conclusions: Considering the presented cases, it is suggested that HO should be kept in mind in the differential diagnosis in stroke patients presenting with spontaneous joint pain or limitation. Early recognition and treatment are important for those caring for patients with acquired neurological deficits, and permit improved patient outcomes.

 High frequency ultrasound and botulinum toxin injection into the pectoralis minor muscle to diagnose and treat thoracic outlet syndrome: A case series



Connie Jiang, Albert C. Clairmont

Case Diagnosis: Thoracic outlet syndrome. Case Description: Case 1: A 26-year-old female presented with 6 months of left upper limb pain, dysesthesias in digits 4 and 5, decreased grip strength, and hand pallor. Electrodiagnostic (EDX) testing was normal. High frequency ultrasound (HFUS) showed tightness of the left pectoralis minor, but no obvious blood flow restriction. She underwent OnabotulinumtoxinA injections to the left pectoralis minor, major, and some cervical muscles, which resolved her skin discoloration and improved dysesthesias by 90%. Left first rib resection followed, with good results. Case 2: A 28-year-old male presented with 2.5 years of left neck and upper limb pain, weakness, and dysesthesias in digits 2 and 3. EDX testing was normal. HFUS revealed tight left pectoralis minor with outward bowing worsened with provocative maneuvers. He underwent OnabotulinumtoxinA injections to the left pectoralis minor with 80% improvement. Left first rib resection yielded minor improvement. Subsequent left pectoralis minor tenotomy resulted in significant improvement. Discussions: Thoracic outlet syndrome (TOS) is a complex entity caused by neurovascular compression, presenting with related signs and symptoms affecting the upper limbs. Characterizing the anatomy of the thoracic outlet in regards to etiology of compression is important in guiding treatment. HFUS is useful tool for dynamic evaluation of this region. In this case series, HFUS identified tight pectoralis minor. OnabotulinumtoxinA injections targeted to this muscle were diagnostic, therapeutic, and helped guide surgical interventions. Conclusions: Diagnosis of TOS is challenging. HFUS is a useful tool for dynamic evaluation to characterize the anatomy of the thoracic outlet and to identify specific muscles to target with botulinum toxin injections. This warrants further investigation as no standard botulinum toxin treatment protocol currently exists for TOS.

 High proportion and degree of severity of disability in hospitalized patients, Honduras 2019



Jessica M. Galeas, Erika Calderon, Yanitza Hernandez, Jackeline Alger, Elpidio Sierra, Maria F. Calderon, Karla Funes, Edna J. Maradiaga, Claudia Martinez, Mauricio Gonzales

Case Diagnosis: Disability includes deficiencies in functions and structures, activity limitations, and/or participation restrictions. In 2011, the World Health Organization World Disability Report estimated 15.0% of the world's population lives with a disability, 80.0% of which lives in developing countries. A 2016 study in a national hospital, reported 86.8% of inpatients had a disability. the objective was to determine the proportion and degree of disability in patients ≥18 years old admitted to four hospitals, Honduras, April-June 2019. Case Description: Observational cross-sectional study, medical-surgical wards. Inclusion Criteria: patients without cognitive disorders, with a family member/caregiver to provide the information, voluntary participation through written informed consent. Sample according to OPEN-EPI n=415; simple random sampling, interview with WHODAS 2.0 questionnaire (version 12 questions). Univariate analysis, with frequencies, percentages and central measurement trends (EPI-INFO 7.2.2.6). Discussions: 415 patients, disability proportion of 88.0% (CI95%=84.5-90.8), there was no gender predominance, male 50.8% (211) y female 49.2% (204), age =51.1±18.3 years (R=18-97), Mild disability 40.5% (168), moderate-extreme 47.5% (197). Acquired cause (common disease plus trauma) 98.6% (409). Entry diagnostic categories: musculoskeletal 20.7% (86), Oncological 20.5% (85) and gastrointestinal 17.8% (74). Most affected structures: related to movement 37.6% (156) and digestive 27.5% (114), nervous system 16.9% (70). Most affected functions: musculoskeletal 55.4% (230), digestive 25.3% (105), sensory and pain 21.7% (90). The affected domains of WHODAS 2.0: mobility with 59.1% (245), social participation 40.5% (168) and personal care 35.1% (145). Conclusions: The proportion of disability found in four hospitals from the main cities in Honduras (88.0%), is similar to the Results found in one national hospital in 2016 (86.8%). A high proportion of disability with a moderate to extreme severity was found, requiring immediate actions to provide rehabilitation during their hospital stay for the management of the disabilities related to the admitting diagnosis and the prevention of possible complications.

 Hirayama disease



Jonathan Chapekis, Arham Hazari, Waleed Ijaz, Nuri Jacoby, Susan Stickevers

Case Diagnosis: Hirayama Disease. Case Description: A 19-year-old Middle Eastern male presented with a six-month history of left upper extremity weakness and inability to grasp objects with his left hand. His grandfather reported a history of weakness and a “nerve condition.” Physical exam revealed atrophy of the rotator cuff musculature and deltoid. ⅖ muscle strength was noted in the deltoid, biceps, triceps and ⅗ muscle strength was noted in wrist flexors/extensors and intrinsic muscles of the left hand. The brachioradial, biceps, and triceps deep tendon reflexes were +1. There were no sensory deficits. Routine cervical spine MRI was negative. Discussions: Hirayama Disease (HD) is a rare cervical myelopathy in which short/tight dura mater is unable to compensate for the increased length of the vertebral canal during neck flexion. This causes cervical cord atrophy resulting in a progressive, unilateral atrophy of the upper extremity. Distal muscles are often affected more than proximal muscles, but in 10% the proximal muscles are primarily affected. HD has an insidious onset with gradual progression for several years, followed by stabilization. Asian males, 10 - 25 years old are predominantly affected. EMG reveals evidence of chronic denervation. Dynamic cervical MRI with the neck in flexion is required for diagnosis. HD is self-limiting; however, early diagnosis is necessary because a cervical collar may arrest the progression by limiting neck flexion. Physiotherapy is also helpful in preventing complications resulting from immobility such as joint stiffness and muscle wasting. Conclusions: Hirayama Disease is a rare disorder in which young male patients present with unilateral weakness and atrophy of an upper extremity. The condition cannot be identified on routine cervical MRI. MRI imaging with cervical flexion is required for early detection. Early physiotherapy interventions and use of a cervical collar may prevent long term sequelae and disability.

 HIV mononeuropathy-associated foot drop, a presenting sign of HIV infection, resolving following initiation of antiretroviral therapy



Abhinav Mohan, Paula Eckardt, Seth Tarras

Case Diagnosis: HIV mononeuropathy. Case Description: A previously healthy 62-year-old man presented with three months of right foot drop, following several months of gradually increasing tripping over the right foot. He had just completed two months of PT with no improvement. He was using right AFO. Examination revealed impaired right foot dorsiflexion (2/5), eversion (3/5), and great toe extension (2/5), with intact sensation. He exhibited steppage gait with increased right knee flexion during swing. Extensive neuropathy-specific laboratory testing was negative except for HIV-1 antibody/RNA suggestive of active HIV infection. EMG/NCS showed acute denervation of the right deep peroneal nerve and absent sensory evoked potential of the right superficial peroneal nerve. MRI RLE showed acute/subacute denervation changes in anterior compartment. MRI L-spine did not support radiculopathy. Abacavir/doltegravir/lamivudine therapy was initiated. He restarted PT. At 6-month follow-up, his foot drop was completely resolved. No recurrence has been noted in subsequent visits over the next 18 months. Discussions: Peripheral neuropathy is a frequent complaint in patients with HIV. Mononeuritis multiplex is known to present early in the course of HIV infection, and can either resolve spontaneously or with antiretroviral treatment. Mononeuropathy is rare and classically described with cranial nerve involvement. We believe our patient experienced HIV-associated deep peroneal motor mononeuropathy leading to foot drop, which was the presenting sign of HIV infection. PT had no benefit until antiretroviral therapy was initiated, after which complete resolution of the foot drop was rapid. Conclusions: This is the first known case of foot drop as the sole presenting sign of HIV infection, and dramatic and rapid resolution of the neurological deficit following initiation of antiretroviral treatment. While we cannot rule out a coincident spontaneous resolution, this case suggests that physiatrists should consider HIV in the differential diagnoses of acute foot drop, even if no signs or symptoms of systemic infection/AIDS exist.

 How does motivation to therapy contribute to functional recovery? A common scenario reveals limited knowledge to assessment and intervention tools for motivation



Riya Fukui, Carolina Gutierrez, Joel Frontera

Case Description: A 64-year-old male with ESRD who presented with acute lower extremity DVT. Workup revealed osteomyelitis and discitis originating from aortic valve endocarditis for which he received bioprosthetic aortic valve replacement, and two-vessel CABG. After the surgery, there was a significant decline in his function. His hospital course was complicated by cerebrovascular accidents, followed by a stay in ICU for post PEG tube placement complication. He then developed pneumonia and bacteremia with psoas abscess. Patient was initially recommended for inpatient rehabilitation program, however due to his lack of motivation, he was ultimately accepted at a skilled nursing facility. Initially, patient demonstrated high level of motivation despite medical and functional setbacks, however when his symptoms worsened with nausea and fever from infection, his motivation declined along with his function. After a motivational intervention including counseling, his motivation to therapy appeared to have increased along with his function. Discussions: Motivation has many definitions, such as self-efficacy, self-confidence or even the will to live. It is a force that drives people to act in life and must also be the driving force behind participation in therapy to recover function and independence. This case highlights the lack of knowledge and evidence in how patient's motivation plays a role in successful recovery. Conclusions: There is limited literature on assessing motivation for therapy in this population. There is an opportunity for further research in motivation and the correlation with therapy participation. With additional research, development of a measuring tool to assess motivation can aid in early intervention and ultimately increase in function.

 Hypopituitarism in brain injury



Jacinta Lewis

Objectives: An important issue with significant clinical associations, the Princess Alexandra Hospital (PAH) Brain Injuries Rehabilitation Unit (BIRU) has attempted to identify hypopituitarism post-brain injury via an admission pathology protocol. This protocol serves to guide junior doctors when completing the admission process, and includes ordering a hypopituitary pathology screen for all new patients regardless of their diagnosis or severity of injury. However, given the paucity of literature and discrepancies in findings around hypopituitarism in non-traumatic brain injury, it stands to reason that these health resources may be inappropriately utilised in this subgroup of patients. The aim of this study was to investigate whether hypopituitarism significantly occurs in non-traumatic brain injured patients. Design: This study was a single site, retrospective audit of patients discharged from a specialty brain injury unit in 2015. Of these patients, two groups were analysed; those with a traumatic cause of brain injury, and those with all other brain injuries (non-traumatic). Of the 141 patients admitted to BIRU in 2015, only 78 were included in the analyses. 63 patients were excluded due to missing blood tests. Results: Full multivariate model with backward elimination of confounders (age and gender) found that trauma did not have an influence on screening outcome, with an unremarkable odds ratio (1.28) thus identifying a lack of association between trauma and hypopituitarism. A Chi Square test failed to demonstrate a statistically significant occurrence of hypopituitarism, regardless of injury type (χ2 = 0.2715, p-value = 0.602). Conclusions: When present, hypopituitarism has proven a clinically salient finding post-brain injury. Noting this, the present study has failed to demonstrate that hypopituitarism occurs to a statistically significant degree in a subspecialised rehabilitation unit, regardless of brain injury mechanism. There is a lack of consensus as to who and when to treat for such a phenomenon.

 Hypothermic peripheral neuropathy



Ashley Mohan, Bonnie J. Weigert

Case Diagnosis: Hypothermic peripheral neuropathy. Case Description: A 21-year-old male suffered a hypothermic cardiac arrest and traumatic brain injury after being found down on a frozen lake for an unknown amount of time. Patient's initial temperature was found to be 25 degrees Celsius. Patient was placed on VA ECMO and rewarmed slowly to 34 degrees Celsius. Upon cardiovascular stabilization, the patient noticed bilateral hand weakness and paresthesias. He had minimal improvement even with aggressive rehabilitation. Five months after the inciting event, nerve conduction studies (NCS) and needle EMG were performed due to persistent symptoms. NCS showed significantly reduced sensory and motor amplitudes in the ulnar, median, and radial nerves bilaterally with mildly prolonged latencies. EMG showed active denervation of FDI, APB, and ADQ with evidence of terminal reorganization. Although the patient refused testing of his lower extremities, he denied any symptoms in the legs. Discussions: Peripheral nerve injury from deep hypothermia has not been well-studied. There have only been a few case reports which showed similar NCS and EMG findings. In this patient, the mechanism of injury is thought to be direct axonal injury from cold causing nerve ischemia. There was some discussion if the patient has a component of critical illness neuropathy, although this is less likely the primary cause given that there was no evidence of sepsis during hospitalization, the lack of improvement over several months, and the preferential effects on the upper extremities. There may also be a secondary demyelinating process occurring from compression at the elbow and wrist due to prolonged swelling and positioning of extremities while in the ICU. The patient will be undergoing decompression surgery at these sites and will be followed to evaluate for changes. Conclusions: This patient has severe bilateral axonal median, ulnar, and radial sensorimotor neuropathies likely secondary to severe hypothermia.

 Hypothyroidism presenting as myoclonic jerks in a patient with a chronic thoracic spinal cord injury



Sarah M. Smith, Audrey Leung

Case Diagnosis: Myoclonus secondary to hypothyroidism. Case Description: A 68-year-old male with T4 motor incomplete paraplegia secondary to a motor vehicle collision in 2010 was initially admitted to the hospital for management of cholecystitis. The patient's hospital course was complicated by perihepatic abscesses following open cholecystectomy and several episodes of hypercarbic respiratory failure requiring mechanical ventilation. Five months into his hospitalization, the patient had two episodes of jerking involving his left leg and bilateral upper extremities one day apart. The patient remained alert and oriented during these episodes. Of note, the patient denied a history of spasticity and did not have increased tone on exam. A complete metabolic panel, magnesium level, phosphate level, and TSH level were obtained. The patient's only abnormal lab value was a TSH of 19.8, elevated from 3.0 three months prior. His thyroid antibodies were negative, ruling out Hashimoto's encephalitis. The patient was started on levothyroxine and the jerking episodes did not recur. Discussions: This patient's myoclonic jerks could have been confused for spasticity. While this was considered, our differential diagnosis also included electrolyte disturbances, thyroid abnormality, epileptic myoclonic jerks, multisystem atrophy, Parkinson's disease, Lewy body dementia, or medication effect. Hypothyroidism is an uncommon cause of myoclonus and thus far has only been reported in the context of Hashimoto's encephalitis. Conclusions: It is important to consider etiologies of abnormal movements outside of spasticity in patients with chronic spinal cord injuries. Although myoclonus in relation to thyroid disease is most commonly associated with hyperthyroidism, hypothyroidism may rarely also present with myoclonus and should be considered in the differential diagnosis of new onset myoclonus. To our knowledge, this is the first described case of myoclonus secondary to hypothyroidism not associated with Hashimoto's encephalitis.

 International classification assessment of women after breast cancer treatment with a significant degree of disability in Poland: Preliminary study



Katarzyna Hojan

Objectives: The ICF is used to build a meaningful and useful system that can be used by various users to determine health policy, ensure the quality of health care and assess the results of therapy within different cultures. In the study we analyze the assessments of the functional status and disability awarded in accordance with the Polish case law system in relation to its international classification (ICF). Design: It was an observational, clinical study in breast cancer women who were admitted with a significant degree of disability according polish health insurance after finish the oncological therapy (surgical method and / or chemotherapy and / or radiotherapy), which were treated in the Poland Cancer Center. Patients underwent a comprehensive functional assessment in accordance with ICF for patients with breast cancer (ICF Core Sets for breast cancer). Results: 88 women (45-70 years) after completed breast cancer treatment (8-60 months) in 77.2% stated a lack (0-4%) or small (5-24%) deficits of function and structure in the group with the prescribed significant degree of disability. The Results of our preliminary studies suggest a significant discrepancy in the assessment of the condition of patients after treatment of breast cancer in ICF classification with government-issued state structures of significant disability in women after breast cancer treatment. Conclusions: The results of this study in women after treatment of breast cancer suggest the use of ICF to fully assess the degree of disability, as well as the use of this classification to a common information platform for both health care workers and those responsible for social insurance or social assistance.

 Identifying a subset of acute stroke patients in clinical equipoise for discharge to an inpatient rehabilitation facility or skilled nursing facility



Kent P. Simmonds, James Burke, Mathew Reeves, Zhehui Luo

Objectives: Whether stroke outcomes are better in Inpatient Rehabilitation Facilities (IRFs) or Skilled Nursing Facilities (SNFs) is unknown. A randomized controlled trial (RCT) is needed to answer this question, but to ethically justify such a trial, patients in equipoise must be identified. Equipoise is the point of clinical uncertainty regarding best treatment option. Our objective was to identify patients in equipoise using a statistical model to predict IRF or SNF discharge for acute stroke patients. Design: We used Medicare standard analytic files (2011-2014) to develop a retrospective cohort of acute stroke patients. Our primary outcome was discharge to an IRF or SNF and a comprehensive set of patient, hospital, and geographic covariates were used multivariable logistic regression models with and without a random effect for hospital. The random effect (R.E) for hospital accounts for clustered observations and Intraclass Correlation Coefficients (ICCs) quantified the variance in IRF or SNF discharge attributable to each hospital. Patients in equipoise were operationally defined as having predicted probabilities of IRF (versus SNF) discharge of 40-60% to best reflect clinical uncertainty. Results: The final sample had 135,415 patients (49.1% IRF and 50.9% SNF). Model 1 had good discrimination (C statistic=0.73) and 42,792 (31.6%) equipoise patients. Hospitals had a large effect on IRF or SNF use as 26% of the unexplained variation was attributable to the hospital (i.e. ICC=0.26 in model 3). The fully adjusted model (model 3) had excellent discrimination (C Statistic=0.82) and fewer patients were in equipoise (n=27,720, 20.5%). The equipoise sample was evenly split (i.e. 50.2% IRF and 49.8% SNF) and interchangeable (i.e. IRF and SNF patient characteristics differences were no longer significant). Conclusions: Our prediction model identified that around 20% of Medicare acute stroke patients met our definition of equipoise. The equipoise sample was equal in size and interchangeable providing a practical ethical basis to randomize.

 Idiopathic intracranial hypertension in the setting of recent concussion in a 34-year-old obese female



Allan Probert, Kevin Moser, Lori M. Grafton

Case Diagnosis: We describe a case of idiopathic intracranial hypertension (IIH) in a 34-year-old obese female diagnosed several months after sustaining a concussion. The potential etiologic causes for IIH are varied and several potential mechanisms have been described. There is a paucity of literature describing IIH in the setting of recent concussion. As these two disease processes may present similarly, this clinical scenario can provide a significant diagnostic challenge. Including IIH as a part of a broad differential post-concussion is important for accurate diagnosis and prevention of patient morbidity. Case Description: A 34-year-old female, BMI 36, presented to clinic two months after a motor vehicle accident in which her stationary vehicle was rear-ended. Immediately after the accident, GCS was 15 and brain CT and MRI were unremarkable. The patient reported symptoms of headache, myofascial neck pain, emotional lability, irritability, and vision changes. Headaches were refractory to treatment over several months, and visual changes worsened. Papilledema was visualized on fundoscopic examination, and she underwent a lumbar puncture, which revealed elevated opening pressures. Patient then underwent MRV showing bilateral transverse sinus stenosis and the diagnosis of IIH was made. Subsequently, she underwent a high-volume lumbar puncture, and a definitive ventriculo-peritoneal shunt which provided resolution of her visual symptoms, but no improvement in headaches. Discussions: IIH is a condition characterized by symptoms of increased intracranial pressure (headache, papilledema, potential vision loss) with elevated opening pressure on lumbar puncture and no other cause of intracranial hypertension evident on neuroimaging. It is most common in obese adult women of childbearing age. From our review, two previous cases in the literature have described IIH in the setting of concussion. Conclusions: This case highlights the importance of recognizing IIH as a potential cause of vision changes and treatment-refractory headaches in the setting of recent concussion, particularly in patients with known risk factors.

 Immediate effect of yoganidra on anxiety and pain intensity of amputees in early rehabilitation phase



Mallikarjun Gunjiganvi, Mohini Shinde, Sushma Sagar, Subodh Kumar

Case Diagnosis: Apart from loco-motor disability, a considerable number of amputees suffer from often neglected psychosomatic issues such as anxiety, post-traumatic stress disorder, depression and acceptance of the situation by self and reintegration into society. Multi-modal treatment options exist to address the issues. Though beneficial effects of Yoga have been well documented in modern medical literature, the beneficial effects of Yoga as therapy in addition to active protocolized rehabilitation programs in amputees has not been studied. Hence, this study was designed to assess the immediate effect of Yoganidra on state anxiety and pain intensity in amputees. Case Description: After departmental approval, isolated limb injury resulting in amputation in the age group 18 to 65 years were enrolled into the study from June 2017 to September 2017. They were administered Yoganidra on day 1 and supine rest sleep on day 2. Yoganidra involves conscious sleep status with visualization of each parts of body. Anxiety was evaluated using self evaluation questionaire (State Trait Anxiety Inventory form) and pain using visual analogue score before and after administering Yoganidra on day 1 and supine rest sleep on day 2. results calculated using Student T test. Discussions: A total of 44 amputees were participated in the study. 36 were males and 8 were female amputees. State anxiety significantly reduced from 53.70 ±9.33 to 50.00 ±8.8 with p value of 0.005, but no change was seen in pain score component. Conclusions: Yoganidra is effective in managing anxiety in amputee patients in the early rehabilitation phase. There is need of further large scale, multi-institutional studies with longer duration of Yoga administration to conclusively derive the effect of Yoga in amputees.

 Immunosuppressive medications in the settings of spinal cord injury: Important considerations



Jason S. Hua, Lisa Wenzel

Case Diagnosis: Perianal abscess rupture after initiation of immunosuppressive medication in a patient with history of ankylosing spondylitis. Case Description: 44-year-old male with past medical history of RA, ankylosing spondylitis (previously on monthly Remicade infusion), morbid obesity admitted to rehabilitation hospital 11 days after a pool accident resulting C6 ASIA B. During the first week of admission, patient complained of chills, hands feeling cold. He indicated same feeling previously when he did not receive his immunosuppressive medications for his Ankylosing Spondylitis and RA. He developed a low-grade fever from 100 to 102 °F. Work up did not reveal infectious etiology. His rheumatologist was consulted and recommended restarting of sulfasalazine. Two days after initiation of sulfasalazine, patient developed a perirectal wounds with open abscess measuring 2 cm x 4 cm and 6 cm x 1.5 cm x 0.1 cm. Plastic surgery debrided wound at bedside and he completed 7 days of antibiotics. The wound healed after 1 month at an LTAC facility. Patient completed his rehabilitation course thereafter. Discussions: Patients with premorbid conditions such as ankylosing spondylitis, rheumatoid arthritis who required immunosuppressive medication in the past poses an interesting dilemma after suffering spinal cord injury. In our case, the patient developed perirectal wound acutely after initiation of sulfasalazine. This was likely due to an underlying abscess that patient could not feel due to sensory deficits from his spinal cord injury. Conclusions: For spinal cord injury patients with premorbid conditions that require immunosuppressive medication. It is important to consider the potential side effects of immunosuppression in this population. Experimental studies has shown that spinal cord injury can trigger a systemic neurogenic immune response syndrome. For this particular population who requires immunosuppressive medication, caution has to be taken as to evaluate for all potential sources of infection. As in this case they can be “drawn to the surface.”

 Impact of direct application of vibratory stimuli for motor function of upper limb in a patient with incomplete cervical spinal cord injury



Atsushi Ota, Kentaro Kawamura, Seiichi Niidome, Yumeko Amano, Seiji Etoh, Megumi Shimodozono

Case Diagnosis: Incomplete spinal cord injury at C4 level, motor dysfunction, impaired dexterity, sensory disturbance, dysesthesia. Case Description: A 73-year-old male with incomplete cervical spinal cord injury (SCI) with impaired motor function and dysesthesia in his right upper limb was started on direct vibratory stimuli with handy massager to his right upper limb for 3 minutes/day added to conventional rehabilitation at 6weeks after the injury. Box and Block Test (BBT) and Nine Hole Peg Test (NHPT) improved from 30 to 39, 145 to 100sec after 3 weeks, respectively. We also assessed immediate effect of vibration. BBT were 39, 44, 46.5 (before, just after, 30min after vibration). NHPT were 100, 74.5, 68sec, respectively. Mean amplitude of F-wave from the abductor pollicis brevis was not significantly changed after vibration. But two-peak form of F-wave amplitude distribution changed to multi-peak form immediately after vibration. The latency of F-wave significantly prolonged just after vibration and shortened at 10min after vibration. Active motor threshold (AMT) and cortical silent period (CSP) were not changed. Discussions: The direct vibratory stimuli to upper limb induced cumulative and immediate effect (at least for 30min) in the improvement of motor function. The various forms of F-wave appeared and F-wave latency was changed after vibration. No change of AMT, CSP means no change of cortical and spinal excitability. These data may indicate that some changes in connection or firing pattern of spinal motoneurons and interneurons relate to the improvement of upper limb function. Conclusions: The direct application of vibratory stimuli to upper limb in the SCI patients could improve their motor function. Vibratory stimuli may facilitate the functional recovery of upper limb due to change in connection or firing pattern of motoneurons and interneurons without change in cortical and spinal excitability. The relationship between functional improvement and spinal change should be confirmed in the future study.

 Impact of early rehabilitation in traumatic brain injury patients: Relationship with functional outcome and length of stay in a limited resource set-up of developing world



Siddharth Rai, Mallikarjun Gunjiganvi, Rupali Awale, Amit Agarwal

Case Diagnosis: Traumatic brain injuries (TBI) often result in disabilities which are burden for any society. Physiatry units have recently been emphasized by the Government of India across all trauma centres. Nevertheless, there is a lack of effective rehabilitation program for TBI patients in the majority of trauma centres in the developing world. Hence this study was done to determine the impact of early PMR intervention in TBI patients on functional outcome and length of stay in setting of a new trauma center. Case Description: Retrospective analysis of prospective maintained data of patients admitted with non- fatal traumatic brain injury either managed operatively or conservatively were obtained from July 2018 to July 2019. Rehabilitation was started within 48hrs of admission in most of the patients. Demographic variables, acute neurosurgical characteristics, medical complications, and rehabilitation outcomes were recorded. Functional outcome was determined using a modification of the FIM score. Descriptive and regression analyses were used to establish the relationship between early physical medicine and rehabilitation intervention and FIM score, length of stay, and discharge planning. Discussions: 290 patients were included in this study with an average age of 58.8 ± 11.1 years. The most common aetiology was road traffic accident (88.06%). Most patients were discharged home directly (78.08%). Patients receiving Rehabilitation management early, within 48hrs functionally improved (P < 0.001). Regression analysis showed by the early rehabilitation management, that there was a statistically significant FIM functional gain of 18.445 points (P = 0.03). The patients who had early PMR intervention, had also fewer complications. Conclusions: Introduction of early PMR intervention in setting of a trauma center with a dedicated physiatrist significantly improves functional outcome in traumatic brain injury patients, decreases the length of stay during acute hospitalization and decreases complication rates. This needs to be promoted and established across all such centers in the developing world.

 Impact of orthopedic disorders of stroke patients on mental health and functional independence



Meryem Frigui

Objectives: The aim of our study was to evaluate the impact of orthopedic disorders (OD) on mental health and functional independance of stroke patients. Design: We conducted a cross-sectional study, which included patients followed for stroke that had occurred over one year, in the Physical and Rehabilitation Department at the University Hospital Tahar Sfar of Mahdia (Tunisia). Evaluation was based on the Hospital Anxiety and Depression Scale (HAD) for mental health. The functional independence measure (FIM) and Barthel scale were used to measure the degree of disability. Results: One hundred twenty four patients were enrolled in this study: 68 men (54.8%) and 56 women (45.2%), with the mean age of 60.5±12 years. OD had been noted in 66.9% of the cases. Capsulitis was the most OD, found in 49.5% of the cases. The functional and psychological repercussions were important. Indeed the mean FMI score was 79.4± 23 and the mean Barthel score was 46.8± 25. For the more, the mean HAD depression scale was 11.4± 3 and the mean HAD anxiety was 9.2± 3.4. Conclusions: It appears from our study the occurrence of OD in stroke patients leads to physical disability and functional dependence, as well as emotional disturbances such as anxiety and depression.

 Impact of poststroke recanalization on general and upper limb functioning: A prospective, observational study



João P. Branco, Alexandra Coelho, Joao P. Pinheiro

Objectives: To assess the impact of recanalization (spontaneous and therapeutic) on upper limb functioning and general patient functioning after stroke. Design: This is a prospective, observational study of patients hospitalised due to acute ischaemic stroke in the territory of the middle cerebral artery (n=98). Patients completed a comprehensive rehabilitation program and were followed-up for 24 weeks. The impact of recanalization on patient functioning was evaluated using the modified Rankin Scale (mRS) and Stroke Upper Limb Capacity Scale (SULCS). Results: General and upper limb functioning improved markedly in the first 3 weeks after stroke. Age, gender, and National Institutes of Health Stroke Scale (NIHSS) score at admission were associated with general and upper limb functioning at 12 weeks. Successful recanalization was associated with better functioning. Among patients who underwent therapeutic recanalization, NIHSS scores ≥16.5 indicate lower general functioning at 12 weeks (sensibility=72.4%; specificity=78.6%) and NIHSS scores ≥13.5 indicate no hand functioning at 12 weeks (sensibility=83.8.4%; specificity=76.5%). Conclusions: Recanalization, either spontaneous or therapeutic, has a positive impact on patient functioning after acute ischemic stroke. Functional recovery occurs mostly within the first 12 weeks after stroke, with greater functional gains among patient with successful recanalization. Higher NIHSS scores at admission worse functional recovery.

 Implications and possible interventions based on natural therapeutic factors in hypoxia on cerebral level: Scientific data and synthetic integrative correlations of related previously achieved and specifically focused studies



Constantin Munteanu, Diana Nicoleta Munteanu, Gabriela Dogaru, Gelu Onose

Objectives: The central nervous system is intolerant to ischemia and 10-30 seconds without oxygen can initiate damages in neuronal, of support and vascular, structures, that can lead to irreversible effects (most serious: cells death) after more than 5 minutes of (quasi) total arrest of blood supply in a brain territory. Hypoxi/ischemic injuries in stroke are devastating conditions that can affect individuals of all ages, possibly occurring perinatally - with consequent encephalopathy - and respectively, in adults and elderly, being one of the major causes of death and disability. Our objectives target, first, to have a better understanding of the actual scientific description of the chronic ischemia detrimental outcomes on cerebral level and secondly, to present some of the intervention possibilities aiming to reduce the consequences of stroke. Despite considerable research, there are still no proven clinically effective pharmacological industrial agents capable to spectacularly mitigate the severity of brain lesions following stroke. Design: We achieved prospective longitudinal analyses in, totally, 55 chronic post-ischemic stroke patients, mean age 69 years, which made rehabilitation treatment: the first group, of 20 patients, performed only kinesitherapy, massage and occupational therapy, during 16 days, at the Clinical Rehabilitation Hospital in Cluj-Napoca, and the second group, of 35 patients, performed the same treatment during 16 days, plus in association with carbonated mineral water baths for 15 minutes daily, mofette therapy for 20 minutes two times per week, kinesitherapy and massotherapy 15 minutes daily, each, and aerotherapy 30 minutes, daily, at Tuşnad Spa Complex, in Băile Tuşnad. Hemiparesis was the most frequent clinical sign, followed by coordination, balance and gait, disorders. Every patient, within both mentioned settings, was clinically assessed before and after treatment, based on: Motor Assessment Scale, TINETTI Balance Scale, 10-m walk test, BARTHEL Index, and Quality of Life Scale, in both groups. Safety issues/adverse reactions were noted. Results: The mean scores, at baseline and after therapy, in each setting, on the scales used, were compared with the paired T-test. On the Motor Assessment Scale, a statistically significant improvement was determined (p < 0.05). When evaluating the patients' performance, using the Barthel Index, and balance on the TINETTI scale, improvements were statistically significant, too (p < 0.05). At the end of the treatment, we also observed an improvement in the walking speed (p< 0.05). Quality of life showed statistically significant improvements (p < 0,05), in both groups. So natural therapeutic agents: carbonated mineral waters and mofettes, together with aerotherapy, have shown, alternatively, good Results. There were no adverse reactions to the treatments, neither in the Clinical Rehabilitation Hospital in Cluj Napoca nor in Tuşnad Complex, Băile Tuşnad. Yet, the stroke survivors evaluated remained with important limitations on participating in social activities, reintegration into the family, community and working life. Conclusions: Natural therapeutic factors, such as carbonated mineral water baths and mofettes, possibly along with aerotherapy, proved useful for rehabilitation treatment in chronic post-ischemic stroke patients, overall influencing the clinical and functional picture and determining significant improvement of their: motor status, autonomy, balance, gait speed, and quality of life. Of the more than 100 “neuroprotective” agents studied in randomized clinical trials on focal ischemic stroke, none has proven unequivocally efficacious. However, the failed trials have greatly increased our understanding of the fundamental biology of ischemic brain injury and have laid a strong foundation for future advance. New intimate pathophysiological targets continue to be identified, which is a fertile area for translational medicine, including in stroke. To avail rehabilitation treatment complementarily in balneal medical spa resorts, using natural therapeutic agents, as emphasized in our previous studies, in the absence of contraindications, is very important, necessary and useful for chronic post-ischemic stroke patients.

 Improved control of trunk/lower limb hypertonia and hyperreflexia after repositioning of intrathecal baclofen infusion catheter from vertebral T3 to T12 location: A case report



Nicholas P. Gut, Stuart Yablon, Robert Ball, Dobrivoje Stokic

Case Diagnosis: Uncontrolled upper and lower limb spastic hypertonia and hyperreflexia 6 months after traumatic C3 AIS-C spinal cord injury (SCI) despite 1,462mcg/day simple continuous ITB infusion with the catheter tip at T3. Case Description: An ITB bolus test dose (75mcg) was administered 3 months postinjury for moderate extremity spasms and hypertonia (median modified Ashworth score [MAS] 2), which decreased to 1 at 4hr post-injection. Two weeks later, an ITB infusion system was implanted with the catheter tip at T3. Minimal change followed titration to 700mcg/day over the next 12 weeks. Catheter Access Port contrast fluoroscopy and Indium-111 reservoir infusion scintigraphy showed no catheter malfunction. Titration to 1,462mcg/day (2000mcg/mL; simple continuous mode) yielded no further clinical benefit. Sedation and hallucinations precluded further dose increases. Median MAS increased to 3. Bilateral soleus H/M ratios, typically absent at doses >200mcg/day, measured approximately 50%. The catheter was replaced and the tip was repositioned to T12. Postoperatively, hyperreflexia was reduced at 150mcg/day. Repeat H/M ratios were approximately 30% bilaterally, with median MAS 3. Resting tone control is improving during dose titration, currently underway. Discussions: Imaging-based troubleshooting results and cognitive adverse effects at high doses suggest integrity in the initial infusion system. Rostral catheter placement afforded no improvement in upper, trunk, or lower limb hypertonia, suggesting compromised ITB diffusion to segments influencing spasticity. After lower thoracic repositioning, hyperreflexia was markedly improved, as documented by decreased H/M ratio, even with a lower dose of 150mcg/day. Hypertonia is also improving, but requires dosage higher than that needed for treatment of hyperreflexia. Conclusions: Rostral positioning of the catheter tip may not provide added upper limb response and may compromise diffusion to thoracolumbar spinal cord segments. Adjunctive H/M ratio measurement can provide objective evidence of ITB diffusion to these segments. Further study is warranted regarding factors important in ITB diffusion and associated clinical response.

 Improving resident wellness through an innovative self care curriculum



Tae Chan Paul Yang, Thaddeus Wilson, Davin Chu, Mary Kim

Objectives: Physician wellness and more specifically burnout has recently gained significant attention in the medical community due to its effect on patient care and job performance. Nearly half of all practicing physicians in the US report experiencing burnout at some point in their career, with higher levels of burnout reported by physicians in training. Although current literature supports the view that reducing burnout requires changes at the organizational level, there is no consensus on how to effectively implement these interventions. To address this issue, a residency wellness task force was formed at a university based PM&R residency program with the goal to develop an intervention to support resident wellness and reduce burnout. Design: A task force was Designated and a literature review on resident wellness within graduate medical training was performed. An interactive session for faculty and residents was held to review the Results from the literature search and discuss their applicability to the residency program. From this session, the intervention of an innovative weekly self-care series was selected addressing aspects of self-care including, but not limited to “Spiritual wellness,” “Tai Chi practice,” and “Mindfulness practice.” Results: University based PM&R residents were surveyed using the Maslach Burnout Inventory (MBI) as well as measures from local GME and ACGME surveys. The interventions were associated with improvement in all three domains of the MBI post-intervention: Burnout, Depersonalization, and Personal Achievement. The greatest improvement was seen in the Burnout domain with a nearly 50% decrease in burnout symptoms experienced at least once a week. Modest improvements were seen from the local GME and ACGME surveys quantifying symptoms of burnout. Conclusions: An individualized resident physician driven wellness curriculum, in the form of a weekly interactive self-care series covering relevant self-care topics, was shown to decrease overall resident physician burnout.

 Incidence of stroke among Saudi population: A systematic review and meta-analysis



Bader Alqahtani, Aqeel Alenazi

Objectives: Stroke is a leading cause of death and disability worldwide. However, our knowledge of the incidence of stroke for Saudi Arabian population is limited. Thus, we aimed to determine the pooled annual incidence of stroke among stroke survivors in Saudi Arabia. Design: This is a systematic review. We conducted a comprehensive literature search of PubMed, Web of Science, and SCOPUS, without language or publication year limits. Outcomes of interest were stroke incidence rate and cumulative stroke incidence. Results: A total of seven studies met the inclusion criteria for this review. The pooled annual incidence of stroke among all stroke patients in Saudi Arabia was 0.029%, (95% CI: 0.018 to 0.042), which is equivalent of 29 strokes per 100,000 people annually, (95% CI: 18 to 42). After restricting the meta-analysis to the four observational studies examining the incidence of stroke in adults suffering a stroke for the first time, the pooled annual incidence of stroke was 0.032%, (95% CI: 0.015 to 0.055) which is equivalent of 32 strokes per 100,000 people annually, (95% CI: 15 to 55). Conclusions: The findings indicate that there are 29 stroke cases for every 100,000 people annually for individuals residing Saudi Arabia. Establishing a nationwide stroke registry is warranted for monitoring and improving healthcare services provided to stroke survivors.

 Incidence, characteristics and outcomes of acute care unit readmissions during inpatient traumatic brain injury rehabilitation in Singapore



Poo Lee Ong, Zhi-Yan Valerie Ng, Chien Joo Lim, Karen Chua Sui Geok

Objectives: To determine the incidence, characteristics and rehabilitation outcomes associated with Acute Care Unit Readmissions (ACUR) during inpatient traumatic brain injury (TBI) rehabilitation. Design: Study design was a retrospective review of electronic medical records from single brain injury rehabilitation unit over 3 years from 1st Jan 2012 to 31st Dec 2014 for all patients admitted to a tertiary rehabilitation center. Inclusion criteria were aged TBI >18 years old, with onset of TBI < 6 months. Exclusion criteria included patients who had ACUR for elective reasons. Patient with ACUR were characterized into types of complications (neurological and medical reasons) that led to ACUR. Main outcome measure included Glasgow Outcome Scale (GOS), Functional Independence Measure (FIM), discharge location and rehabilitation length of stay (LOS). Results: A total of 131 medical records were screened, 121 records met eligibility criteria. 17 patients (14%) experienced at least 1 ACUR episode at median time of 13 days since admission to rehabilitation center. The most common reason for ACUR was neurologic in nature (n=13, 76.47%), while medical reasons accounted for 4 (23.53%). TBI patients who does not require ACUR has higher admission FIM score (mean: 63.36, SD: 21.06, p=0.026) and GOS score (GOS 4&5:81 (91.0%), p=0.026). Patients who experienced ACUR achieved poorer clinical outcome as indicated by lower discharge FIM score (mean 65.75 SD 31.39, p=0.023) compared to non ACUR patients (mean: 85.35 SD: 21.14 p=0.023). ACUR patients also had longer rehab LOS [median: 55 days (34.50-87.50)] compared to non-ACUR counterparts, [median: 28 days (16.25-40.00), p=0.002]. There was no significant difference for FIM gains between ACUR patients (mean 15.24 SD: 23.59) and non-ACUR (mean: 21.99 SD: 14.90, p= 0.117). Conclusions: This study showed there was a significant worsening of functional outcomes for patients with TBI that required ACUR but upon returning to rehabilitation, similar gains were made. Early intervention and precaution should be taken on high risk patients that likely to ACUR to prevent poor outcome.

 Incomplete crural paraplegy for histoplasmosis: Case report



Flávio Henrique N. dos Santos, Paula M. Lucas, Amanda Oliva Spaziani, Talita Costa Barbosa, Raissa Silva Frota, Barbara Mayume de Sousa

Case Diagnosis: To report a case of a patient diagnosed with incomplete paraplegia due to spinal cord histoplasmosis. Case Description: Male patient, 42 years old, alcoholic, non-immunodeficient. Agricultural worker having contact with bats. Two years ago she started developing low back pain associated with paraparesthesia. Three years ago, he was diagnosed with paraplegia due to cerebral and spinal histoplasmosis confirmed by cerebrospinal fluid examination. He was hospitalized for 10 days using intravenous amphotericin B and then referred for rehabilitation. Used fluconazole, omeprazole, nortriptyline. in wheelchair, without sphincter control, in treatment with physiotherapy, speech therapy, orthopedics and physical conditioning. Evolved with better balance and trunk, muscle strength in order to achieve therapeutic transfer of parallel bars orthostatism. Independent for the activities of daily living and starting the training of walkers. Discussions: Classical histoplasmosis, also known as Darling's disease, Humphrey's reticuloendothelial cytomycosis, or cave disease, is a mycosis of the dimorphic fungus Histoplasma capsulatum. The clinical manifestation of this mycosis ranges from asymptomatic infections to severe disseminated diseases, depending on the amount of inhaled conidia, patient predisposing factors and fungus virulence. Conclusions: Usually asymptomatic, the disease caused by the fungus H. capsulatum has a predilection for the respiratory and immune systems and may present with acute, chronic and disseminated, and may affect other organs or even the central nervous system. These complications make diagnosis difficult and, therefore, demonstrate the need for the use of personal protective equipment, avoiding the contraction of the disease. A patient of productive age, without acquired immunodeficiency, presented atypical spinal cord injury, but, with the correct diagnosis, adequate clinical treatment and rehabilitation bring improvement in quality of life, recovering its physical functionality.

 Increased left lower extremity tone 48 h after right middle cerebral artery air emboli infarct following esophagogastroduodenoscopy with dilatation and botulinum toxin a injections for treatment of achalasia: A case report



Julio C. Gomez, Richa Lamba, Todd A. Feathers

Case Diagnosis: 89 year-old fully independent female with new right middle cerebral artery (MCA) air emboli infarct after esophagogastroduodenoscopy (EGD) with significant left lower limb tone within 48 hours of infarct. Case Description: 89 year-old, right hand dominant, previously fully independent, female with past medical history of hypertension, monoclonal gammopathy of undetermined significance underwent EGD with dilatation and botulinum toxin A injections for treatment of achalasia. She became bradycardic and hypotensive in the post anesthesia care unit. On exam, patient demonstrated right gaze preference and left hemiparesis consistent with 4/5 strength in the left upper limb and 1/5 in the left lower limb. CTH showed multiple foci of peripheral gas in the right MCA distribution concerning for air emboli. Patient received tPA and urgent hyperbaric treatment prior to ICU admission. MRI confirmed multifocal acute ischemic infarcts in the right MCA distribution, notably impacting the cortex with relative sparing of the white matter. She developed increased left lower limb tone consistent with a Modified Ashworth Score of 4. Patient was admitted to acute inpatient rehabilitation requiring maximal assistance with activities of daily living. Discussions: There are approximately 20 cases to our knowledge of cerebral air emboli following esophagogastroduodenoscopy. This is the first following EGD with botulinum toxin injections for achalasia. Despite worsening left-sided hemiparesis and persistent left lower limb tone, the patient improved her level of function and independence in activities of daily living after completing an intensive, 4 week, inpatient neurorehabilitation program. Conclusions: This case represents unusual etiology for a right middle cerebral artery air emboli infarct following EGD with botulin toxin A injection associated with acute left lower limb tone 48 hours post-stroke. Acute inpatient rehabilitation improved physical function and independence.

 Individualized onabotulinumtoxina treatment for spasticity in multiple sclerosis resulted in high patient and clinician satisfaction: The ASPIRE study



Daniel S. Bandari, Angeli Mayadev, Mohamed Sakel, Alberto Esquenazi, Joan Largent, Aleksej Zuzek, Gerard E. Francisco

Objectives: Examine onabotulinumtoxinA utilization and effectiveness to treat spasticity in multiple sclerosis (MS) patients. Design: Multicenter, international, prospective, observational registry (NCT01930786), examining adult patients with spasticity across multiple etiologies treated with onabotulinumtoxinA at their clinician's discretion. Assessments: utilization (each visit) and clinician (next visit)/patient (5±1 weeks post-treatment) satisfaction. Results: Patients (N=730) were on average 54y, 52% female, 63% continuing botulinum toxin treatment for spasticity. Common etiologies: stroke (n=411; 56%), MS (n=119; 16%). In MS patients, the most common upper limb presentation was flexed elbow (18%); onabotulinumtoxinA doses were 25-550U. Muscles injected: biceps brachii (100%), brachioradialis (54%), brachialis (46%), other (4%); anatomical localization (60%) was most frequently utilized. Most common lower limb presentation was equinovarus foot (61%); onabotulinumtoxinA doses were 15-875U. Muscles injected: gastrocnemius (79%), soleus (73%), tibialis posterior (46%), flexor digitorum longus (15%), other (11%), flexor hallucis longus (2%); EMG localization (57%) was most frequently utilized. Overall (N=730), ≥76% patients and ≥91% clinicians reported extreme satisfaction/satisfaction that onabotulinumtoxinA helped patient's ability to participate in therapy/exercise; 92% patients and ≥98% clinicians would definitely/probably continue treatment. Overall (N=730), 261 patients reported 831 adverse events (AEs); 23 treatment-related. 94 patients reported 195 serious AEs; 3 treatment-related. No new safety signals were identified. Conclusions: ASPIRE provides valuable, real-world data on dosing, injection guidance, and muscle targeting over 2 years, that may help guide clinical strategies. ASPIRE captured the individualized nature of onabotulinumtoxinA utilization for spasticity in MS patients, while consistently demonstrating high satisfaction among patients and clinicians, the majority indicating that onabotulinumtoxinA helped patients participate in therapy/exercise. These results add to the body of evidence on the safety and effectiveness of onabotulinumtoxinA for spasticity.

 Influence of single nucleotide polymorphism in BDNF and COMT genes on dysphagia after stroke



Hua Li, Mingzhu Xu, Xiaodong Wang, Xun Luo, Yulong Wang, Qing Mei Wang

Objectives: We hypothesized that SNPs in BDNF and COMT may play a role in swallowing function after stroke. We aimed to investigate the influence of BDNF Val66Met and COMT Val158Met genotypes on recovery of swallow in stroke patients during acute inpatient rehabilitation. Design: Inclusion criteria include diagnosis of stroke with CT or MRI, acute inpatient rehabilitation, whole genome sequence available in Partners HealthCare Biobank. The primary functional outcome was relative gain of swallowing function during inpatient rehabilitation as calculated with Montebello Rehabilitation factor Score (MRFS). The Secondary outcome measures were FIM total score at discharge, discharge destination and length of stay. There were 570 stroke patients identified in the Biobank. Among those patients, 172 were admitted to acute inpatient rehabilitation from 2006 to 2017. During inpatient rehabilitation, all subjects were evaluated by speech pathologist for dysphagia using American speech-language-hearing association/functional communication measures (ASHA/FCM) scores. Seven-nine patients were diagnosed with dysphagia. T-test, Chi-squared test and ANOVA test were performed to determine the differences among the groups. Results: Average of swallowing function at discharge was significantly higher than admission (P=0.001). There was no significant difference in MRFS of swallowing score among BDNF Val66Met genotypes (ANOVA, F=0.139 P=0.871) or COMT Val158Met genotypes (ANOVA F=0.151 P=0.86). Co-occurrence of BDNF Val66Val and COMT Met158Met did not generate significant difference in MRFS as compared to all others (t=0.483, p >0.05). Conclusions: These data suggest that genetic variation of BDNF Val66Metand COMT Val158Met may not affect recovery of swallowing function during subacute phase post stroke.

 Influences of different parameter settings of the lower body positive pressure treadmill training module on immediate heart rate and blood pressure in patients after stroke: A cohort study



Junjie Liang, Yuxin Zheng, Peixi Lian, Shijuan Lang, Hongxin Chen, Wanting Mo, Haining Ou, Qiang Lin

Objectives: Safe and effective gait training pose a challenge for stroke patients. Lower body positive pressure (LBPP) treadmill training could lead to weight reduction and has the potential advantage of allowing people to achieve walking as exercise with relatively low heart rate, blood pressure, and oxygen consumption. These parameters could be beneficial to stroke patients, especially elderly stroke patients with comorbid hypertension. However, relevant research concerning the exact effects on this training have rarely been found. Design: We analyzed 40 consecutive stroke inpatients from 2018 to 2019 for gait exercise treatment using the LBPP treadmill. The primary immediate values of the blood pressure and heart rate (HR) before and after each LBPP training session were documented and analyzed. Results: Of the 40 stroke patients, 29 patients suffered from hypertension. 888 valid LBPP training sessions out of 1195 sessions, in which the top five body-weight settings of 70%, 65%, 60%, 80%, and 75% BW, were documented, and the top five speed settings for training were 1.2, 1.0, 1.4, 1.5, and 0.8 mph, respectively. The primary outcomes showed no significant differences in immediate systolic blood pressure (SBP) before and after each LBPP training session versus significant differences in immediate diastolic blood pressure (DBP) or HR. However, the mean differences were 7 mmHg and 4 HR, which were still in the safety range. Furthermore, the speed was divided into three grades: low speed, < 0.9 mph; intermediate speed, 0.9 mph < Speed<1.8 mph; and fast speed > 1.8 mph. There were no significant differences in SBP among the three speed grades, but significant differences in HR were noted. Conclusions: The key finding of this analysis indicated that the LBPP treadmill could provide stroke patients could be safe the circulatory system using the LBPP treadmill during gait training.

 Inpatient rehabilitation course of Larsen syndrome patient post carotid paraganglioma resection with postsurgical CVA: A case report



Rohit Nalamasu, Adam Kafka

Case Diagnosis: Larsen Syndrome is a genetic disorder with variable presentation that affects development of bones throughout the body, presenting with clubfeet and multiple dislocations of hips, knees, and elbows. It can also present with hearing abnormalities, congenital cardiac septal defects, and acquired abnormalities of aorta and mitral valve. Patients present with hypermobility and short stature along with moderate to severe spine curvature with potential respiratory or cardiovascular compromise as a result. It can be a cause of possible spinal cord compression secondary to non-traumatic cervical displacements. Case Description: We present a case of a 22 year old female patient who underwent resection of left carotid paraganglioma with resulting cranial nerve X and XII sacrifice. She had sudden left gaze palsy with right-sided hemiparesis with imaging showing left M2 occlusion. She had a complicated inpatient rehabilitation stay including bilateral Pseudomonas-klebsiella healthcare-acquired pneumonia, urinary tract infections, swallowing, speech, and sleep concerns. Discussions: The rehabilitation course of this complicated patient is important for the future care of other patients with similar ailments. While multiple studies have discussed malignant hyperthermia and spinal cord compromise in Larsen syndrome, no studies have shown a concomitant Larsen syndrome patient with CVA or paraganglioma. Conclusions: This rare case may provide early insight into correlations between Larsen's and post-surgical CVA or carotid paragangliomas, as well as aid in the rehabilitation course of similarly complex CVA patients.

 Integrating suicide prevention in a spinal cord injury practice



Sunil Sabharwal

Objectives: Suicide is more common in people with spinal cord injury (SCI) than in the general population, but literature on suicide prevention initiatives in SCI practice is lacking. This report summarizes experiences and lessons learned from systematic efforts for suicide prevention at a Veterans Affairs (VA) SCI Center over a one-year period. Design: We implemented systematic screening for suicidal ideation during SCI annual evaluations, using item 9 of PHQ-9, followed by the Columbia Suicide Severity Rating Scale (C-SSRS) for positive responses. All SCI staff, regardless of profession, were educated about warning signs of suicide. We optimized existing practices for conditions that increase suicide risk (e.g., depression, substance use disorders, chronic pain). We increased awareness of crisis lines and services (e.g., the National Suicide Prevention Lifeline number) by posting in the SCI clinical areas and providing the information on wallet cards and bracelets. Given that firearms are a common means of suicidal deaths, we placed gunlocks in easily accessible clinical areas. Results: Screening for suicidal ideation during routine annual evaluation was well accepted. Administering screening in a conversational style worked best versus firing off questions from a template. Concerns included inconsistent interpretation of nebulous responses to the PHQ-9 question. Staff identified need to standardize follow-up actions based on severity and temporality of suicide risk (such as criteria for formal safety plans or involuntary hospitalization). Linking staff education to known or suspected suicidal deaths increased relevance and engagement. The non-intrusive method of making gun locks available facilitated their use, with many veterans taking one during clinic visits. Specific effort to augment protective factors for vulnerable individuals, who were less likely to access available resources themselves, was recognized a key element of suicide prevention in SCI. Conclusions: Our experiences and efforts to systematically address suicide prevention may provide practical guidance to other programs for implementing similar initiatives.

 Interside latency differences in somatosensory evoked potentials of greater occipital and great auricular nerves



Jorge E. Gutierrez

Objectives: Impairment of the Greater Occipital Nerve (GON) or the Great Auricular Nerve (GAN) can occur after C2-C3 injuries or nerve entrapments, causing pain and sensory loss. Somatosensory evoked potentials (SSEP) may be used to document neurophysiological injury of these nerves. Limits of the interside latency differences may be the most valuable parameter when interpreting asymmetric SSEP recordings of sensory nerves. The aim was to analyze the normal upper limits of interside latency differences of SSEP from the GON and the GAN in normal subjects. Design: We prospectively studied 85 healthy subjects aged 16 to 87 years (mean age 46.1 ± 14.7; 41 females, 44 males). Cortical SSEP waveforms derived from the C5'/C6' - FPz montages were obtained by electrical stimulation. Stimulating electrodes were placed (1) 2.6 cm laterally from the midline at the superior nuchal line (GON-SSEP); (2) 6 cm caudal to the bony external acoustic meatus along the posterior border of the sternocleidomastoid muscle (GAN-SSEP). We analyzed the latencies of P1 waves and the amplitudes of P1 for GON and GAN SEP bilaterally. The interside differences for these parameters were calculated and analyzed. Results: We obtained reproductible evoked responses of both nerves in all subjects. We found an upper limit for the interside latency differences of 2.0 ms for GON, and 1.9 ms for GAN. No effects of age, sex or height were noted in the determination of the upper limits. The ratio of the smaller amplitude to the bigger amplitude less than 50% was present in up to 37% of the SSEP recordings. Conclusions: Reproductible SSEPs of the GON and the GAN can be obtained in healthy adults with little side-to-side difference. The presented reference values of interside differences of SSEP latencies enable a comparison with patient data in cases of suspected occipital or great auricular neuropathies.

 Intradural extramedullary myxopapillary ependymoma presenting as recurrent low back pain: A case report



Eric Liu, Tomas W. Salazar, Beverly Hon, Sara Cuccurullo

Case Diagnosis: Intradural extramedullary myxopapillary ependymoma. Case Description: This patient is a 45-year-old male with a past medical history significant for chronic back pain who initially presented to his chiropractor for worsening back pain. He denied any neurological changes in sensation, strength, bowel or bladder function. Due to persistent pain, an outpatient MRI was ordered which showed a large intradural extramedullary enhancing mass at L1-L2 along with severe canal stenosis. The patient was referred to neurosurgery for further evaluation. Subsequently, he underwent a T12-L2 laminectomy and resection of the mass. Post-operative MRI showed mild clumping of cauda equina nerve roots due to arachnoiditis and steroid taper was started. Pathology demonstrated a myxopapillary ependymoma WHO grade I. Patient was eventually discharged to acute inpatient rehabilitation. Discussions: Ependymomas are most commonly categorized as intradural and intramedullary. A recent literature review found that there have been only limited reports of intradural extramedullary ependymomas. Symptoms were based on tumor location but often included pain, motor and sensory deficits, and urinary dysfunction. In this case, the patient only presented with worsening chronic back pain with no neurological or urinary complaints, making detection of the tumor difficult. Following diagnosis and resection, he underwent an acute rehabilitation program and was discharged home independent with ambulation, transfers, and activities of daily living. Conclusions: Nonspecific back pain can remain a challenge to health care providers who wish to avoid the overuse of unnecessary imaging as the majority of cases tend to be self-limiting and benign. Spinal cord tumors such as myxopapillary ependymomas, despite their rarity, can often present as nonspecific lower back pain making diagnosis difficult. By keeping spinal cord tumors on the differential list for chronic back pain, clinicians can arrive at a more expeditious diagnosis and institute earlier treatment, which can ultimately lead to better outcomes.

 Intrathecal baclofen dosing regimens in patients with spasticity: A retrospective chart review



Jacob Pfeiffer, Mary E. Nelson, John McGuire

Objectives: The use of intrathecal baclofen (ITB) to treat spasticity secondary to spinal cord injury (SCI) started in 1984. Since that time, ITB has also been used to treat spasticity secondary to stroke, cerebral palsy (CP), traumatic brain injury (TBI), and multiple sclerosis (MS). Despite over three decades of use, there have been no guidelines for clinicians for appropriate/stable dosing of ITB to manage spasticity. Design: This study was a retrospective chart review of patients with an ITB pump from 1/1/08 to 8/19/15. Data collected included demographic information, medical diagnosis, all dosing adjustments, system malfunctions, and concurrent antispasmodic treatments. The stable dose was defined as no change in dose for a 6 month period. Results: There was no difference (P >0.05, one-way ANOVA) between diagnosis in the initial or stable dose of ITB. In ascending order, initial doses of ITB (in mcg) were: MS, 61±24 (n=27); stroke, 96±50 (n=17); SCI, 125±69 (n=33); CP, 141±73 (n=24) and TBI, 142±103 (n=18). In patients who achieved a stable dose of ITB, the doses (in mcg) were: MS, 121±149 (n=17); stroke, 163±89 (n=3); TBI, 371±330 (n=8); SCI, 394±313 (n=14) and CP, 450±266 (n=16). The initial and stable doses of ITB were lower in ambulatory vs. non-ambulatory patients (initial dose: 85±36 mcg vs. 132±86 mcg, respectively, n=68, 51, p< 0.001, t-test; stable dose: 141±115 mcg vs. 398±304 mcg, respectively, n=39,19, p< 0.001, t-test). The initial and stable doses were also lower in paraplegic vs. quadriplegic patients (initial dose: 80±32 mcg vs. 134±88 mcg, respectively, n=32, 67, p=0.001, t-test; stable dose: 193±241 mcg vs. 377±297 mcg, respectively, n=16, 38, p=0.33, t-test). Conclusions: When considering the stable dose of ITB to manage spasticity, one should consider ambulatory status and/or plegia type as opposed to underlying diagnosis.

 Intrathecal baclofen pump use in management of paroxysmal sympathetic hyperactivity in the setting of NMDA encephalitis



Priyanca Shah, Stephen Hampton

Case Diagnosis: NMDA encephalitis with paroxysmal sympathetic hyperactivity. Case Description: 47 year old female presented with subacute headaches and encephalopathy which progressed to a coma within a week of admission followed by status epilepticus. Diagnosed with NMDA encephalitis attributed to paraneoplastic syndrome from metastatic ovarian clear cell tumor. The patient underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and multiple rounds of chemotherapy with no neurologic improvement. Also found to have small round cell PNET not amenable to chemotherapy. Throughout her hospital course patient had severe paroxysmal sympathetic hyperactivity (PSH) with labile vitals and on multiple oral agents, including morphine, versed, and precedex. Discussions: After intrathecal baclofen pump placement, titration, and additional of as needed bolus dosing given during an episode of PSH, the overall patient required less PRN versed and morphine and was weaned off of precedex and vital signs were more stable than prior. Unfortunately, patient is now deceased due to her metastatic cancer, however, after ITBP placement, titration, and creating a nurse-driven protocol for bolus dosing the patient's care significantly improved as nursing was able to manage her care easier, the patient was safer, vitals were more stable, and less sedating medication was being given. Conclusions: Intrathecal baclofen pumps with appropriate titration and nurse-driven bolus dosing protocols allow for a decrease in sedating medication use and improved patient care.

 Intrathecal chemotherapy: A rare cause of spinal cord toxicity in a pediatric patient



Laura Prince, Abigail Ho, Melissa Villegas, Sara Liegel

Case Diagnosis: Thoracolumbar spinal cord injury secondary to intrathecal methotrexate and cytarabine. Case Description: An 18 yo female with diffuse large B-cell lymphoma underwent treatment with multi-agent systemic chemotherapy and intrathecal methotrexate, cytarabine, and hydrocortisone. Two months after initiation of treatment, patient developed bilateral leg pain and mild difficulty ambulating followed by fluctuating bowel and bladder incontinence. MRI was negative for structural spinal cord abnormalities. During a subsequent admission for planned chemotherapy, patient developed profound bilateral leg weakness with sensation and proprioception deficits. Repeat MRI demonstrated non-enhancing T2 hyperintense lesions of the central and posterior tracts in the thoracolumbar cord. CSF showed elevated myelin basic protein. Chemotherapy was discontinued, and patient received leucovorin, vitamin B12, and dextromethorphan for neurorecovery. Patient achieved significant functional improvements and recovered ability to retain urine following inpatient rehabilitation. Repeat bone marrow biopsy demonstrated remission of lymphoma. Discussions: Intrathecal chemotherapy can result in a wide variety of neurological side effects ranging from asymptomatic arachnoiditis to severe leukoencephalopathy and myelopathy. The exact mechanism and incidence of spinal cord toxicity remains unknown, and symptoms may develop immediately following intrathecal administration or months later. Presentation frequently includes urinary dysfunction, encopresis, and predominantly motor versus sensory deficits. Intrathecal methotrexate and cytarabine are the most commonly implicated agents, and providers should maintain a high index of suspicion for patients receiving these agents intrathecally. Limited, experimental treatments exist, though prognosis remains unclear with variable recovery. Patients may benefit from acute rehabilitation. Conclusions: Spinal cord toxicity from intrathecal chemotherapy is an uncommon cause of spinal cord injury among oncology patients with potentially devastating complications. Patients should be educated and closely monitored for neurological side effects, and practitioners should maintain a low threshold for spinal cord imaging and delay of further intrathecal chemotherapy in the setting of unexplained symptoms to minimize further injury.

 Investigation of brain computer interface combined with wrist passive motion training in chronic stroke patients



Rongrong Lu, Tianhao Gao, Yi Wu, Jie Li

Case Diagnosis: Rehabilitation improves motor impairment after stroke. In chronic stroke patients with severe upper limb impairment, impairment of wrist and hand often lasts and this remains as a difficult and important issue in rehabilitation. We Designed this study to investigate the feasibility and effectiveness of motor imagery based brain computer interface with wrist passive movement in chronic stroke patients with wrist extension impairment. Case Description: This was a before-after study. Fifteen chronic stroke patients with a mean age of 47.60±14.66 were recruited from March 2017 to June 2018. A 12-Channel High-Resolution EEG Systems following 10-20 international system was used to record the EEG signals which can be analyzed to evaluate participants' motor imaginary ability. Motor imagery based BCI system with wrist passive range of motion training was used to train the stroke patients. Both range of motion of paretic wrist and Barthel index was assessed before and after the intervention. Participants were asked to complete a questionnaire when they completed the whole therapy. Discussions: Among 15 chronic stroke patients admitted in the study, 12 patients finished the whole therapy. 3 patients failed to pass the initial assessment. Totally 12 participants completed the whole sessions of the treatment. After therapy, their ability of control EEG was improved. And 12 participants regained the ability to actively extend the affected wrist. And 3 failed to actively extend their wrist. Those who regain the control of the paretic wrist accounted for 75%. The activity of daily life of all the participants did not change significantly before and after intervention. Conclusions: In chronic stroke patients with wrist extension impairment, motor imagery based brain computer interface with wrist passive movement training might be feasible and effective. This might be a promising therapy for those chronic stroke patients with severe upper limb impairment.

 Involvement of peripheral and spinal FPR2/ALX receptors in the anti-inflammatory effect of manual therapy in an animal model of postoperative pain



Daniel Fernandes Martins, Lisandro Ceci, Afonso Salgado, Daiana Cristina Salm, Daniela Ludtke, Júlia Koerich, Gustavo Mazzardo, Kamilla Frech, Rodolfo Parreira, Carlos Omura, Francisco J. Cidral Filho, Leidiane Martins

Objectives: Several patients develop chronic pain after surgical procedures, but the underlying mechanisms of the transition from acute to chronic states aren't totally understood. Nowadays it's well established that acute inflammation is accompanied by an active resolution program with specialized pro-resolving mediators. Manual therapy is a widely used therapeutic modality for pain management. In this study we investigated one of the underlying mechanisms of action. Objective: evaluate the involvement of peripheral and spinal FPR2/ALX receptors on the anti-hyperalgesic effect of ankle joint mobilization (AJM) in a mouse model of postoperative pain. Design: Male Swiss mice (25-35g) were subjected to plantar incision (PI). Mechanical hyperalgesia was evaluated with the von Frey test; paw edema was assessed with a micrometer; and paw temperature through thermography. Animals were treated with AJM (either slow or rapid manipulation) or BML-111 (a FPR2/ALX receptor agonist) for 5 consecutive days. Other animal groups were injected (intraplantar route) with vehicle or WRW4 (a FPR2/ALX receptor antagonist) and treated with placebo AJM or AJM for 3 consecutive days. Results: BML-111 and slow AJM (sAJM) treatment, but not rapid AJM (rAJM), reduced mechanical hyperalgesia. BML-111 and sAJM treatments did not affect paw edema. sAJM increased paw temperature 24h after PI. BML-111 reduced paw temperature 48h and 72h after PI. WRW4 i.pl. and i.t. pre-treatment prevented the anti-hyperalgesic effect of both BML-111 and AJM. Conclusions: Slow AJM reduced hyperalgesia in a mouse model of postoperative pain. Results are mediated, at least in part, by peripheral and spinal FPR2/ALX receptors.

 Ipsilateral hemiballism improves following treatment of contralateral spasticity with chemodenervation



Daniel Moon, Gerard Limerick

Case Diagnosis: Hemiballismus, spasticity, dystonia. Case Description: 51-year-old right-handed male with recent infarcts to the left caudate, putamen, corona radiata, anterior temporal lobe and insular cortex presented with complaints of uncontrolled movements of his left arm and stiffness of his right hand, wrist, ankle and foot. On physical examination, he had increased tone in the right wrist flexors (Modified Ashworth 1+) and a stiff right ankle (Modified Ashworth 3) with tenderness to palpation of the extensor digitorum brevis (EDB). He demonstrated uncontrolled ballistic movements of his left arm that were triggered with passive and attempted extension of the right wrist and EDB palpation. Baclofen was not effective, therefore he underwent chemodenervation with botulinum toxin to the right flexor carpi radialis, flexor hallucis longus, EDB and extensor hallucis longus. Following treatment, he was able to extend his right wrist without triggering left hemiballism. There was also reduced pain and stiffness at the left foot/ankle with increased volitional movement. Discussions: Hemiballism is a rare movement disorder typically caused by basal ganglia dysfunction resulting in the appearance of sudden, involuntary flailing of the limb(s). Most cases are reportedly continuous. However this case is unusual as it was triggered by contralateral limb stretch, palpation or volitional movement. Anti-dopaminergic agents are typically used to treat hemiballism, but there was concern that these agents could cause worsening spasticity or dystonia on the contralateral side. Fortunately, a trigger was identified and successfully addressed with focal chemodenervation. Conclusions: Ipsilateral hemiballism is extremely rare but has been reported in the literature to occur with contralateral hemiplegia. There may also be co-exisitng spasticity and/or dystonia on the contralateral side due to upper motor neuron syndrome. Though mechanisms are unclear, the pathways responsible for spasticity, dystonia and hemiballism may be intertwined and a better understanding of this relationship may lead to improved treatment outcomes.

 Is it really transverse myelitis? A perplexing thoracic myelopathy



Abhinav Mohan, Alan Novick

Case Diagnosis: Thoracic Dural Arteriovenous Fistula. Case Description: A 68-year-old woman, previously independent, presented with acute-onset lower-extremity weakness. She was unable to walk. Contrast-enhanced T-spine MRI showed central cord hyperintensity from T7-L1, with conus/cauda equina involvement. Laboratory studies including LP, aquaporin-4-IgG, and paraneoplastic/rheumatologic/infectious panels were negative. She was diagnosed with longitudinal-extensive transverse myelitis. Her strength/gait improved with steroids and inpatient rehabilitation. However, she experienced frequent lower-extremity weakness “flares” with three subsequent acute-hospital readmissions, each time prompting steroids and/or plasmapheresis plus inpatient rehabilitation. Her disease course also included varying signal level (highest was T4), lower-extremity hypoesthesia, neurogenic bladder, and recurrent UTIs. Physical exertion was noted to transiently exacerbate her weakness. Repeat contrast-enhanced T-spine MRI showed small, previously-unseen serpentine flow-voids posterior to the cord at T9-T12; angiogram confirmed dural arteriovenous fistula. L1-L3 laminectomy and surgical clipping was performed, followed by inpatient rehabilitation. She has since experienced significant improvement and has been an independent community ambulator with rollator for several weeks. Discussions: Spinal dural arteriovenous fistulas are abnormal connections between an artery and a vein in the subdural space. When blood from the high-pressure arterial system enters the low-pressure venous system, blood supply is compromised and venous congestion/swelling occurs, leading to potentially irreversible damage. Symptoms include weakness, numbness, paresthesia, pain, bowel/bladder incontinence, and even paraplegia; however, many are asymptomatic. MRI is frequently nondiagnostic, so strong clinical vigilance and access to spinal angiography is required. Radiographic embolization is first-line therapy, but in this case surgery was necessary due to microvascular collateral circulation. Once repaired, spinal cord blood flow improves but damage may not reverse. Conclusions: Spinal arteriovenous fistulas should be suspected in any case of paraparesis of non-definitive etiology, especially when there is exertion-associated weakness. As early management portends a better prognosis, we hope that this case educates physiatrists on this clinical pathology and leads to improved patient care/outcomes.

 Is the anticipated U-turn different from the unanticipated U-turn in poststroke hemiplegic patients?



Emna Jelili, Marylène Jousse, Camille Leroux, Laurent Oudre, Rémy Barrois, Alain Yelnik

Case Diagnosis: Turning during ambulation is a common action. Balance control through trunk movement and correct body segments sequencing (temporal coordination) ensure a safe U-turn. However, it could be challenging after stroke. We previously described U-turn strategies in post-stroke patients (Barrois RP, et al. Observational Study of 180° Turning Strategies Using Inertial Measurement Units and Fall Risk in Poststroke Hemiparetic Patients. Front Neurol. 2017), regarding to the side chosen to turn (healthy or paretic) and the first step used to turn (healthy or paretic). But U-turns were anticipated, while in daily life, we hypothesize that the most dangerous situation is when U-turns are unanticipated. We Designed this study to investigate the differences between anticipated and unanticipated U-turns. Case Description: Thirty chronic stroke patients walked at a self-selected speed and were instructed to make U-turn after ten-meter walk, with four inertial measurement units on the head, trunk, and feet. They did three unanticipated and three anticipated U-turns. The turning duration, body segments sequencing and energy expenditure by the root mean square of accelerations at the trunk (RMSa) were analyzed. Discussions: Turning duration of unanticipated U-turns was the shortest (2.28 (0.84) vs. 2.58 (0.90) seconds) (p=0.01). Body segments Sequencing was different in anticipated and unanticipated U-turns (p< 0.01). When the U-turn is unanticipated, patients tend to turn simultaneously their heads and trunks, or to turn their trunks before their heads, unlike in the anticipated U-turns, where the head starts to move before the rest of the body. There was no correlation between RMSa with turning strategies, nor with body segments sequencing. Conclusions: Unanticipated U-turns differ from anticipated ones in duration and body segments sequencing. These findings suggest an altered temporal coordination of gaze and posture during unanticipated U-turns, which may lead to an increase falling risk after stroke.

 Isolated trapezius weakness after resection of lipoma



Arline Edmond, Jason Bitterman, Rex Ma, Gautam Maholtra

Case Diagnosis: Spinal accessory nerve (SAN) injury after lipoma resection presenting as shoulder pain. Case Description: A 55-year-old male presented with left shoulder pain and difficulty with upper body dressing two months after ipsilateral posterolateral neck lipoma resection. Exam revealed left lateral displacement of scapula, downwardly rotated scapula with abduction, and trapezius weakness. Nerve conduction testing revealed severely diminished compound muscle action potential amplitude from the trapezius when compared to the right. Electromyography revealed denervation potentials and polyphasic motor unit action potentials in the left trapezius with normal findings in the sternocleidomastoid (SCM). Magnetic resonance imaging revealed normal neuroforaminae and intact proximal left SAN. However, the distal nerve could not be visualized. Therapeutic exercises were prescribed focusing on scapular retraction, and normalizing scapula upward rotation during shoulder abduction. The patient's range of motion and strength improved. Discussions: The ubiquity of shoulder pain necessitates familiarity with its diverse differential including peripheral nerve injury. This case illustrates the need for physiatrists to consider the SAN particularly with isolated trapezius weakness after ipsilateral neck surgery. The SAN exits the jugular foramen into the posterior triangle of the neck, crossing anterior to the jugular vein to innervate the SCM and trapezius. The trapezius contributes to scapular retraction and upward rotation. Thus, injury can lead to significant disability. Surgical repair is challenging and introduces risk. Therefore, it is crucial to meticulously identify deficits to be addressed with physical therapy and bracing to optimize scapulothoracic stability. Conclusions: SAN injury, given its superficial course, can be a complication of neck surgeries. While not well described in physiatric literature, it is important for physiatrists to have a high index of suspicion for injury when evaluating shoulder dysfunction after a cervical procedure. NCS and EMG can play an important role in diagnosis of these lesions.

 Isolated unilateral cranial XI nerve palsy after traumatic brain injury: A case report



Dohun Lee, Yunsoo Soh, Hee-Sang Kim, Jong Ha Lee, Dong Hwan Yun, Jinmann Chon, Yong Kim, Myung Chul Yoo, Eun Jeoung Lee, Euntaek Lee, Yun Kyung Seo, Seona Chae

Case Diagnosis: Isolated Unilateral Cranial XI Nerve Palsy After Traumatic Brain Injury : a Case Report. Case Description: A 60-year-old male was sent to emergency department after falling down from 3m height during roof repair. According to the patient he started noticing weakness in right shoulder area after the recovery. The symptoms worsened and he visited rehabilitation unit two months later for further evaluation of the symptoms. On initial assessment, he had difficulty at shrugging and abduction of right shoulder. At right side, lateral winging scapula and trapezius muscle atrophy was also observed. (Figure 1) Brain CT taken at the time of the accident, revealed a contusional hemorrhage in right anterior temporal fossa and subarachnoid hemorrhage, and a fracture of the base of skull extending to the jugular foramina. Right cranial XI palsy was confirmed based on the collective findings confirm in eletromyography. Discussions: There have been several reports of various traumatic lower cranial neuropathies that usually followed a fracture through the jugular foramen or occipital condyle fracture (OCF). Thus, the anatomical location can account for the frequent occurrence of lower cranial nerve deficits following these fractures but only a few cases are reported and isolated single nerve palsy is extremely rare. We report a case of skull base fracture near pars vascularis of right jugular foramen, which was clinically associated with isolated unilateral cranial nerve XI palsy with shoulder weakness as the chief complaint. Conclusions: Since patients traumatic brain injury could be affected, skull fracture should be considered in patients with isolated unilateral cranial XI neuropathy.

 Keratinocytes endothelin-B receptors involvement in peripheral opioid analgesia induced by light-emitting diode photobiomodulation in male and female mice



Bruna Hoffmann de Oliveira, Rafaela Hardt da Silva, Verônica Vargas Horewicz, Daiana Cristina Salm, Afonso Salgado, Francisco J. Cidral Filho, Anna Paula Piovezan, Daniel Fernandes Martins

Objectives: Currently LEDT is gaining space in the scientific and clinical environment. However, no study has investigated the biological effects caused by different irradiations, and the analgesic mechanism by which LEDT presents its effects remains unknown. Thus, the objective of this study was to evaluate the effect of two different LEDT irradiances (3.5 and 90 mW/cm2) – given a 630nm wavelength and a 2 J/cm2 dose – on mechanical hyperalgesia following Complete Freund's Adjuvant (CFA) intraplantar (i.pl.) injection in mice. Additionally, the role of peripheral opioid and endothelin-B receptors (ETB-R), and the sex difference was investigated. Design: Different groups of male or female mice were evaluated 6 and 96 hours after CFA. Mechanical hyperalgesia was evaluated 30min after treatments. Naloxone or Bq-788 administration, fifteen minutes before LEDT or Sarafotoxin S6c, helped determine the involvement of peripheral opioid and ETB-Rs on LEDT effects. Lastly, ETB-Rs skin immunocontent in both sexes was quantified after LEDT consecutive daily treatments. Results: LEDT at an irradiance of 90mW/cm2 was more effectively than 3.5mW/cm2. Bq-788 and naloxone administration prevented LEDT and SRTX S6c effects; however, LEDT did not influence peripheral ETB-Rs immunocontent. The Results suggest that irradiance influences LEDT effect; and that activation of ETB-R play a role in peripheral LEDT opioid induced analgesia. Lastly, LEDT effects do not appear to be sex-dependent. Conclusions: Through our findings, we suggest a possible analgesic role of the LEDT that when reaching keratinocytes promotes the release of ET-1 that activates peripheral ETB-R releasing opioids. The clarification of this pathway facilitates the understanding of the effects of LEDT in both genders and supports its clinical use.

 Knee rehabilitation in 3 phases: Effects on functionality according to the ICF



Pavel Loeza Magana, Adalberto Loyola-Sanchez

Objectives: To determine the effects of the three-phase post-surgical knee rehabilitation program (RPQx) on the functionality determined by the ICF; and verify if the core set of gonarthrosis is applicable in these patients. Design: Qualitative retrospective descriptive observational longitudinal, analytical. The records of 27 patients with gonarthrosis, 15 operated by arthroscopy, 12 with arthroplasty were reviewed. RPQx program lasted an average of 20 weeks. Participants completed phase 1 with analgesia, electrotherapy, cryotherapy, range of mobility, isometric exercise and walking with a walker or cane; phase 2 with full-range mobility, isotonic strengthening, closed kinetic chain exercise, proprioception and balance; phase 3 was performed with isokinetic device (Con-Trex MJ) in flexion and extension concentric/concentric modality, 16 sessions, 3 per week, with 2 sets of 10 repetitions at 60°/s and 180°/s, with initial and final evaluation; in addition to gait training. The measurements were made according to the ICF: Sensation of falling (b2402), Pain in joints (b28016), Edema (b4158), Hyperthermia (b5501), Range of movement limitations (b7100), Joint instability (b7150), Hypoesthesia (b7202), Muscle Weakness (b7301), Difficulty walking (d450), Difficulty climbing stairs (d4551). Results: The analysis was carried out with the Cochran's test, obtaining a reduction in all the variables and statistical significance, getting to obtain complete absence in edema, hyperthermia and sensation of instability, but maintaining the difficulty to climb stairs and the limitation of the ROM. The balance increased with almost complete improvement. Conclusions: The RPQx is useful to improve the functionality of patients, and it is appropriate to describe these changes according to ICF, prioritizing the levels of action according to the functional and biological stage in which the person is. Phase 3 of RPQx with isokinetic strengthening is a safe and useful exercise affecting the functionality. The core set for gonarthrosis is not useful since it does not include certain applicable codes for this population.

 L2 arteriovenous fistula rupture status post epidural spinal injection



Mariyam Wasay, Yu-Jen Lai

Case Diagnosis: Type 1 L2 Dural AV fistula. Case Description: A 66 year old female with past medical history lumbar stenosis who underwent epidural spinal injection for back pain. One day after the epidural spinal injection, patient presented with acute onset of numbness, bilateral leg weakness and urinary retention. MRI revealed abnormal signal in the thoracic and lumbar spine from T8 conus and flow voids. MRA revealed Type 1 L2 dural AV fistula untreatable by embolization. Patient underwent L1-3 Laminectomy with dural AV fistula clipping. Upon admission to acute rehabilitation, patient had mild weakness of the hip flexors and knee extensors. Patient also had decreased sensation to light touch below bilateral knees. Patient had a foley catheter in place on admission. Patient recovered the ability to ambulate with a rolling walker, 150 feet, independently. Upon removal of foley catheter, patient was able to void. No bowel issues appreciated. Discussions: Spinal dural arteriovenous fistulas occur due to an abnormal connection between an artery and a vein, disrupting the normal circulation of the spinal cord. The etiology is unclear. It usually affects males over age 50. Due to the increase in spinal cord venous pressure, there will be resulting spinal cord congestion, swelling and neurological malfunction. This will result in weakness, abnormal sensation and bowel/bladder issues. Treatment includes embolization or spinal surgery if embolization is not possible. Once the fistula is treated, patient outcomes are dependent on the severity of initial damage as well as the level and size of the injury. Conclusions: This is an atypical case of a female patient with a spontaneous L2 arteriovenous fistula rupture after epidural spinal injection.

 La la lungs: A feasibility study on singing therapy as an intervention for pulmonary rehabilitation among spinal cord injury patients in Malaysia



Sara A. Easaw, Julia Engkasan, Nazirah Hasnan, Jin Hin Yap

Objectives: Respiratory impairment following spinal cord injury is a common occurrence, secondary to weakness of the respiratory and abdominal muscles. Singing as a therapeutic intervention for improving lung volumes has been studied in this population, although with limited local evidence. Here we conceptualized a hospital-based singing programme, aimed at patients with cervical and thoracic spinal cord injury. This is a feasibility study which aims to determine if such a programme may be successfully implemented in Malaysia. Design: 12 patients with cervical and thoracic spinal cord injuries were registered to participate in a 2-weekly singing class, conducted by an expert vocal trainer. Classes were held for a period of 3 months or 12 scheduled classes. We looked at class attendance as well as the progress of the participants in terms of pitch matching, phonation and exhalation length. This was followed by a one-to-one post intervention interview, to obtain feedback from participants. Results: The targeted attendance for a feasible result was set at 80% attendance of 80% of participants. Results showed that the average attendance was far below this target. The average attendance over the 3 month period was 16.67% which translated to only 1 out of 12 classes. The reasons for this dismal outcome were identified as work commitments and transportation difficulties. Participants who did attend classes demonstrated overall improvement in their secondary outcome measures. Recommendations that were suggested for improving this programme included short intensive music camps, online singing programmes and provision of transport services. Conclusions: In conclusion, this singing programme was unable to meet the desired targets and hence is deemed non-feasible. However, further studies should be conducted to implement the enlisted recommendations. This may create a more feasible outcome, thus providing great benefits to our patients in terms of pulmonary health, quality of life and general wellbeing.

 Labor market participation of people with spinal cord injury in Germany: Results of the German Spinal Cord Injury Survey



Andrea J. Bökel, Yorck B. Kalke, Christoph M. Gutenbrunner, Christian Sturm

Objectives: Multiple organizations like UN and WHO call for the collection of internationally comparable data on living and supply conditions of people with disabilities. Furthermore, reliable national data are necessary for ensuring appropriate care. Regarding patients with Spinal Cord Injury (SCI) in Germany, only data on diagnostics or therapeutic interventions is currently available. The International Spinal Cord Injury Survey aims at collecting reliable data of people with SCI in 21 countries and developing recommendations for actions to be taken by policy-makers and other decision-makers. Design: In 2017, eight specialized SCI-centers across Germany sent a standardized questionnaire to their patients who had diagnosis of SCI, and were older than 18 years (n=5,598). The questionnaire could be completed paper-based or online. Results: 1,479 patients participated in the study and were included in data analysis. On average, participants were 55.3 years (SD=14.6) old, ¾ were male. Almost ¾ of the participants, belonged to the working age population, of those 42.5 % (n=461) were employed. Although a well-trained and qualified population was identified (69.4 % completed vocational training and 21.2 % had a university degree), more than half of the unemployed people expressed their wish to work (59.5 %, n=319), while ¾ of those felt subjectively able to work (71.4 %, n=220). The reasons why they were still not working were for example health status and disability (64.1 %), an employment could not be found (36.4 %), inadequate access to a potential workplace (22.7 %) and fear to lose financial support (22.3 %). ¼ described a lack of aids for working. Conclusions: Results identified a well-educated population, but also a group of people willing and feeling subjectively able to work, but who do not participate in the Labor market. Therefore, vocational rehabilitation and participation in Labor market and inclusion for people with SCI should be significantly strengthened.

 Lance Adams syndrome after anoxic brain injury



Alexander Heck, Sheital Bavishi

Case Diagnosis: Lance-Adams Syndrome. Case Description: A 30 year old male, with childhood history of seizure disorder off AED, admitted to inpatient rehabilitation hospital (IPR) after cardiac arrest secondary to an asthma exacerbation. Cardiopulmonary resuscitation performed in the field. After stabilization, patient developed upper extremity myoclonus. Started on propofol, switched to levetiracetam. EEG negative for epileptogenic focus. Movements improved with levetiracetam, however still interfered with ADLs and mobility. During admission, myoclonus improved with rest and relaxation, and worsened with stress. Clonazepam added and uptitrated, with improvement in control of myoclonus, ADLs, and mobility. This was evidenced by his FIM scores: improving from 1 (total assist) to 4 (minimal assistance) for eating, 1 to 5 (supervision) for grooming, and 2 (maximal assistance) to 5 for UE dressing by discharge. Discussions: Lance-Adams syndrome is a rare sequalae of hypoxic brain injury, with less than 200 cases reported. Lance-Adams is described as post-hypoxic myoclonus. Often misdiagnosed as post-hypoxic seizures, Lance-Adams is distinguished as a persistent intentional myoclonus. Exacerbating factors include intention and external stimuli, with sleep and rest improving. Imaging and EEG can exclude alternatives, however there are no hallmark findings to rule in Lance-Adams. Treatment aims to reduce myoclonus. Levetiracetam, valproate, and clonazepam are most frequently used. Although these treatments have been shown to improve function, Lance-Adams syndrome can result in significant disability. Conclusions: Lance-Adams syndrome is a rare but important sequelae of hypoxic brain injury, the hallmark of which is action myoclonus. Given it's frequent misdiagnosis and potential for significant morbidity, it is an important syndrome for clinicians to be aware of. Rehabilitation considerations include not only medication management, but also educating patients about stress management, therapists on adaptations to assistive devices (ie weights on walkers), which can improve quality of life for patients with Lance Adams Syndrome.

 Lesion impact on recovery by restitution versus compensation in the hemiparetic lower limb



Silvi Frenkel-Toledo, Shay Ofir, Nachum Soroker

Objectives: Recovery of voluntary movement of the hemiparetic lower limb (HLL) and regaining walking ability are major goals in stroke rehabilitation, achieved by restitution and compensation processes. Here we aimed to assess the long-term impact of lesion topography on recovery of (1) HLL movement quality, largely representing restitution, and (2) walking capacity representing the combined effect of restitution and compensation strategies. Design: Walking was assessed in 58 chronic stroke patients at their homes (28 with left hemisphere damage (LHD) and 28 with right hemisphere damage (RHD), one year or more after stroke onset), by the 3-meter walk test. HLL movement was assessed by the Fugl-Meyer lower extremity (FMA-LE) test. Normalized lesion data were used for voxel-based lesion symptom mapping (VLSM) analyses of lesion impact on HLL movement and walking, separately for RHD and LHD groups. Results: In the LHD group, voluntary movement of the HLL was affected by damage to peri-Sylvian cortex and the projection fibers (posterior limb of internal capsule and corona radiate) carrying the cortico-spinal tract. There was no significant impact to damage in any of the atlas regions on walking capacity in this group. In the RHD group, HLL movement was affected mainly by damage to the insula, sensorimotor cortex, projection- and association fibers, basal ganglia, and a restricted effect of damage to other cortical structures. In this group lesion topography affected also the walking capacity, mainly by damage to the insula, projection- and association fibers and the putamen. Voxels where damage affected both HLL movement and walking capacity were found mainly in the rolandic operculum, insula and putamen, in the RHD group only. Conclusions: Recovery by restitution and by compensation are affected differently by stroke lesion topography. VLSM points also to important differences in recovery mechanisms operating after damage to the dominant and non-dominant hemispheres.

 Levetiracetam induced rhabdomyolysis in an acute rehabilitation patient: A rare case report



Tomas W. Salazar, Alexander G. Watson, Richard J. Malone, Sara Cuccurullo

Case Diagnosis: Levetiracetam induced rhabdomyolysis. Case Description: This 25-year-old male developed new-onset tonic-clonic seizures and was started on levetiracetam during admission to an acute care hospital. He was found to have a brain tumor and underwent a craniotomy and tumor resection, followed by discharge to acute rehabilitation facility. On day seventeen of levetiracetam treatment, nursing reported cola-colored urine. He was found to have asymptomatic transaminitis with normal abdominal exam. Due to concern for acute liver failure from levetiracetam, seizure prevention was transitioned to pregabalin. Acute liver failure workup including ultrasound and blood testing was unrevealing. CPK was significantly elevated, while BUN and creatinine were normal, prompting a rhabdomyolysis diagnosis. At that time, he denied joint tenderness, worsening weakness, or myalgias, and strength testing was unchanged. He was started on IV fluids, and AST, ALT, and CPK trended downward slowly following levetiracetam taper. He remained seizure-free and made substantial gains while in acute rehabilitation, including significant motor recovery. Discussions: This is the first documented case to our knowledge of levetiracetam induced rhabdomyolysis in an acute rehabilitation patient. Additionally, this case is the latest onset of rhabdomyolysis after initiation of levetiracetam, presenting on day seventeen of treatment. While other cases presented with muscle weakness or pain, his first sign was cola-colored urine. If the adverse medication effect had not been discovered, he would have been at risk for renal failure and death. Conclusions: Rhabdomyolysis is a rare but significant adverse effect of levetiracetam, that can manifest weeks after initiation of the medication, including while undergoing acute rehabilitation. This can be a significant barrier to therapies due to the muscle weakness and pain it can cause and can be life-threatening. Therefore, all physiatrists must be aware of it as a debilitating side effect of the commonly used anti-epileptic drug.

 Limited evidence of physical therapy on balance after stroke: A systematic review and meta-analysis



Aurelien Hugues, Julie Di Marco, Michel Cucherat, Isabelle Bonan, Francois Gueyffier, Gilles Rode

Case Diagnosis: Stroke results in balance disorders and these directly affect autonomy and quality of life. The purpose of this systematic review and meta-analysis was to determine the efficacy of physical therapy (PT) on balance and postural control after stroke. Case Description: We included all randomized controlled trials assessing the efficacy of PT on balance and postural control in adult patients after stroke without language restriction. Medline, Embase/Scopus, Cochrane Central Register of Controlled Trials, PEDro, Pascal, and Francis databases were searched until January 2019. Primary outcomes were balance (Berg Balance scale and Postural Assessment Scale for Stroke) and postural control with postural deviation or stability measurement in sitting or standing static evaluation. A pair of independent reviewers selected studies, extracted data, and assessed risk of bias. Meta-analyses with subgroups (categories of PT, time post-stroke, and lesion location) and meta-regression (duration of PT) were conducted. Discussions: A total of 145 studies (n=5912) were selected from the 13,123 records identified. For balance, evidence was found in favour of the efficacy of functional task-training alone (standardised mean difference 0.39, 95% confidence interval [0.09; 0.68], heterogeneity I2=63%) or associated with musculoskeletal intervention and/or cardiopulmonary intervention (0.37, [0.19; 0.55], I2=48%), electrostimulation (0.91, [0.49; 1.34], I2=52%) immediately after intervention, compared to sham treatment or usual care (ST/UC). For postural deviation eyes open, assistive devices were more effective than no treatment (-0.21, [-0.37; -0.05], I2=0%) immediately after intervention; for postural stability eyes open, functional task-training and sensory interventions were more effective than ST/UC (0.97, [0.35; 1.59], I2=65% and 0.80, [0.46; 1.13], I2=37% respectively) immediately after intervention. Conclusions: Functional task-training associated with musculoskeletal intervention and/or cardiopulmonary intervention and sensory interventions seem to be immediately effective in improving balance and postural stability, respectively. The heterogeneity of PT and the weak methodological quality of studies limited the interpretation and the confidence in findings.

 Longitundal transverse myelitis in a pediatric patient after a viral illness



Eduardo Maldonado-Colón, Jose R. Vives, Edwardo Ramos

Case Diagnosis: Longitudinal Transverse Myelitis. Case Description: A 10 year old girl with past medical history of vitiligo, who developed a viral syndrome secondary to influenza infection, treated with Oseltamivir, on December 2018. Three week later, patient developed headache, neck and back pain, and lower extremity weakness. Symptoms progressed to involve four extremity weakness and respiratory failure. Laboratory Results including rheumatologic work up, including cerebrospinal analysis, was essentially unremarkable; no oligoclonal bands identified. Neuroimaging revealed extensive cervical and thoracic myelitis with cord expansion, as well of focus of increased intensity within the medulla. Patient was diagnosed with Longitudinal Transverse Myelitis and treated with high dose steroids, intravenous immunoglobulins (IVIG), and plasmapheresis, as well as intensive rehabilitation, with significant improvement. Discussions: Initial evaluation in the Pediatric Intensive Care Unit was remarkable for tetraplegia with bulbar preservation. Initial MRI was remarkable for cervical and thoracic myelitis. Lumbar Puncture was remarkable for normal glucose, protein, and white blood cell levels. The IgG synthesis rate and index were normal, no oligoclonal bands identified. In addition, inflammatory markers were normal and work-up for Herpes and Influenza were negative. Regardless, she was treated aggressively with steroids, IVIG, and plasmapheresis. Afterwards, she regained antigravity strength in left hemibody and improved strength in right hemibody. Upon admission to inpatient rehabilitation, continued progress was seen in functional outcomes although patient is yet unable to walk. Conclusions: This case represents a rare presentation of Longitudinal Tranverse Myelitis in children. In this particular case, the etiology was attributed to the Influenza virus given the viral syndrome 3 weeks prior presentation and negative work-up for rheumatologic and other infectious causes. Longitudinal Transverse Myelitis may be seen in children following a viral syndrome such as Influenza infection. Treatment with steroids, IVIGs, plasmapheresis, and high intensity rehabilitation seems to improve functional outcomes, although full recovery may be variable.

 Long-term safety and efficacy of incobotulinumtoxina for the treatment of blepharospasm in botulinum toxin-naïve subjects: Results of a phase III study



Fernando Pagan

Objectives: IncobotulinumtoxinA is efficacious for blepharospasm. Here we present complete data from the first, randomized, Phase III study (NCT01896895) in toxin-naïve subjects, where the safety and efficacy of incobotulinumtoxinA for benign essential blepharospasm (BEB) in was assessed. Design: Subjects (18–80 years) with bilateral BEB, Jankovic Rating Scale (JRS) severity subscore ≥2, and no BEB treatment with any botulinum neurotoxin (BoNT) serotype within past ≥12 months, were enrolled. In the main period (MP), subjects were randomized (1:1:1) in a double-blind manner to single intramuscular injections of incobotulinumtoxinA 25U (12.5U/eye), 50U (25U/eye) or placebo, with an observation period (OP) of 6–20 weeks. Subjects with a need for re-injection (JRS severity subscore ≥2 at final MP visit) were eligible for the open-label extension period (EP): a single dose of incobotulinumtoxinA ≤70U (≤35U/eye) with a 6–20-week OP. Mean change from baseline in JRS severity subscore and safety were assessed. Results: Overall, 61 subjects were randomized (mean 55.0 years; 59.0% female); 55 completed the MP and 39 entered and completed the EP. At MP Week 6, JRS severity subscore significantly improved from baseline with incobotulinumtoxinA 50U versus placebo (p=0.0004), and numerically improved with incobotulinumtoxinA 25U versus placebo. Sustained improvements were seen with incobotulinumtoxinA ≤70U from EP baseline to EP Week 6 (–1.2) and to EP final visit (–0.7), and from MP baseline to EP final visit (–1.0) (all p< 0.0001). In the MP, more adverse events (AEs) were reported with incobotulinumtoxinA 50U (42.1%) versus 25U (31.8%) or placebo (30.0%). AEs were less frequent in the EP (all incobotulinumtoxinA-treated: 28.2%). Most AEs were of mild-to-moderate severity. Conclusions: IncobotulinumtoxinA showed sustained efficacy in toxin-naïve subjects with BEB. Long-term safety results were in line with the known safety profile.

 Loss of transgender identity following human herpesvirus-6 encephalitis



Derek J. Boyd, Christine L. Johnson

Case Diagnosis: A transgender female (assigned male at birth), who no longer identifies as female following what was diagnosed as human herpesvirus 6 (HHV-6) encephalitis. Case Description: 26 year old transgender female initially presents with worsening headache. At that time, patient was living independently, identified by her female name for several years, and was living with her significant other. The patient tested positive for influenza and was treated with Tamiflu. Shortly after her visit to her PCP, she started having seizures, eventually requiring sedation and intubation for status epilepticus. An MRI of the brain showed bitemporal edema. CSF was positive for Human Herpes Virus-6, and patient was treated with Ganciclovir, then to Foscarnet. On admission to post-acute facility, patient reported that he identifies by his male name and gender. Discussions: HHV-6A has not been linked to any disease process. HHV-6B is universal in human populations. HHV-6B has been linked to causing Roseola infantum and neurological disease in children (Febrile Status Epilepticus). CSF positive for HHV-6 has been associated with encephalitis in adults, however, recent studies suggest encephalopathy is due to the sequelae of high fever, and not of the infection itself (ie: not encephalitis). The mechanism proposed for finding HHV-6 DNA in CSF is likely due to chromosomal integration, rather than encephalitis. Therefore, the diagnosis of HHV-6 encephalitis cannot rely solely on viral DNA levels in CSF. Prior to arrival to our post-acute brain injury inpatient neurorehabilitation program, accommodations were discussed to ensure safety and quality of care being delivered, including early discussion of gender identity, and making a double room into a private room. Conclusions: Loss of transgender identity in a patient with status epilepticus, bitemporal edema on MRI, and CSF positive for HHV-6. Also how recommended accommodations for transgender patients can be implemented in an inpatient rehabilitation facility.

 Lost for words: Carbidopa-levodopa as a therapeutic adjunct for speech apraxia



Kelly M. Brander, David L. Ripley, Benjamin Ingraham

Case Diagnosis: A 58-year-old male was admitted to an acute inpatient rehabilitation hospital with right sided hemiplegia, non-fluent aphasia, and speech apraxia due to a resected parietal lobe abscess. Case Description: Speech therapy evaluation demonstrated significant motor apraxia of speech with severe impairments in increasing word length and moderate difficulty articulating multisyllabic words. Due to the severe speech apraxia, carbidopa-levodopa 25-100mg 1 tab twice per day was started and up-titrated to four times per day dosing. He was not on another neuostimulant at the time of initiation. The patient's baseline score on the Apraxia Battery for Adults (ABA) increasing word length subtest was 8, indicating severe impairment and ABA repeated trials subtest of 14, indicating moderate impairments. After 1 week of aggressive speech therapy with the initiation of carbidopa-levodopa, his increasing word length subscore improved to 4 and repeated trials subscore improved to 21, indicating mild impairment. As the patient's carbidopa-levodopa was gradually increased and he continued in speech therapy, his increasing word length subscore further improved to 2 and repeated trials subscore improved to 20. Discussions: This case report demonstrates improvement in speech apraxia symptoms with a combination of intensive speech therapy and treatment with carbidopa-levodopa. This and one other case report, which has demonstrated successful treatment of speech apraxia with carbidopa-levodopa, support the need for continued study on the appropriate clinical indication and effective dose. Conclusions: Carbidopa-levodopa is a potential pharmacological treatment for managing individuals with motor apraxia of speech in conjunction with intensive speech therapy.

 Lumbosacral pain secondary to chronic recurrent multifocal osteomyelitis alleviated with L4-S3 lateral radiofrequency ablation



Jason A. Kaushik

Case Diagnosis: Lumbosacral pain secondary to chronic recurrent multifocal osteomyelitis (CRMO) alleviated with L4-S3 lateral radiofrequency ablation (RFA). Case Description: A 24-year-old female with CRMO presented to pain clinic with chronic lumbosacral pain. Her disease process started in 2011 and presented with sudden-onset severe low back pain. Initial MRI was negative but repeat showed lesion (with inconclusive bone biopsy) on left sacrum in close proximity to sacroiliac joint which was subsequently removed surgically and provided patient with 5-6 months of near-complete relief. Her pain worsened in 2013 and imaging revealed similar lesion on right side of sacrum (which was not biopsied). She was followed by rheumatology starting in 2015 who trialed various biologics and oral steroids for her flare-ups. She had been seeing a chiropractor regularly for her mechanical symptoms. On assessment, her symptoms mimicked sacroiliac joint pain both on presentation and examination. Discussions: CRMO is a rare autoinflammatory disorder that primarily affects children, characterized by insidious onset of bone pain with local swelling, often associated with fever, skin involvement, and arthritis. Its etiology is largely unknown and treatment mostly empiric. It is a diagnosis of exclusion with no specific diagnostic test. While it is generally self-limited, it can have a prolonged course resulting in significant morbidity. Conclusions: CRMO is often accompanied by sacroileitis that can cause chronic low back pain refractory to traditional anti-inflammatory or rheumatologic medications. Our patient endorsed a few hours of symptomatic relief in the past with sacroiliac joint injections and decision was made to proceed with bilateral L4-S3 medial/lateral branch blocks which provided >70% relief. She then underwent bilateral L4-S3 lateral RFA which has given almost complete resolution of her pain thus far. This is the first case report of sacroiliac pain due to CRMO successfully managed with RFA and clinicians should consider early referral to interventional pain in such circumstances.

 Lumbosacral radiculoplexus neuropathy in patient with previously uncontrolled DM



Andrew Bloomfield

Case Diagnosis: Lumbosacral radiculoplexus neuropathy (LRPN) related to previously uncontrolled diabetes mellitus. Case Description: A 65 year old male with PMHx of DM II, hypercholesteremia, hypertension, and morbid obesity presents with left hip instability, increased pain and multiple falls over two weeks. He was admitted due multiple falls and LLE weakness. Over the course of admission, EMG revealed LLE weakness secondary to LRPN. Neuropathy was attributed to diabetes that had been controlled for nearly two years. Discussions: LRPN originally described in diabetic patients is a condition characterized by debilitating pain, weakness and atrophy most commonly affecting the proximal thigh muscles asymmetrically. The syndrome is usually monophasic and preceded by significant weight loss (Bhanushali et al, 2008). However, the exact cause of diabetic lumbosacral plexopathy is not known and the incidence of diabetic plexopathy in a controlled diabetic as well as the timing of symptoms in relation to weight loss is poorly described in the literature. Conclusions: This patient had uncontrolled diabetes mellitus type II for decades before undergoing laparoscopic gastric bypass surgery. Pre-procedural HbA1c was steadily around 9-10%. Preoperatively the patient never suffered from lower extremity nerve pain. After his bypass procedure the patient began eating a heart healthy diabetic diet, maintained an active lifestyle, and lost a significant amount of weight. Soon after the surgery the patient was weaned off of his daily insulin regimen and his HbA1c levels trended and stabilized into normal reference range. Nearly two years postoperatively the patient began experiencing left lower extremity nerve pain that was diagnosed with EMG as LRPN. We postulate that although the patient had controlled DM and normal HbA1c for two years, he began to acutely suffer a plexopathy related to his previous uncontrolled DM. This case report will aid in the understanding and timing of LRPN as it relates to patients with previously uncontrolled DM.

 Management and morbidity of paroxysmal sympathetic hyperactivity and sequelae in young female with anoxic brain injury



Jeremy R. Benhamroun-Zbili, Leora Boussi, Richard Doobay

Case Diagnosis: Paroxysmal Sympathetic Hyperactivity. Case Description: PSH is characterized by sympathetic and motor dysfunction affecting up to 10% of patients surviving acquired brain injury. Diagnosis and management of PSH is discussed in literature, but not routinely integrated into practice guidelines. PSH can be difficult to recognize and often goes undiagnosed, contributing to increased morbidity, LOS, and healthcare costs. We present the case of a 35-year-old female one-month post anoxic brain injury secondary to hypoxic respiratory failure. The patient subsequently developed PSH, and we discuss approaches to management of her acute episodes. Patient was optimized medically and discharged to a skilled nursing facility on a palliative regimen. Patient died secondary to presumed aspiration and failure to thrive one month following discharge. Discussions: Patient had a complicated course including ICU stay, aspiration, sepsis and multiple readmissions. Dexmedetomidine, propranolol, clonidine, levetiracetam, gabapentin, cyclobenzaprine, and baclofen, acetaminophen, ibuprofen, midazolam, fentanyl, morphine , labetalol, lorazepam and clonazepam were trialed. Patient's family opted for DNR with palliative measures and were opposed to opiates and intrathecal baclophen pump. Literature reviewed and patient was optimized on propanalol, gabapentin, clonidine, and oral baclophen with persistent breakthrough. Episodes were characterized by severe tachycardia, extensor posturing, hypertension, teeth grinding and diaphoresis. IV pushes of labetalol and lorzepam were trialed. Patient's condition stabilized with clonazepam and PRN lorazepam, and patient was discharged on palliative measures. Conclusions: The differential diagnosis for PSH is wide making it difficult to diagnose. Limitation in existing protocols confers challenges in management. Beta blockade, A2 blockade, opiates, baclophen, dopamine modulators, and benzodiazepines are commonly used, however further data is needed to establish concrete guidelines. This case demonstrates potential efficacy of benzodiazepine use in PSH maintenance and acute exacerbation management. As seen in our case, patient likely succumbed to gastrointestinal complications, re-enforcing the morbidity of PSH as a multisystem disorder.

 Management of new-onset choreiform movements and acute behavioral changes in a patient with an acute thalamic infarct



Jessica F. Casey, Christopher D. Meserve, Michael V. Nguyen, Jeremy Adam

Case Diagnosis: Acute ischemic thalamic infarct resulting in acute mania, impulsivity and chorea. Case Description: A 79-year-old man presented with choreiform movements on his left side, impaired balance, and acute impulsivity. Given the acuity of the changes, an MRI of the brain was obtained, which showed an acute infarct within the anterior right thalamic nucleus extending to the genu and posterior limb of the internal capsule. He was medically stable upon transferring to the acute rehabilitation unit, but continued to demonstrate choreiform movements, impulsivity, and inappropriate behavior. He required an interdisciplinary approach while on the rehabilitation unit, which included physiatry, neurology, and psychiatry. The patient required a mood stabilizer and an anti-psychotic to control his choreiform movements. These medications in addition to an interdisciplinary rehabilitation approach resulted in a successful discharge home with control of his symptoms. Discussions: Cases of post-stroke movement disorders and mania have been reported, but usually in different areas of the brain compared to this patient. Most cases are self-limited and resolve within 12 months. Common characteristics found in patients with post-stroke mania include male gender, a right cerebral infarct, and no history of psychiatric disorders. However, the literature mentions very little on the rehabilitation of such patients and the management of their symptoms. Additionally, there is little evidence guiding pharmacologic therapy for movement disorders and mania after strokes, but this patient's course exhibits that treatment is effective under the guidance of multiple disciplines over the course of several months. Conclusions: Post-stroke movement disorders and mania are sparsely described in the literature, and information regarding the course of these patients through rehabilitation is limited. This case highlights the continued need to define effective treatment strategies for these stroke patients. Also, it emphasizes the need to collaborate effectively with multiple disciplines in order to achieve the best outcome for the patient.

 Managing heterotopic ossification in a patient with gastritis and high bleeding risk: A case report



Namratha Ramavaram, Thomas S. Kiser

Case Diagnosis: 73 year old gentleman with C5 ASIA D SCI found to have Heterotopic Ossification (HO). Case Description: 73 yo gentleman with C5 ASIA D SCI admitted for acute rehabilitation for SCI. Initially, patient was found to have guaiac positive stool and hemoglobin level below 7 requiring blood transfusions. GI was consulted where EGD showed gastritis, and oral NSAIDs were discontinued. On day 16 of stay, patient complained of right elbow pain. He had decreased range of motion (ROM), tenderness and swelling in the elbow joint. Topical diclofenac gel was used instead of oral NSAID's with improvement in tenderness and pain around the joint area. Patient continued to exhibit restricted ROM. X-ray of right elbow did not show any acute process. Triple phase bone scan was inconclusive per radiology, but images showed increased uptake near right elbow. Due to patient's clinical presentation and work up, patient was started on Etidronic acid for HO in addition to continuing the topical diclofenac gel for inflammation management. Discussions: Patient had significant improvement with inflammation, pain, and ROM. At patient's outpatient clinic follow up, patient had functional ROM of his right elbow and minimal symptoms. HO is serious complication in patients with SCI. When suspected, it's imperative to start treatment quickly to prevent progression. Traditional treatment for HO consists of maintaining ROM, NSAIDs to mitigate inflammation, and bisphosphonates for slowing down progression of bony formation and pain relief. The patient's medical comorbidities prevented conventional treatment with oral NSAID's but topical diclofenac appeared to be just as effective. We were not able to find any case reports in the literature where topical diclofenac gel was used in the management of HO. Conclusions: While HO remains a commonly encountered secondary complication in SCI, this case represents a potential alternative to oral/systemic administration of NSAIDs if contraindicated by a patient's medical condition.

 Man-in-the-barrel syndrome following elective aortic valve replacement and aortic aneurysm repair: A case report



Mina K. Shenouda, Steven Markos, Iqbal Jafri, Anthony Doss, David Brown, Sara Cuccurullo

Case Diagnosis: The patient is a 62 year old previously independent woman with a history of bicuspid aortic valve status post commissurotomy and ascending aortic aneurysm who developed profound upper extremity paresis and visual and cognitive deficits after undergoing elective aortic valve replacement and aortic aneurysm repair. Case Description: Computed tomography of the head and cervical spine were unrevealing and she was transferred to acute rehabilitation. Physical exam revealed profound bilateral left worse than right arm weakness, full leg strength, positive Hoffman and upgoing Babinski signs bilaterally. Brain magnetic resonance imaging (MRI) revealed multifocal subacute infarcts in the right greater than left frontoparietal and bilateral occipital regions. Electrodiagnostic studies (EDX) of the left arm revealed acute left brachial plexopathy involving all trunks. The patient's rehabilitation regimen was subsequently amended. The patient underwent comprehensive acute inpatient and subsequent outpatient stroke and cardiac rehabilitation. Repeat EDX five months later revealed nearly normal EDX. Patient made significant functional improvements. Discussions: Man-in-the-barrel syndrome (MBS) is described as bilateral upper extremity paresis with intact leg strength. MBS is a rare and functionally debilitating complication following cardiothoracic surgery, and is usually attributed to hypotensive shock during surgery causing bilateral watershed cerebral infarcts. Brachial plexopathy due to stretch or compression injury is another potential surgery-related complication that should be monitored. This patient's unique concurrent diagnoses of brachial plexopathy and strokes contribute to the patient's prognosis and increase the complexity of the patient's rehabilitation management. Conclusions: This unique presentation combining multiple concurrent disease processes contributes to challenge of diagnosing this medically complex rare entity. It is essential for physiatrists to know the potential complications of surgical procedures and to recognize pertinent indications for further diagnostic evaluation with MRI or EDX. Accurate diagnosis will allow the patient to receive the appropriate medical and rehabilitation management.

 Manual therapy reduces pain behavior and oxidative stress in a murine model of complex regional pain syndrome type I



Afonso Salgado, Juliana Stramosk, Daniela Ludtke, Ana Kuci, Daiana Salm, Lisandro Ceci, Fabrícia Petronilho, Drielly Florentino, Lucineia Danielskid, Aline Gassenferth, Gislaine Rezin, Francisco J. Cidral Filho, Leidiane Martins, Willian Reed, Daniel Fernandes Martins

Case Diagnosis: Complex regional pain syndrome type I (CRPS-I) is a chronic painful condition. Our objective was to investigate whether manual therapy (MT), in a chronic post-ischemia pain (CPIP) model, is capable of reducing pain behavior and oxidative stress. Case Description: Male Swiss mice were subjected to ischemia-reperfusion (IR). Animals received ankle joint mobilization (AJM) 48h after IR, and response frequency to mechanical stimuli was evaluated. Thiobarbituric acid reactive substances (TBARS), protein carbonyls, superoxide dismutase (SOD) and catalase (CAT) levels were determined, as well as mitochondrial function. Discussions: IR induced mechanical hyperalgesia which was subsequently reduced by acute MT. The concentrations of oxidative stress markers increased following IR; MT prevented increases in TBARS and protein carbonyls. IR diminished SOD and CAT activity; MT prevented CAT but not SOD decrease. IR also diminished mitochondrial complex activity; MT did not affect this decrease. Conclusions: We conclude that repeated MT sessions resulted in antihyperalgesic effects mediated, at least partially, through antioxidative effects (reduced TBARS and protein carbonyls levels, as well as increased CAT activity).

 Mapping of 1633 goals from the TOWER study reveal a higher proportion of activity and participation-related goals in spasticity patients



Klemens Fheodoroff, Sylvia Ramusch, Astrid Scheschonka, Jorg Wissel

Objectives: In order to gain insight into areas of interest from the spasticity patient's perspective, we mapped the goals from the TOWER study using the International Classification of Functioning, Disability, and Health (ICF) categories and the EQ-5D domains. Design: A total of 1,633 individualized spasticity-related treatment goals collected according to the Goal Attainment Scale (GAS) during the TOWER study were mapped by following the ICF linking rules and the EQ-5D domains. Two researchers familiar with the ICF and ICF linking rules independently reviewed the goals. In the case of ambiguity, a third expert provided the final decision on the most appropriate linking. The degree of consensus and differences acts as a measure of comprehensibility of the goals. Goal categories are described according to the ICF framework. Results: A high level of agreement in the main ICF concept (i.e., what the goal is about) was achieved (N=1570; 96.1%) and was dependent upon 3 factors: knowledge of ICF items, understandable goal statements, and appropriateness of linking rules. Eight hundred and ninety seven (54.9%) goals were task related (activity/participation). The main domains were problems with walking / mobility (N=318, 35.4%) undertaking single/multiple tasks (N=170; 18.9%) and dressing (N=112, 12.5%). Body functions were represented in 44% of patient goals: 21.4% related to pain and 44.7% related to muscle tone. Only 65% of goals were to be linked to the EQ-5D categories. Conclusions: The results reveal a higher proportion of activity/participation-related goals including single/multiple tasks such as stretching, positioning and exercising. This analysis sheds new light on the patient need and also the perspectives of patient-centered goal-driven botulinum toxin treatment in spasticity. The ICF offers a broader framework for patient-centered goal setting and may increase comparability of clinical data. EQ-5D seems to miss more than 35% of goals that matter to patients with focal spasticity.

 Marantic endocarditis, a rare insidious disease which can lead to stroke



Mina Gayed, Brian D. Greenwald, Sara Cuccurullo

Case Diagnosis: Marantic Endocarditis. Case Description: Patient is a 65 year old male smoker who had been intermittently taking Xarelto for a DVT. He suffered a right MCA stroke and during the workup was found to have non-infectious mitral valve endocarditis. Chest imaging had also revealed left lung lesion which was consistent with probable cancer. The cause of his stroke was determined to be marantic endocarditis as a consequence of lung cancer. Discussions: Marantic endocarditis is a rare disease usually found postmortem in autopsies with incidence ranging from 0.9 to 1.6%. Advanced malignancy contributes to 80% of reported cases. Platelet deposition interwoven with fibrin and mononuclear cells characterize these vegetations. This form of endocarditis is dangerous in that it is much more likely to break off and embolize elsewhere due to the lack of inflammatory activity at the site of attachment. Embolization is catastrophic and causes significant infarction with the spleen, kidney, skin, and extremities being the most common sites. In our patient, this likely led to his prior DVT. Uncommonly, these vegetations can travel to the brain and cause cerebral infarction. This is usually how this otherwise insidious disease can be quickly found. Conclusions: Marantic endocarditis is a rare disease often found postmortem. Anticoagulation is essential in preventing complications such as stroke. As this disease is rarely diagnosed antemortem, further research should place emphasis on early detection.

 Measurement of regional cerebral blood flow by the noninvasive arterial spin labeling method with MRI in patients during rehabilitation process



Tadato Oikawa, Takashi Morotomi

Case Diagnosis: Recent technical advance of MRI has been developed the nonivasive measurement of regional cerebral blood flow (rCBF) by ASL. We have been used ASL method in the in the clinical diagnosis of pahophysiological condition in the brain injured patients and the objective evaluation of recovery process by rehabilitation. In this presentation, we report the results of rCBF by ASL method in the brain damaged patients in our hospital. Case Description: ASL method is the technique to acquire perfudion image using labeled blood flowing into the brain tissue without Contrast-Enhanced. We measured rCBF of brain injured patients by ASL perfusion. MRI scanner was 1.5T MRI system. Participants consisted of 115 cases with cerebrovascular diseases, Parkinsonism, degenerative diseases, hyper-perfusion syndrome and brain neoplasm in acute recovery and chronic stages. Discussions: In the measurement of rCBF by ASL method, we observed the reduced rCBF corresponding to damaged site of brain injured patients. Especially, when the pathogenic regions were unclear in T1,T2 weighted and FLAIR image of MRI , we could find out the pathogenic regions by decrease or increase of rCBF based on behavior of ASL. In the chronic stage before discharge of hyper-perfusion syndrome a decrease of rCBF in the whole right hemisphere of injured side and decrease of rCBF in the contralateral cerebellum were recognized. Patients with Parkinson disease showed the reduced rCBF at onset of cerebral infarction. The rCBF of the patients of rCBF image by ASL were markedly improved during recovery and discharge. Conclusions: Our results showed the usefulness of ASL method in the clinical diagnosis, and the objective evaluation of recovery process by rehabilitation.

 Medical assistance in dying in acute severe neurological injury: Who defines informed consent?



Natalja I. Tchajkova, Karen Ethans, Stephen Smith, Jitender Sareen

Case Diagnosis: High suicidality in people who have sustained a spinal cord injury (SCI) is common. However, little is known about how people with an acute SCI process their suicidal intentions, what they relate to, and how this may change with time. Understanding this information can assist healthcare teams in providing relevant counsel to patients seeking medical-assistance-in-dying. Case Description: We conducted a layered qualitative study consisting of a focus group of 5 people, followed by individual interviews of 23 people with diverse time frames post-SCI, injury levels, and causes of SCI. The semi-structured interviews were recorded and transcribed verbatim. A thematic analysis approach rooted in Grounded Theory was used to code the data, assign definitions, and classify recurring themes. Discussions: Suicidality was common among all neurological levels of injury and severity (52% of participants) early after SCI (< 2 years), but decreased in individuals >2 years post-SCI. The suicidality emerged within the distinct themes of fear of lost life potential after injury. A reframing process gradually redefined views and understanding of the possibilities of life post-SCI. Although acutely suicidality was high, no participants thought that they could have made an informed decision about MAiD during the time early post-SCI before this reframing. Most expressed need for autonomy to make an informed decision regarding MAiD in chronic SCI ( >2 years) however. Suicidality and the process of reframing was noted to be poorly addressed by healthcare teams. Conclusions: Our qualitative data offers insight into a process of reframing and the reduction of acute suicidal ideation within 2 years post-SCI as this process occurs. This information will help physicians provide relevant counsel regarding suicidal intention, MAiD, and rehabilitation to people who have sustained a severe acute neurological injury, but who may foreseeably have a normal life expectancy with altered function that reframes into an acceptable way of life.

 Metabolic, nonischemic stroke: A case report of mitochondrial encephalomyopathy, lactic acidosis, and stroke-like syndrome



Aye Mon Win, Mahesh Ramachandran

Case Diagnosis: 49 year-old female with MELAS syndrome complicated by seizures and neuropsychiatric disorder presented with three day history of word-finding difficulty and left-sided weakness. MRI revealed an evolving subacute infarct of the right temporal and parietal lobes and small evolving subacute infarct of the posterior right thalamus. Also noted were old left hemispheric infarcts and encephalomalacia. She was continued on home doses of L-arginine, lacosamide, lamotrigine, and keppra. Case Description: Her acute care and rehab courses were complicated by fluctuations between agitation and lethargy. Family reported prior history of this behavior. On day two of rehab admission, she was transferred back to acute care facility due to lethargy and inability to follow commands. CT head revealed continued evolution of subacute right cerebral infarct. Mental status improved and she returned to rehab the following day. Mental status continued to fluctuate despite pharmacologic and behavioral interventions. Psychiatry followed. On day thirteen of rehab, during a period of lethargy, she was found to be hypotensive with blood pressure 74/44. She was emergently transferred back to acute care hospital and found to have severe non-anion gap metabolic acidosis and acute renal insufficiency with renal tubular acidosis thought to be secondary to L-arginine. Discussions: MELAS syndrome is a progressive neurodegenerative disorder due to inherited gene mutations in mitochondrial DNA. Resultant dysfunction in oxidative phosphorylation profoundly effects cerebral tissue due to high energy requirements. Additionally, impaired nitric oxide production leads to microvasculopathy, causing stroke-like episodes, myopathy, and lactic acidosis. Additional features include seizures, psychiatric disorders, dementia, short stature, and cardiomyopathy. Conclusions: Stroke prophylaxis in MELAS syndrome requires reduction of constant oxidative stress. Limited clinical trials support supplementation with the nitric oxide precursor, L-arginine. Our patient however had an adverse reaction to high-dose L-arginine which was difficult to recognize due to her fluctuating mental status.

 Metastatic spinal cord compression mimicking cauda equina syndrome illustrating importance of adequate diagnostic imaging



Jonathan L. Holt, Joseph Hill, Karyn Doddy, Farzin Farhandnejad, Se Won Lee

Case Diagnosis: Cauda Equina Syndrome from metastatic lesion due to prostate cancer. Case Description: We present a case of a 66-year-old Caucasian morbidly obese male, with prostate cancer and extensive metastatic involvement of the axial skeleton. He experienced acute onset of low back pain, bilateral lower extremity weakness, paresthesia, and urinary incontinence. CT was unchanged from two weeks prior to his acute admission with diffuse metastatic disease throughout the spine, severe spinal stenosis L2-L5 and no definitive epidural tumor. MRI was unattainable due to patient's large body habitus, but suspicion of Cauda Equina Syndrome remained paramount. L2-L5 laminectomy was completed. The patient showed improvement to motor strength and sensation in the lower extremities immediately following decompression. Seven days later the patient developed acute worsening of paralysis and complete paresthesia of his lower extremities. Repeat CT remained unchanged. Spinal myelogram was performed revealing a contrast block at T6-T7 consistent with an epidural tumor. A T4-T8 laminectomy and epidural tumor evacuation was performed. Discussions: MRI is the gold standard for diagnosis of spinal cord compression (SCC) with 93% sensitivity and 98% specificity. Inability to obtain the MRI can hinder proper management in the emergent case of SCC. Inability to obtain definitive imaging does not give excuse to stop diagnostic work up. Alternative imaging modalities do exist and are useful for differential and definitive diagnosis. Conclusions: Especially in cases where multiple lesions can be present, it is important to have definitive diagnosis with appropriate imaging studies. This case illustrates the importance of adequate imaging to determine the exact cause of SCC even during an emergency mimicking cauda equina syndrome. Current guidelines recommend CT myelogram if the patient is unable to undergo MRI.

 Mirtazapine-induced hyponatremia in the acute rehabilitation setting



Eugene Palatulan, Chi-Chang D. Lin

Case Diagnosis: Mirtazapine-induced hyponatremia. Case Description: An 88-year-old man sustained a subdural hematoma (SDH) and subarachnoid hemorrhage (SAH), pubic rami fractures, and extraperitoneal hematoma after a fall at home. Neurosurgery and Orthopedics deemed patient non-operative, made WBAT and started on Keppra prophylaxis. On admission, he was at moderate assistance with mobility and ADLs. Patient was meeting all goals in rehabilitation and planned for simulated 'independent stay.' Patient had altered mental status before planned independent stay becoming a barrier to therapy. Workup revealed sodium level 123 compared to 139 on admission. The only change throughout rehab course was being started on Mirtazapine. Repeat CT head showed resolving SAH/SDH. A chest X-ray performed revealed a possible left lower lobe consolidation versus atelectasis although patient remained afebrile and still hemodynamically stable. Patient underwent fluid challenge, started empiric antibiotics and monitored closely in medical stepdown. Patient ultimately completed his planned independent stay and discharged home at modified independence. Discussions: Mirtazapine is a tetracyclic antidepressant commonly started on patients in acute rehabilitation for appetite boost. Other antidepressants such as Selective Serotonin Reuptake Inhibitors have been associated with hyponatremia but the association of mirtazapine with hyponatremia is less well documented. Studies have shown that those most at risk for mirtazapine-induced hyponatremia are geriatric patients. It has been identified in the Beers Criteria per American Geriatric Society as a potentially inappropriate medication to be used with caution in patients older than 65 due to its potential to cause hyponatremia and should be monitored after initiation. Mirtazapine-induced hyponatremia is a serious cause of morbidity for patients and a significant barrier to inpatient rehabilitation. Conclusions: Mirtazapine-induced hyponatremia in acute inpatient rehabilitation poses a significant barrier to meaningful goal-oriented therapies and can lead to serious morbidity. When patients especially above age 65 and with cardiac co-morbidities are started on mirtazapine, sodium levels should be monitored closely.

 Modafinil induced tachycardia, an uncommon side effect



Mina Gayed, Brian D. Greenwald, Sara Cuccurullo

Case Diagnosis: Modafinil induced tachycardia. Case Description: Patient is a 25 year old female with severe TBI who had been prescribed Modafinil in acute rehabilitation as a stimulant for improved wakefulness. Throughout her hospital course, the patient had been dealing with episodes of tachycardia. Cardiology became involved, but the workup was unremarkable for the heart itself. It was theorized that the reason for the tachycardia was due to autonomic dysfunction from her severe TBI. The patient was trialed on Propranolol and Metoprolol, but this treatment was abandoned due to her low blood pressure. The patient had improved in her overall status after a VP shunt was inserted in the middle of her hospital stay, and Modafinil was eventually discontinued. After the discontinuation, it was noted that her tachycardia immediately resolved. Discussions: Tachycardia is a classic presentation in the brain injury population, and there could be many causes. Drug induced tachycardia is a common phenomenon, but in the literature, Modafinil is associated with only a 2% incidence of tachycardia as an adverse reaction. It is important to note that the primary use of Modafinil is in those with sleep apnea. It is unclear if the medication's side effects have been studied in the brain injury population as their brain physiology is unique. Conclusions: The dynamic changes involved in the neurotransmitters in our brain injury population requires us to carefully consider all medication side effects regardless of how uncommon they may be. Extra attention should be paid to stimulant medications.

 Model for implementation of poststroke depression screening in the acute phase of care



Daniela A. Iliescu, Karl Sandin, Eric Villanueva

Objectives: Prevalence of Post-Stroke Depression (PSD) is as high as 35% and is associated with multiple adverse outcomes including decreased functional recovery during acute rehabilitation and increased mortality. Early PSD screening is Class I recommendation based on AHA/ American Stroke Association 2018 guidelines. Baseline interrogation revealed no PSD screening in our hospital, preventing treatment prior to the post-acute care setting and potentially limiting recovery. Our aim was to achieve 30% compliance with PSD screening in four months using PHQ-9. Design: Over a four-month period, four serial PDSA cycles tested the changes predicted to achieve our aim in a single center prospective quality improvement study. Participants were patients over age of 18 admitted with imaging evidence of ischemic or hemorrhagic stroke with exclusion of patients with TIA, coma, anosognosia, aphasia, or cognitive impairment. Interventions included the following in cumulative manner; 1. Availability of printed PHQ-9 tools. 2. Algorithm for the workflow with preassigned tasks and adding a smart phrase into EMR. 3. Immersion of dedicated members into the process and pitfall identification. 4. Education and inclusion all members of the care team, developing an advanced documentation template into EMR and using mobile apps for ease. Results: Among 53 patients screened, the compliance increased over the four PSDA cycles with 1%, 25%, 50% and 53% respectively and overall compliance of 33%. Qualitative data collected guided the intervention in the subsequent cycles. Barriers included lack of dedication and awareness, and workload. Conclusions: Implementing PSD screening in the acute phase of care workflow using a multidisciplinary approach as outlined above can be an effective tool to improve compliance with evidence-based intervention. Additional cycles are planned to implement the protocol into EMR for consistency in all five full-service hospitals and rehabilitation centers in network.

 Modulation of motor-related cortical activity with non-invasive cervical spinal stimulation: A case report



Zachery Hernandez, Nuray Yozbatiran, Gerard E. Francisco

Case Diagnosis: A 66 year-old male with chronic stroke caused by an ischemic infarct in the left pons 30 months prior to the start of this study was enrolled. He presented with mild to-moderate motor impairment in the right upper extremity (FMA score=52), and was enrolled in a therapy program combined of transcutaneous spinal direct current stimulation (tsDCS) and robotic-assisted arm training. Case Description: Treatment sessions were designed to assess polarity dependent effects of tsDCS (10 sessions of anodal, cathodal and sham stimulation). At each session 75 minutes of robot-assisted training was applied in conjunction with 20 minutes of cervical tsDCS (intensity at 2.5mA). Functional arm tests (Fugl-Meyer Arm, JTHFT, ARAT, NHPT and MAS) were performed. Cortical neural changes were monitored with EEG and reported as changes in slow cortical potentials (0.1-1 Hz) and lateralized readiness potentials. Discussions: Changes in arm impairment (FM-UE score), muscle tone (MAS), and performance (ARAT) were not significant between treatment groups after treatment and at follow-up. However, speed related performance in JTHFT and NHPT has shown slight improvement (10 and 3.2 second decrease in completion time compared to baseline) only in the cathodal stimulation group. Both cathodal and sham conditions displayed significant lateralization changes toward the non-affected side post-movement (i.e. motion initiation/execution), however the separation of distribution was greater for the cathodal treatment. No significant change was found in the anodal condition. Conclusions: Apart from local effects, tsDCS seems to modulate supra-spinal and or cortical networks, as suggested by animal and human studies These findings are appealing to use cervical spine as the stimulation site in neurological disorders, such as acquired brain injury due to stroke or traumatic brain injury, when cortical or corticospinal neural circuits are severely injured. Further study is warranted with a larger sample size to understand polarity-dependent neural and clinical effects of tsDCS and repetitive movement treatment.

 More than meets the eye: Gabapentin therapy for Charles Bonnet syndrome



Michael Mosier, Larry Guinto, Eric Martinez

Case Diagnosis: Charles Bonnet Syndrome. Case Description: 71-year-old male with uncontrolled diabetes initially presented with slurred speech and altered mental status. CT Head showed chronic subdural hemorrhage and MRI revealed acute infarct in the left PCA distribution affecting the occipital and medial temporal lobe. No neurosurgical intervention was recommended. Glucose optimized with strict insulin regimen and patient transferred to acute rehabilitation. While in unit, patient expressed concern regarding new visual disturbances, which included “elements of nature,” “a man milling about,” and an “insect walking along the table.” He reported history of floaters, but noted that the disturbances were different and more importantly, not real. Ophthalmologic visual field testing revealed right homonymous hemianopsia. Despite no previous mental illness, Psychiatry consulted and concluded no acute issues. Rehab team determined that hallucinations were presumptively caused by Charles Bonnet Syndrome due to acute vision loss from his CVA. Discussions: Charles Bonnet Syndrome refers to symptoms of visual hallucinations following loss of visual field/acuity. While this is most commonly reported following chronic vision loss, such as in macular degeneration, acute presentations have been reported with multiple proposed mechanisms. One popular theory is that of a release hallucination, similar to the pathophysiologic mechanism due to sensory deprivation such as that seen in phantom limb pain. Concurrently in this patient, low dose Gabapentin was started and subsequently increased to 300mg TID for his diabetic peripheral neuropathy. Interestingly, patient endorsed that his paresthesias improved and visual hallucinations ceased with increased dosing. He also denied disturbances on follow up several weeks after discharge. Conclusions: It is imperative that visual disturbances after CVA are evaluated for ophthalmologic and psychiatric etiologies. However, Charles Bonnet Syndrome should be considered on the differential diagnosis of such hallucinations following acute infarct. Reassurance is often the only treatment necessary, but Gabapentin is a reasonable and safe therapeutic option.

 Motor first: A proposed approach to the JFK Coma Recovery Scale-revised for the consulting physician



Kristen Harris, Mark Linsenmeyer, Justin Weppner, Terry Breisinger, Allyson M. Yukevich, Gary Galang, Amy Wagner

Objectives: Consult physiatrists may be asked to assess neurological status and provide prognostic guidance for patients with disorders of consciousness (DoC). The JFK Coma Recovery Scale-Revised (CRS-R) is a standardized tool for assessment of recovery in DoC patients and can be very useful for prognostication, however time constraints and familiarity with its subscales can be barriers to regular use by consult physiatrists. The aim of this study is to investigate whether performing the CRS-R subscales in a different order, and stopping once the patient is determined to be emerged or minimally conscious (MCS), may shorten the time required to complete the assessment while still providing accurate information for a consultant. Design: CRS-R scores for patients admitted to our inpatient DoC program from December 2015 through August 2019 were reviewed. Thirty-five patients were identified with CRS-R subscales documented, for a total of 97 assessments. The subscales were retrospectively reviewed in the following adjusted order: Motor, Communication, Visual, Oromotor, Auditory, and Arousal. If the patient met criteria for emergence or MCS after specific subscale completion, no further subscales were reviewed. If criteria for MCS were not met at any subscale, the entire CRS-R was completed. Results: Of 97 assessments, 60 could be stopped prior to completion of the entire CRS-R. Five assessments concluded after Motor, 34 concluded after Communication (32 MCS, 2 emerged), and 21 concluded after Visual. Thirty-seven assessments required completion of the full CRS-R to determine the level of consciousness. Conclusions: Reorganization of the CRS-R may allow a consult physiatrist to more efficiently provide prognostic guidance for DoC patients. A limitation is the lack of total scores which are helpful for tracking recovery over time. This reorganization would not replace the CRS-R, but suggests CRS-R components can be used in an alternative format for efficient DoC screening in the acute setting.

 Multi organ involvement in a challenging case of recurrent Stevens–Johnson syndrome after spinal cord injury



Moh'd Rami H. Alahamr, Abeer Alomari

Case Diagnosis: Challenging recurrent Stevens-Johnson Syndrome, Spinal Cord Injury. Case Description: 17 years old male patient who sustained T6 SCI AIS (A) when he was 12 years. He developed skin eruptions, oral tissues involvement , photophobia and ocular complications after treatment with antibiotics for a simple urinary tract infection ; his case has been complicated by a severe skin and oral ulcers with progressive auto immune corneal melting and ulceration with limbal stem cell deficiency for which he underwent many amniotic membrane surgeries and flaps, IV IG , steroids and anti TNF, he is still suffering from severe pain and severe visual impairment despite his maximum treatment. Discussions: Stevens-Johnson syndrome, is a life threatening diseases causing toxic epidermal necrolysis, and erythema multiforme cutaneous eruptions but also affects other vital organs and can be difficult to manage. We report a case which becomes dilemmatic because of some clinical and histological features can be a manifestation from pemphigus vulgaris but diagnosed and followed as a challenging case of unusual SJS. The patient was under supervision in Jordanian Royal Medical Services by a Mutli-Disciplinary Approach MDT at our Clinic Spinal rehabilitation, Dermatology and Ophthalmology Department and by Immunologist. Despite all our joint efforts we face challenges every time this young boy steps into our clinics but patient still fighting his condition and scoring good marks in one of the best school for Excellence despite his social, psychological and functional disability. Conclusions: Physicians writing prescriptions for their patients must warn them about possible side effects and they must therefore consider SJS as a potential complication of treatment after antibiotics, especially when use of medication is questionable. It takes one sad story like this to let us think 1000 times before jumping into treatment. MDT approach is crucial in these cases to ease patients suffering and to confirm diagnosis.

 Multidimensional evaluation is necessary to assess hand function for patients with charcot-marie-tooth disease type 1A



Vivien Reynaud, Isabelle Conforto, Pascale Givron, Pierre Clavelou, Catherine Cornut-Chauvinc, Frédéric Taithe, Bruno Pereira, Emmanuel Coudeyre

Objectives: Background. Charcot-Marie-Tooth (CMT) disease type 1A (CMT1A) is the most common hereditary neuropathy. Several studies have assessed the relation between strength and dexterity parameters, but not all used standard or validated tools, and none incorporated severity of impairment of electrophysiological parameters. Objective. The purpose of this study was to evaluate the relation between severity of electroneuromyography impairment and its impact on function and quality of life in people with CMT1A. Design: Methods. Grip and lateral pinch strength were evaluated with specific dynamometers: the Jamar and the Pinch Gauge. Dexterity was explored with the Sollerman, Jebsen, and Nine-hole Peg tests; and the CMT impact on well-being was assessed by validated scores and scales: Medical Outcomes Study Short Form 36 (SF-36), Beck Depression Inventory, and Fatigue Severity Scale and disease severity by the CMT neuropathy score and Inflammatory Neuropathy Cause and Treatment sensory sum score. Finally, axonal loss and demyelination process was assessed by electroneuromyography. Results: We included 33 participants (23 females, mean [SD] age 47.0[4.7] years). We found lack of correlation between severe electroneuromyography impairment (frequency of abnormal Results >80%), significant distal amyotrophy (70%) and quality of life (mean[SD] scores for physical and mental SF-36 were 36.4 [10.0] and 48.4 [11.5]), autonomy for activities of daily living, and hand function that remains relatively preserved. We found a correlation between lateral pinch and dexterity according to the Sollerman test (r=0.52, p< 0.05) but no correlation among the other parameters. Conclusions: In CMT1A, the deficit in the hand's intrinsic muscles seems to be compensated by use of extrinsic muscles to maintain grip and dexterity function. The manual function is complex and requires an overall, quantitative, qualitative and multidisciplinary assessment. Each tool (Pinch Gauge, Jamar, Sollerman, Jebsen, Nine-hole Peg) measures a specific element of manual function and is necessary when performing a grip function analysis.

 Multifocal motor neuropathy in a long-term HIV survivor with azidothymidine exposure and intravenous immunoglobulin therapy



Kishan Patel, Richard Jermyn, Deanna Janora

Objectives: Multifocal motor neuropathy (MMN) is a rare, purely motor neuropathy, characterized by progressive, asymmetric, distal limb weakness with minimal sensory impairment. The etiology is deemed immune mediated and treatable with intravenous immunoglobulin (IVIg) therapy. Design: A 67-year-old woman presented HIV positive since 1994 with a history of intermittent limb paresthesias and sensory polyneuropathy from 2002-2009. In 2010, she experienced progressive left hand and bilateral leg weakness. Nerve conduction studies (NCS) showed axonal peripheral polyneuropathy affecting motor nerve fibers preferentially. She was started on IVIg with slight improvement in five months. However, due to insurance denial, she was soon taken off IVIg. August 2011 NCS showed worsening left motor peroneal and tibial nerve amplitudes. In 2012, she was back on IVIg and reported less fatigue and fewer cramps. In 2016, she complained of headaches with IVIg and skipped her treatments. Subsequently, she had a fall and injured her face and right knee. In 2018, due to insurance and surgeries, she again declined treatments and experienced frequent falls. This year, motor NCS amplitudes and conduction velocities have further worsened in both upper and lower extremities. Results: Overall, this patient had a progressive decline in the amplitudes and conduction velocities of her median, tibial and peroneal motor fibers. Left side showed more prominent weakness compared to her right. The support for IVIg is heightened after her relapses following multiple discontinuations. Laboratory Results demonstrated CD4 counts > 300 and viral load < 50 copies to indicate she was virally suppressed. Conclusions: This case illustrates the potential for MMN following initial use of azidothymidine in long-term HIV survivors. Although the motor neuropathy seen in this patient is rare, it is a predictable side effect of azidothymidine use. Recognition of this condition is critical to implement early NCS screenings for patients and apply appropriate IVIg therapy to prevent deterioration.

 Multi-level and multi-pattern lower- and upper-limb spasticity treatment with incobotulinumtoxina in children and adolescents with cerebral palsy



Edward Dabrowski, Henry Chambers, Florian Heinen, Petr Kanovsky, A. Sebastian Schroeder, Kerr Graham, Marta Banach, Hanna Dersch, Thorin L. Geister, Francisco Martinez-Torres, Irena Pulte, Deborah Gaebler-Spira

Objectives: In two phase III studies; a lead-in prospective, double-blind, randomized study (TIM) followed by an open-label, non-controlled study (TIMO), we assess efficacy and safety of incobotulinumtoxinA in lower-limb (LL) or combined LL/upper-limb (LL/UL) spasticity in children and adolescents with cerebral palsy (CP). Design: TIM had three parallel dose groups (4 U/kg body weight (BW), 12 U/kg BW, 16 U/kg BW); subjects were randomized in a 1:1:2 ratio and received 2 double-blind injection cycles. In TIMO, subjects who had completed TIM, or newly recruited treatment-naïve or pre-treated subjects, received 4 injection cycles with the highest dose of TIM. The primary endpoints of TIM were change from baseline in Ashworth Scale (AS) of the plantar flexors (PF) score at Week 4 of Cycle 1, and the Investigator's Global Impression of Change of Plantar Flexor Spasticity Scale (GICS-PF) score at Week 4 of Cycle 1. TIMO was focused on safety, and did not have primary efficacy endpoints. Results: In TIM, all 3 dose groups experienced a statistically significant improvement in AS-PF score 4 weeks post-injection versus baseline. In TIMO, cumulative improvements in AS scores for the PF, knee flexors and thigh adductors were observed from TIM baseline to 4 weeks post-injection. Investigator's GICS-PF scores indicated a positive response to treatment in all dose groups 4 weeks post-injection in TIM Cycle 1 and improvements were maintained in all treatment groups in Cycle 2. Respective clinical assessments also confirmed consistent improvement in LL and UL spasticity at Week 4 in all TIMO injection cycles. Both studies had good overall safety profiles. Conclusions: IncobotulinumtoxinA at total doses up to 16–20 U/kg is effective and well tolerated for the multi-level, multi-pattern treatment of LL/UL spasticity due to CP in children and adolescents.

 Multi-minicore myopathy



Jonathan Chapekis, Sharonpreet Singh, Muhammad S. Rizwan, Yaacov Anziska, Susan Stickevers

Case Diagnosis: Multi-Minicore Myopathy. Case Description: A male child presented to MDA clinic with hypotonia, global weakness, delayed developmental milestones, scoliosis, difficulty swallowing, and limited spinal range of motion. His parents reported that he had decreased muscle tone and weakness since birth. A muscle biopsy was performed which established the diagnosis of Multi-Minicore Myopathy. Spine fusion surgery was performed and he was admitted to acute inpatient rehabilitation following surgery. He was provided with supramalleolar orthoses and he was able to walk without an assistive device. He was provided with a wheelchair for use in school. Speech therapy was provided for oral exercises and dietary modifications to facilitate swallowing. BiPAP and a mechanical insufflator-exsufflator were provided for management of restrictive lung disease and secretion management. He was placed on Digoxin and Enalapril for management of his cardiomyopathy. Discussions: Multi-Minicore Disease is a rare, congenital autosomal recessive neuromuscular disorder featuring multiple core structures on biopsy formed as a result of reduced oxidative activity along the longitudinal axis of the muscle fiber. It is a rare condition with unknown prevalence, but the incidence of all congenital myopathies is estimated at around 0.06/1,000 live births. This patient has the classic form which presents at birth or in the first few months with hypotonia and delay in achieving motor milestones. The hallmarks of classic Multi-Minicore Myopathy are spinal rigidity, early scoliosis and respiratory impairment. Other features include a high-pitched voice, myopathic facial features, feeding difficulties, right ventricular dysfunction, axial and proximal weakness, and a progressive scoliosis, often associated with lateral trunk deviation and respiratory impairment in the second decade of life. Conclusions: This case demonstrates the importance of prompt evaluation and diagnosis of Multi-Minicore Myopathy, a rare neuromuscular disorder, and the importance of an interdisciplinary approach in management of patients with this condition.

 Muscle contractures in children with cerebral palsy: Epigenetic DNA methylation and senescence patterns in resident muscle stem cells



Shannon Strader, Lydia Sibley, Nicole Broda, Wendy Gross, Austin Menezes, Vineeta Swaroop, Henry Chambers, Sudarshan Dayanidhi, Richard Lieber, Andrea Domenighetti

Case Diagnosis: In cerebral palsy (CP), muscle contractures are associated with significant loss of muscle mass and strength. We have reported that the number of resident muscle-generating stem cells, called muscle satellite cells (MuSC), is 60-70% reduced in contractured muscles of children with CP. Our current hypothesis is that development of muscle contractures in CP is in part driven by epigenetic changes in DNA methylation causing a “reprogramming” of MuSCs, leading to their premature cellular senescence and exhaustion. Our main objective is to understand the cellular and molecular mechanisms that may lead to differences in MuSC proliferation, differentiation, and premature senescence in muscles of children with CP versus children who are typically developing (TD). Case Description: MuSCs were isolated from hamstring muscle biopsies obtained from CP and from TD children as a control group (n= 6-8 patients/group). MuSCs were expanded into a population of proliferating myoblasts in 0.5% gelatin-coated plastic dishes, using a high-serum proliferative medium. We modulated DNA methylation levels by treating myoblasts with 5 uM 5-Azacytidine (AZA) in high-serum proliferative medium for 24 hours. AZA is a DNA methyltransferase (DNMT) inhibitor currently approved by the FDA for the treatment of myelodysplastic syndromes. ACEA's xCELLigence RTCA equipment was used to measure proliferation and migration rates of CP and TD myoblasts, treated and non-treated with AZA. RNA-sequencing and DNA methylation profiling, followed by bioinformatics clustering analysis of modulated biological pathways were used to characterize DNA methylation-dependent changes of gene expression in proliferating CP myoblasts treated with AZA. IRB provided ethical approval, and appropriate assents/consents were obtained from children and their parents. Discussions: We found that untreated CP myoblasts proliferated and migrated faster than untreated TD myoblasts. This hyperproliferative phenotype was associated with a genome-wide increase in DNA methylation levels and a specific transcriptional overexpression of DNA methyltransferases DNMTs together with upregulation of markers for proliferation, cellular senescence, and DNA damage repair. AZA treatment normalized global DNA methylation levels to TD levels and led to a decrease in cell proliferation and migration rates in CP myoblasts. AZA treatment was also associated with a DNA methylation-dependent downregulation of DNMTs and other markers for cell proliferation, cellular senescence, and DNA damage repair. Finally, AZA treatment upregulated transcripts coding for protein and extracellular matrix synthesis and cell-cell adhesion receptors. Conclusions: These observations support the hypothesis that muscle impairment in CP is in part driven by dysregulation of DNMTs leading to a hyperproliferative phenotype that may lead to premature exhaustion of the muscle-generating MuSC pool. The data also identify DNMTs as candidates for mediating the expression of matrix and receptor components, which in turn, could support MuSC self-renewal and/or differentiation into new muscle fibers. We propose that DNMT inhibitors like AZA could potentially be repurposed as candidate therapeutic target for the maintenance of a healthy population of MuSCs in contractured muscles. We are currently dissecting the role of DNMTs and DNMT inhibitors in muscle tissue and muscle stem cell homeostasis. We are also testing whether genome-wide changes in DNA methylation patterns will correlate with premature cellular senescence in MuSCs from contractured CP muscles.

 Musculoskeletal modeling analysis of spastic gait in cervical myelopathy patients



Ippei Kitade, Hideaki Nakajima, Ai Takahashi, Shuji Watanabe, Mayumi Matsumura, Seiichiro Shimada, Akihiko Matsumine

Objectives: Although some reports have shown a change in gait motion in cervical myelopathy patients using a three-dimensional (3D) gait analysis system, there has been no musculoskeletal modeling parameters investigating; muscle-tendon lengths (MTL) and velocity (MTV). This study aimed to investigate musculoskeletal modeling parameters of gait motion in cervical myelopathy patients. Design: Subjects were 42 patients with cervical myelopathy classified as to its severity using the Japan Orthopaedic Association score excluding the upper extremity items: group 1 ( >10 points); group 2 (7-9 points); and group 3 (< 6 points), and 40 healthy volunteers (controls). A 3D gait analysis system (VICON 370) was used to obtain the spatiotemporal, kinematic, and kinetic parameters . The changes in MTL during gait were calculated using musculoskeletal modeling software (SIMM Gait), which calculates the MTL (using a Hill-type model) from changes in the main muscle based on joint motion recorded using the Vicon Clinical Manager. MTL was calculated as the distance along the modeled path of the adductor longus, rectus femoris, the biceps femoris, the gastrocnemius, and anterior tibialis between the muscle's origin and insertion. MTV were estimated by computing the numerical derivative of the MTL data with respect to time. Results: Genu recurvatum, deteriorated lower-extremity joint motion, and MTV were observed in group 3. MTV of the long head of the biceps femoris in controls, group 1 and 2 showed a bimodal waveform in the negative direction during the initial contact and pre-swing phases, whereas these characteristics were not present in group 3. Conclusions: The strategies of MTV of the biceps femoris during gait motion in severe cervical myelopathy patients were different from those of the normal gait pattern. The imbalance between agonist and antagonist muscle tissue during gait could be involved in the occurrence of genu recurvatum.

 Music-associated head banging and brain injury: A systematic review



James B. Meiling

Objectives: “Head banging” to music, particularly rock, punk, or heavy metal; is a common form of self-expression exhibited by musicians and listeners that includes rhythmically – and violently – swinging their head in all directions, as directed by the beat of the song. Such motions of extreme flexion, extension, or perhaps even spinning motions, has led to dire consequences, few of which have been reported in academic journals. This systematic review will summarize all of the studies that have been published regarding head banging to music and injuries to the brain that individuals have encountered when engaging in this rocking act. Design: A systematic review of PubMed was performed. Search terms included head banging, music, rock, heavy metal and concerts. Studies were included if they discussed head banging in the context of music and brain injuries. Articles discussing head banging in the context of physical trauma or childhood developmental disorders were excluded. The reference sections of the remaining articles were used to screen for additional articles on this subject. Results: In total, the reviewer found 12 articles – 11 case reports and 1 observational study –that fit into the inclusion criteria of this review. These cases included brain injuries primarily by hematomas and arterial aneurysms, dissections, and thromboses. Conclusions: When considering the prevalence of rock, punk, and heavy metal musicians and listeners; 11 case reports and 1 observational study on brain injury might seem pretty minimal. While the number of reported cases might seem small, it's postulated that there is a much higher incidence rate than is reflected by the current literature, due to clinically silent symptoms or spontaneously resolving post-concert mild headaches. A single occurrence of these mild self-resolving brain injuries might not mean much, but compounded and multiplied by numerous occurrences, these minimal headaches could do further damage than is currently seen.

 Myeloperoxidase negatively regulates neutrophil–endothelial cell interactions by impairing Amβ2 integrin function in sterile Inflammation



Alan Tseng, Jaehyung Cho

Objectives: Interactions of neutrophils with endothelial cells (ECs) and platelets contribute to tissue damage and vascular occlusion under sterile inflammatory conditions, such as in ischemic stroke. However, the molecular mechanisms regulating the cell–cell interactions remain poorly understood. Previous studies suggest that reactive oxygen species, such as hydrogen peroxide (H2O2), produced from NADPH oxidase 2 play a critical role in platelet–neutrophil interactions by regulating the function of neutrophil αMβ2 integrin during sterile inflammation. In this study, we further demonstrate a role for myeloperoxidase (MPO) in regulating the adhesive function of neutrophils through αMβ2 integrin. Design: This study utilized real-time fluorescence intravital microscopic imaging of WT and MPO knockout (KO) mice in a mouse model of vascular inflammation induced by tumor necrosis factor-α (TNF-α). A hepatic ischemia/reperfusion injury (IRI) mouse model was also used. Neutrophils isolated from WT and MPO KO mice as well as healthy human volunteers were used in various in vitro assays such as flow cytometry, parallel plate flow chamber adhesion assays, and immunoblotting. Results: We showed that loss of MPO promoted neutrophil–EC interactions and neutrophil emigration but did not affect neutrophil–platelet interactions under inflammatory conditions. We found that compared to wild-type neutrophils, MPO (KO) neutrophils exhibited a significant increase in extracellular H2O2 and surface level of αMβ2 integrin following agonist stimulation and that these effects were dependent on MPO activity. Compared to wild-type mice, MPO KO mice displayed a pro-migratory phenotype of neutrophils but a significant reduction in tissue damage. Conclusions: These results suggest that MPO activity negatively regulates the adhesive and migratory function of neutrophils by impairing αMβ2 integrin function under sterile inflammatory conditions. Overall, our results suggest differential regulation of αMβ2 integrin function depending on the level of ROS generation and the complex cellular environment.

 Near total loss of autologous bone flap after cranioplasty due to spontaneous resorption, impressively demonstrated with three-dimensional computed tomography image reconstruction



Kelsey Darlington, Stuart Yablon, Amy Ng

Case Diagnosis: Spontaneous resorption of autologous cranioplasty bone flap. Case Description: A 15 year-old male sustained severe right hemispheric ischemic stroke with dense left hemiplegia due to right carotid artery dissection following a motor vehicle crash. Two days post-injury, patient underwent right fronto-temporo-parietal decompressive craniectomy to relieve malignant intracranial pressure. After a complicated hospital course, he was transferred to the brain injury program at a rehabilitation hospital. Examination was remarkable for an alert, oriented male with dense left hemiplegia, left neglect, left homonymous hemianopsia, and a large, deep right hemisphere skull defect. He reported severe daily headaches that improved after autologous bone flap cranioplasty, 3 months post-injury. Several weeks after cranioplasty, the patient presented to clinic complaining of persistent, progressively worsening headache, described as worse in severity than pre-surgical headache. CT head demonstrated near total resorption of the bone flap. Three-dimensional imaging reconstruction impressively demonstrates these radiographic findings. After acrylic replacement of the previously resorbed bone flap, the patient's headache resolved. Discussions: Bone resorption commonly occurs after cranioplasty to some degree, but rarely with total loss of the skull flap. Given the prevalence of bone resorption, some neurosurgeons advocate reevaluating the utility of autologous bone for cranioplasty. This patient experienced rapid resorption of his autologous bone flap, heralded by worsening headache, which resolved after acrylic cranioplasty. Conclusions: Spontaneous resorption commonly occurs after autologous bone cranioplasty and sometimes involves considerable or near total loss of the flap, necessitating reoperation. In some cases, this may be heralded by worsening headache. If a patient presents after autologous bone flap cranioplasty with complaints of persistent headache, it is prudent to evaluate for bone flap resorption.

 Nemaline rod myopathy



Jonathan Chapekis, Muhammad S. Rizwan, Sharonpreet Singh, Nuri Jacoby, Susan Stickevers

Case Diagnosis: Nemaline Myopathy. Case Description: An Ashkenazi Jewish male immigrant from Uzbekistan presented to MDA Clinic with weakness, dysphagia, and difficulty ambulating. He achieved normal developmental milestones until age 2.5 years when he developed difficulty rising from a seated position and ambulating. He was diagnosed with an unknown muscle disorder in Uzbekistan but due to limited medical resources he received no formal treatment. Muscle wasting and weakness were pronounced by age 15 when he immigrated to the United States. Exam in MDA clinic revealed cachexia, mild scoliosis, scapular winging, weakness, and diminished reflexes. A biopsy was performed, and he was diagnosed with nemaline myopathy. Discussions: Nemaline myopathy is a rare, genetic disorder that affects filament proteins required for muscle tone and contraction resulting in thread-like structures in muscle fibers. Weakness is most severe in proximal muscles, and affected individuals exhibit feeding and swallowing difficulties, foot deformities, scoliosis, and contractures. It can be inherited in an autosomal-recessive or autosomal-dominant pattern. People of Ashkenazi Jewish descent are at risk for nemaline myopathy, and other genetic disorders, including, but not limited to: Tay-Sachs Disease, Canavan's Syndrome, Cystic Fibrosis, Gaucher's Disease, Familial Dysautonomia, Niemann Pick Disease, and Mucolipidosis. Dor Yeshorim is an organization that offers free pre-marital genetic carrier screening to assess risk for hereditary disorders. Dor Yeshorim has been successful in preventing fatal and debilitating genetic disorders in the Jewish community through early detection of carriers. While this and other free genetic screening programs are located internationally, our patient's family did not have access to them in Uzbekistan. Conclusions: This case demonstrates the benefits of pre-marital genetic carrier screening and counseling in at-risk populations which participate in consanguinous marriages. The incidence and impact of genetic diseases on families may be mitigated with widespread use of genetic carrier screening prior to pregnancy.

 Neuralgic amyotrophy with paraspinal involvement on needle EMG: A case report and review of the literature



Joshua L. Elkin, Jeremy Beckworth

Case Diagnosis: Neuralgic Amyotrophy (NA). Case Description: A 19-year-old lefthanded D1 baseball pitcher developed right shoulder pain one month prior to clinic presentation. As the pain improved, he noticed weakness in this shoulder along with scapular winging. On interview, he had no recent trauma but did endorse flu like symptoms prior to pain. On examination, there was right posterior scapular winging, however sensations and reflexes were normal. Nerve conduction studies (NCS) were normal. Needle EMG was abnormal with 2+ fibrillation potentials and positive sharp waves in the serratus with neuropathic units and recruitments. Similar 2+ fibrillation potentials and positive sharp waves were seen in the cervical paraspinal muscles. Cervical spine MRI was normal without neural compression. History, exam, and EMG were suggestive of neuralgic amyotrophy. Discussions: NA classically presents in patients as severe neck, shoulder, or arm pain that progresses to weakness of the ipsilateral extremity with preserved sensation. 80% of patients recover by three years, however persistent disability is seen in 20% of cases. The debilitating nature of this condition demands recognition by clinicians in shoulder or arm pain that precedes weakness. Although this syndrome is primarily diagnosed clinically, imaging and NCS/EMG are beneficial. MRI is commonly used to exclude radiculopathy as an etiology of the acute pain. NCS of relevant muscle groups are usually normal and thus exclude mononeuropathies, while EMG will commonly show denervation. Conclusions: This case was unique because paraspinal muscles are not typically involved in this syndrome, and MRI did not suggest radiculopathy. NA is considered a brachial plexopathy, and normal paraspinals on needle EMG and abnormal amplitudes on sensory NCS are the pathognomonic finding in most plexopathies. This unusual presentation highlights the importance of utilizing clinical history and NCS/EMG as an extension of the physical examination.

 Neurocysticercosis resulting in acute gait impairment: A case report



Mohamed Alfath, Alexander Turfe

Case Diagnosis: Neurocysticercosis. Case Description: A 37-year-old male presented with a chief complaint of frequent falls. An MRI brain was done, revealing extensive ring-enhancing lesions and a calcified lesion in the frontal lobe consistent with neurocysticercosis. The patient subsequently underwent a frontal craniotomy for biopsy of some of the lesions. Repeat MRI showed improvement in the lesions while the patient was on steroids for vasogenic edema. He was also improving clinically, so the decision was made to hold off on antiparasitic agents. The patient was then transferred to an acute inpatient rehabilitation hospital. Initially, he required total assistance with a rolling walker to ambulate, but made significant gains and was eventually discharged home without the need of an assistive device. Discussions: Although infectious workup (including brain tissue biopsies) came back negative, the patient met criteria for definitive diagnosis of neurocysticercosis based on the following: 1) MRI brain showing enhancing lesions, and a typical parenchymal calcification (two major neuroimaging criteria); 2) epidemiological exposure criteria (he worked as a cook for 12 years with Latino immigrants preparing various types of meats, and also traveled to Mexico in the past, which could have exposed him to Taenia solium eggs). Conclusions: Neurocysticercosis can be diagnosed in patients with relevant clinical symptoms, exposure history, and neuroimaging findings despite a completely benign infectious workup. Resultant neurologic deficits can improve with therapy and steroids without the use of antiparasitic agents.

 Neurogenic fever following T12 Asia a spinal cord injury



Richard G. Ellis, Eytan Koch, Jaimie John, James Healy, Amit Bansal

Case Diagnosis: Neurogenic Fever, C4 recovering to T12 Asia A SCI. Case Description: 28M, previously healthy, was an unrestrained passenger in a rollover motor vehicle collision. On admission acute care, the patient was found to have T12/L1 complete injury along with T2-T11 epidural hemorrhage and underwent emergent T12-L1 decompression. At transfer to acute rehab with absent sensation below T7, reduced strength in the bilateral arms (3-4/5), and absent motor activity in both legs, qualifying him as a C4 Asia A with ZPP from C4 to T7. Over the course of his rehabilitation he recovered to T12 Asia A. Additionally, He developed a fever on day 3 and was found to have a Klebsiella UTI. He was started on antibiotics, which were escalated for ongoing fevers. Repeat urine and all blood cultures were negative. He completed 10 days of antibiotics but remained febrile 6 days after discontinuation of all antibiotics. Discussions: Although imaging was negative for cervical injury, the patient presented with bilateral upper extremity weakness, possibly due to incomplete C4 injury in addition to his known complete T12 injury. Additionally, the patient demonstrated recurrent fever despite appropriate treatment, likely due to neurogenic fever, which accounts for ~8% of post-injury fevers. Conclusions: Here we identify a case of likely multiple spinal cord injury (C4 and T12) complicated by neurogenic fevers. Multiple spinal cord injury represents an area of difficulty for the Asia Impairment Scale (AIS). This patient improved from C4 to T12 Asia A, likely due to recovery from an incomplete cervical injury. This has profound functional implications but is not well described by the AIS. We also identify a case of neurogenic fever in thoracic injury. Ongoing fever despite treatment is suspicious for neurogenic fever, as appropriate treatment is conservative and therefore warrants discontinuation of antibiotics to reduce the risk of medication side-effects and resistant infections.

 Neurorehabilitation for a rare case of nonalcoholic Wernicke's encephalopathy in a young female related to tonsillectomy, intractable vomiting and newly diagnosed celiac disease



Andrew McCoy, Joseph P. Staszel, Rohit Navlani, Gary Galang

Case Diagnosis: Non-Alcoholic Wernicke's Encephalopathy. Case Description: 29-year-old non-pregnant female with history of gastritis and 40-pound weight loss following tonsillectomy three months prior to presentation was transferred from a community hospital with intractable vomiting and confusion. Initial infectious and neurologic work-up were negative. EEG demonstrated global slowing. Brain imaging revealed a left basal ganglia cyst and bilateral dorsomedial thalami T2 FLAIR abnormalities consistent with Wernicke's encephalopathy (WE). Patient was treated with high-dose intravenous thiamine. Further workup found elevated anti-Gliadin antibodies with low vitamin D and vitamin B12. Complications included dysphagia, extrapyramidal side effects from anti-nausea medication, and refeeding syndrome. Initial functional assessments demonstrated ataxia, oculomotor derangements, need for moderate assistance with ambulation and stair negotiation, maximum assistance for functional transfers, and minimum assistance for self-care tasks. Three weeks of neurorehabilitation allowed for discharge home with a regular diet, modified independence in self-care and transfers, and independent mobility with a wheeled walker. Discussions: WE is caused by thiamine deficiency, related most often to alcoholism, and characterized by ataxia, nystagmus, ophthalmoplegia, and confusion. Cases not associated with alcoholism include hyperemesis gravidarum and inflammatory bowel disease. This case of non-alcoholic WE represents a unique cascade of pre-disposing events never described in the literature. The nitrous oxide (NO) anesthesia used for the tonsillectomy led to a known side effect of NO inhalation which is irreversible oxidation of cyanocobalamin rendering it inactive. This led to vitamin B12 deficiency causing posterior hypopharyngeal dysphagia potentiating the presentation of intractable nausea and vomiting. Undiagnosed celiac disease left her vulnerable to malnutrition, leading to further hypovitaminosis and eventual thiamine deficiency. Conclusions: There is a dearth of literature describing neurorehabilitation for patients with WE. The loss of function associated with WE would have been devastating for this young and employed mother of two children. While she received delayed diagnosis, she represents a positive outcome of neurorehabilitation.

 Neurorehabilitation in a rare survivor of disseminated military nocardiosis with nocardia farcinica



Joseph P. Staszel, Andrew McCoy, Kerry Deluca

Case Diagnosis: Disseminated Military Nocardiosis. Case Description: 56-year-old male with history of alcohol use presented with 1-month insidious onset of confusion. Brain magnetic resonance imaging (MRI) demonstrated innumerable ring-enhancing lesions in cortical, subcortical, and cerebellar structures. Chest imaging demonstrated necrotic left upper lung lobe and mediastinal masses concerning for malignancy. Work-up notable for persistent lymphopenia, co-existent Lyme's disease and negative human immunodeficiency virus testing. Hospital course complicated by cerebral edema, non-convulsive status epilepticus, respiratory failure, and tracheoesophageal fistula. Endobronchial biopsy and blood cultures were positive for Nocardia Farcinica treated with Linezolid, Meropenem, and Bactrim. Neurologic examination remarkable for left gaze preference, delayed processing, impaired memory, and bilateral proximal weakness. Initial functional assessment demonstrated maximum assistance for transfers, poor balance, and total assistance for self-care activities of daily living. Discussions: The well-documented differential diagnosis for ring-enhancing lesions on brain MRI includes tuberculomas, abscesses, septic emboli, malignancy, cysticercosis, toxoplasmosis, and nocardiosis. Nocardia farcinica is a gram-positive, partially acid-fast, aerobic actinomycete, which is opportunistic and the least common of the Nocardia spp. Multifocal brain abscess formation from disseminated Nocardia spp is responsible for 2%–20% of brain abscesses in immunocompromised hosts, with those affected by Nocardia farcinica having mortality rate of 7%-85%. The lungs (40%) and brain (22%) are most commonly affected. The incidence for neurologic impairment following brain abscess survival is 20%-70%. Our patient had significant functional and neurologic deficits associated with pulmonary deconditioning, dysphagia, and evidence for critical illness myopathy related to his complicated medical course. Conclusions: Disseminated military nocardiosis is an exceedingly rare disease with high mortality rate most commonly affecting immunocompromised individuals. Based on the Nocardia spp tropism for neural tissue as well as pulmonary parenchyma, patients who survive this illness have significant functional impairments and pulmonary deconditioning. We present a case describing the rehabilitation course addressing the functional impairments related to neurologic and pulmonary Nocardia involvement.

 Nitrous oxide poisoning leading to mulit-level subacute combined spinal cord degeneration of thoracic spine in a young adult patient: A case report



Fady Boutros, Nathaniel Dusto

Case Diagnosis: Sub-acute combined cord degeneration is a known manifestation of B12 deficiency. Nitrous oxide abuse rapidly depletes B12 levels leading to B12 deficiency. Case Description: A 19 year old male with history of nitrous oxide abuse presenting with 1-2 months rapidly progressive weakness and numbness. Patient started using nitrous oxide at the age of 14 years including daily use for past year. Patient had ascending numbness. Weakness became profound that he was bed bound. Patient presented with a low-normal B12 level of 200 (Ref range 193-986) as well as elevated homocysteine. Patient also had elevated CPK, and LFT's consistent with rhabdomyolysis. Thoracic MRI imaging revealed lesions at T3 and T12. The patient was treated with B12 injections and at time of discharge, his B12 level was 619. Discussions: At initial evaluation for inpatient rehab, the patient's strength was notable for multiple 3's, including the distal left upper extremity grossly, and in the majority of muscle groups in bilateral lower extremities. At time of discharge, the patient had only one muscle group of a 3, with the upper extremity muscle groups majority 4 and lower extremity groups with a majority of 5. The patient's FIM scores on evaluation for rehab are notable 12 out of 19 scores of 4 or less with an average FIM score of 3.89. Following vitamin B12 treatment and multidisciplinary therapy, the patient showed drastic improvement with only 3 out of 19 scores of 4 or less with an average FIM score of 6.0 at time of discharge. Patient had rapid improvement in both overall strength as well as functional independence measures. Conclusions: While improvement in B12 deficiency related neurologic deficits is expected with B12 treatment, the rate of objective improvement in function in this patient suggests the importance of pairing vitamin supplementation with inpatient rehabilitation.

 NMDA-R Ab negative opsoclonus-myoclonus-ataxia syndrome in a patient with ovarian teratoma



S. M. M. Mohar, Wei Xiaofang, Ruth Alejandro

Case Diagnosis: 16-year-old female presented with one week history of vertigo, gait instability, tremulousness, abnormal, eye movement, tremor, and anxiety. Imaging showed right ovarian teratoma, underwent right salpingo-oophorectomy and subsequently received IVIG, pulse steroid and Rituximab. Patient was admitted to inpatient rehabilitation with the diagnosis of NMDA-R negative opsoclonus-myoclonus-ataxia syndrome with marked improvement of symptoms and function. Case Description: The child with history of pseudoseizure since 5 years of age, was off medication and seizure free for 8 years, initially presented with vertigo, gait instability, tremulousness, abnormal eye movement (ocular flutter), tremor, weakness, pruritus, anxiety and panic attack. Whole body MRI work up revealed right ovarian teratoma. CSF study showed pleocytosis and elevated protein. She underwent right salpingo-oophorectomy and subsequently received IVIG, pulse steroid and Rituximab with some improvement of symptoms. On rehab admission, physical examination showed hypertension, impaired recall and cognition, vocal tremor, increased vocal pitch, rapid bilateral horizontal nystagmus worsened with focusing, titubation worsening on sitting or standing, improved on lying, dysmetria with heel shin test and finger nose test in late phase of trajectory, brisk patellar reflex in left knee, left ankle clonus, ataxic gait. Motor strength was 5/5 in all extremities. Patient's Berg balance scale improved from 18/56 to 46/56. Discussions: Our case showed marked improvement of function and symptoms after tumor resection, treatment with IVIG, pulse steroid and rituximab along with 6 weeks of acute inpatient rehabilitation in a low stimulation environment setting. She was discharged with rolling walker, supervision in ambulation, stair negotiation with one hand rail, coordination of extremities without loss of balance, no titubation or ataxia. Conclusions: Opsoclonus-myoclonus-ataxia syndrome is a rare clinical condition which may have better prognosis in NMDA-R antibody negative ovarian teratoma cases if combined with early whole body MRI work up, tumor resection, medical treatment and intensive rehabilitation therapy.

 Nontraumatic intracerebral hemorrhage in a patient with still's disease



Nahyun Kim, Andrew Bloomfield, Mery Elashvili

Case Diagnosis: Intracerebral hemorrhage in adult-onset Still's disease (AOSD). Case Description: A 49-year-old male with AOSD (diagnosed 2 years ago) presented to the hospital with confusion and abnormal speech. Non-contrast head CT and MRI both showed acute hemorrhagic infarction of left basal ganglia in addition to chronic hemorrhage of the right basal ganglia. Patient developed right leg swelling due to DVT and IVC filter was placed. Leukocytosis was present and patient's rheumatologist recommended continuing prednisone as patient has had severe flares of AOSD in the past. During rehabilitation, patient received intensive inpatient rehabilitation services including daily physical, occupational, and speech therapies as well as frequent neuropsychological assessments. Secondary stroke and seizure prophylaxis measures were implemented. Patient was discharged in stable condition with markedly improved function. Discussions: AOSD is a rare multisystemic autoinflammatory disorder that usually affects young adults (median age at diagnosis is 36 years) with a prevalence ranging from 0.0001 to 0.0034 % worldwide. Although AOSD is regarded as a benign disease with low mortality rate and stroke is a rare complication in AOSD, there is increasing evidence suggesting that AOSD is associated with ischemic stroke and cerebral hemorrhage. In addition, there has been multiple case reports and reviews demonstrating the association between AOSD and thrombotic microangiopathy which could cause increased stroke in AOSD patients. In our case, AOSD may have contributed to both intracerebral hemorrhage and DVT as well. Conclusions: Stroke in a young patient is rare, and AOSD should be considered as a differential diagnosis for patients demonstrating non-infectious fever, rash, and arthralgia. As physiatrists, we are uniquely positioned in examining and treating patients after stroke. Therefore, familiarizing ourselves with symptoms of AOSD would benefit patients by assisting early detection of this rare disease and subsequently improve the prognosis.

 Not your average teen liver: A case report



Scott Klass, Richard Rosales, Gemayaret Alvarez

Case Diagnosis: Heparin-induced hepatotoxicity. Case Description: An 18-year-old male presents to inpatient rehabilitation following polytrauma with sub-arachnoid and right epidural hematomas, left bimalleolar fracture, and facial fractures after being struck by a vehicle while skateboarding. His rehab admission labs revealed an elevated alanine transaminase (ALT) of 158 and aspartate transaminase (AST) of 80. Repeat testing after 15 days showed an ALT of 1358 and AST 281. The patient denied abdominal pain, drug use, autoimmune disorders, and had no jaundice. Hepatology's workup was unremarkable. Upon review of medications, heparin was the only medication with risk of hepatotoxicity. After discontinuing heparin, the ALT and AST trended down to 578 and 71 at 4 days and normalized 5 weeks later. Discussions: Heparin is commonly used in hospitalized patients with limited mobility for DVT prophylaxis. It is known for risk of hemorrhage and thrombocytopenia, but it is also associated with drug-induced liver injury (DILI) in 8% of patients. This is likely underreported, as healthy subjects showed a >50% rate of DILI with heparin use. In this case, our patient's liver enzymes were increased to >5 times the upper limit of normal. This drastic elevation has an incidence of less than 2%. Heparin-induced hepatotoxicity generally presents asymptomatically and starts within one week. It has no predisposing factors and normal bilirubin levels are seen. After cessation of heparin, liver enzyme levels normalize. Warfarin and novel oral anticoagulants comparatively demonstrated a 1-3% risk, making them adequate alternatives. Conclusions: At baseline 49% of TBI patient's exhibit mild to moderately elevated ALT within 30 days of admission. This case highlights the importance of trending and investigating when levels acutely worsen. By understanding the course and symptomatology of heparin-induced hepatotoxicity, we broaden our differential. This allows us to make a prompt diagnosis, eliminate unnecessary testing, minimize rehab stay, and ultimately improve patient's quality of life.

 Occam's razor for use in the diagnosis of motor neuron disease in the setting of multilevel spinal stenosis, peripheral neuropathy and carpel tunnel syndrome



Richard G. Ellis, Andreas Neophytides

Case Diagnosis: Motor Neuron Disease. Case Description: 67 M with history of C3-7 posterior cervical laminectomy and fusion and L5-S1 lumbar fixation and fusion for spinal stenosis presented with subacute onset bilateral leg and arm weakness to neurosurgery and referred for EMG to evaluate for spinal stenosis. MRI with C4-5 moderate-severe canal stenosis and foraminal stenosis. Nerve conduction study revealed mild right carpel tunnel syndrome and mild axonal polyneuropathy. EMG study revealed right C4-C5 membrane instability consistent with possible radiculopathy, as well as median nerve membrane instability. Bilateral leg testing demonstrated diffuse, fibrillation and positive waves in distal and proximal muscles at multiple spinal levels. Diffuse CRD's were also heard. Discussions: While most individual findings on EMG in this patient could be explained by current imaging, past surgical history or nerve condition Results, the observed diffuse membrane instability was out of proportion to more local findings. Taken together, multilevel cervical and lumbar stenosis, polyneuropathy and carpel tunnel syndrome can cause diffuse denervation on EMG, however the rule of parsimony suggested underlying motor neuron disease as the more likely diagnosis. Conclusions: Most modern patients typically present for EMG with partial work-up including already bearing common diagnoses such as radiculopathy, peripheral neuropathy and carpel tunnel syndrome, and with increasing numbers of comorbid conditions. Even with careful testing of additional extremities and proximal muscles these can be difficult to distinguish from diffuse processes. Careful effort to avoid anchoring and confirmation bias as well as application of the rule of parsimony on behalf of the electromyographer remain staples of effective diagnosis.

 One-and-a-half syndrome plus impaired convergence after ischemic stroke



Edward W. Ference, Elisabeth N. Theodossiou, Mary Merlin, Shanti Pinto

Case Diagnosis: One-and-a-half Syndrome plus Impaired Convergence after Ischemic Stroke. Case Description: A 63-year-old African American male with a history of hypertension, hyperlipidemia, coronary artery disease, type II diabetes, and previous lacunar stroke presented with blurry vision and right eye deviation. MRI demonstrated 1.2 x 0.3 cm acute lacunar infarct in the left paramedian pons. He was unable to look left with either eye and the left eye would not adduct past midline at inpatient rehabilitation admission. He had impaired convergence and right-beating nystagmus with right eye abduction without deficits in strength, sensation, cerebellar testing, or other cranial nerve. Occupational therapy focused on visual scanning and visual attention during functional tasks. Bioness Integrated Therapy System was utilized to improve functional reach and visual motor coordination. Speech therapy incorporated strategies for complete viewing, such as item positioning, and management of diplopia with use of an eye patch. At outpatient rehabilitation follow-up he had photographic evidence of improved ocular movements and resolution of diplopia. Discussions: One-and-a-half syndrome is a disorder of horizontal eye movements defined by ipsilateral conjugate horizontal gaze palsy (one) with ipsilateral internuclear opthalmoplegia (INO; half). Pathology involves the abducens nucleus, medial longitudinal fasciculus (MLF), and paramedian pontine reticular formation (PPRF). The syndrome most commonly occurs due to cerebrovascular disease, particularly brainstem infarction. While horizontal eye movement impairment is the hallmark of one-and-a-half syndrome, convergence is typically spared unless midbrain structures are also involved. There is ongoing research into a pontine structure, the nucleus reticularis tegmenti ponti, which has implications on the vergence pathway and may account for our patient's convergence deficit. Conclusions: Our patient presented with visual impairments consistent with one-and-a-half syndrome plus impaired convergence. He made significant recovery during inpatient rehabilitation; therefore, vision therapy is a crucial component of the comprehensive rehabilitation program.

 Ottobock C-brace for management of lower extremity musculoskeletal disability: A case report



Madeeha K. Lughmani, Mohammad Alaqrabawi

Case Diagnosis: Dystrophy of lower leg secondary to ankle injury. Case Description: A middle-aged male presented to orthotics for a brace to assist in walking. Twenty years ago, a brake drum fell on his right ankle causing multiple fractures and nerve impairments. Over time, he lost sensation and strength of the right lower extremity. Despite multiple surgeries and spinal stimulation therapy, symptoms worsened. He has been wheelchair-bound for the past four years, causing atrophy in his left leg as well. He was referred to orthotics for brace fitting to assist mobility. The routine braces were attempted, but he had an unstable, circumduction gait; therefore, he used a walker or cane with the brace. The team began to investigate braces and came across the Ottobock C-Brace. It was an extensive process to obtain this brace, but he now walks with complete independence, easily performs his daily activities, and returned to outdoor hobbies that were thought impossible for half his life. Discussions: The C-Brace overcame the limitations of attempted braces, including SPL 2 Fillauer and FreeWalk Ottobock. It covers the thigh to foot and contains a sensor enabling a real-time gait cycle analysis. Based on this, changes in resistance for knee flexion/extension are made through a hydraulic system. It is a lightweight brace that enables dynamic changes, which prevents tripping, allows mobility on different terrains, and has multiple settings (e.g. cycling mode). Conclusions: This brace has significantly changed the lives of those that before felt disabled with limited or no independent activity. It costs 75,000 USD (MSRP 90,000 USD), a clear obstacle. Future research to create a similar, more accessible brace would benefit patients with musculoskeletal limitations.

 Pain mediators affect differentiation function of tendon derived stem cell in tendinopathy



Yong-Taek Lee, Sun Up Noh, Kyung Jae Yoon, Jong Geol Do, In-Sik Lee

Objectives: Tendon-derived stem cells (TDSCs) in tendons are responsible for tenogenesis and tendon healing. Aberrant nontenogenic differentiation of TDSCs have been suggested as pathogenesis of tendinopathy. Therefore, regulatory factors for differentiation function of TDSC could be targets for the treatment of tendinopathy. Pain mediators, such as substance P and macrophage migration inhibitory factor (MIF), have been increasingly discussed as an important factor in the pathogenesis of tendinopathy. The purpose was to evaluate whether the pain mediator affects differentiation of TDSC. Design: For in vivo study, rats were classified into tendinopathy model and sham. Tendinopathy rat model was established with supraspinatus overloading exercise, and the supraspinatus tendons were harvested and prepared for RT-PCR. For in vitro study, TDSC was isolated and cultured from the supraspinatus tendon of SD rats, and classified into 4 groups as follows: treated with recombinant Substance P; treated with recombinant MIF; transfected with small interference RNA (siRNA) for MIF gene knockdown: control TDSC. The TDSC culture mediums were prepared for RT-PCR. Results: For in vivo study, tenogenic genes (SCX, Egr1, tenomodulin, Collagen type 1) were down-regulated and pain mediator (MIF) was up-regulated in tendinopathy models compared to sham (p< .05) while chondrogenic genes (BMP2, aggrecan, Sox9) were similar between the two groups. For in vitro study, Substance-P treated TDSC showed down-regulated tenogenic gene expression (SCX, Egr1, Tenomodulin and Collagen type 1) and chondrogenic genes (Sox9 and aggrecan) except BMP2 were up-regulated compared with control TDSC (p< .05). Recombinant MIF treated TDSC showed up-regulated chondrogenic genes expression and down-regulated tenogenic genes expression compared with control TDSC (p< .05). Intriguingly, MIF gene knockdown TDSC showed findings in reverse as with recombinant MIF treated TDSC. Conclusions: Pain mediator (Substance-P and MIF) appears to be associated with pathogenesis of tendinopathy via enhance the aberrant nontenogenic differentiation and suppression of tenogenic differentiation of TDSC.

 Parosmia following anosmia after traumatic brain injury: A case report



Richard Rosales, Lorenzo Diaz, Lauren T. Shapiro

Case Diagnosis: Post-Traumatic Parosmia. Case Description: A 30 year-old woman sustained a left temperoparietal subarachnoid hemorrhage, bilateral frontal contusions, and a left temporal bone fracture after falling off a horse. While she reported an impaired ability to smell and poor appetite early after her injury, her oral intake initially remained adequate when served her preferred foods. Approximately three months following her injury, she began to experience an inability to tolerate the scents of many foods she previously enjoyed eating, reporting that they now had the odor of “burnt plastic.” Her oral intake drastically declined and she had an unintentional weight loss of 15.5 kilograms over a six-month period. She underwent an endoscopic sinonasal examination which was unremarkable, as were her thyroid function tests. She completed food planning and mindful eating exercises during outpatient neuropsychology treatment with minimal improvement. Treatment with mirtazepine was initiated for appetite stimulation and situational depression. Discussions: Parosmia is defined as experiencing distortion in the sense of smell. Sufferers often perceive unpleasant odors, such as burning plastic, feces, rotting flesh, or mold. When they perceive these smells from food, it can result in poor intake and malnutrition. It mostly commonly occurs following a viral illness, but may impact up to a third of survivors of traumatic brain injury (TBI). In these patients, it commonly occurs after a period of anosmia. Treatment options are limited; psychotherapy, antiepileptic medications, and surgical excision of the olfactory mucosa have been described in the literature. Conclusions: Parosmia can be a very distressing experience for TBI survivors and may contribute to malnutrition. Its impact on patients may be more severe than that of the anosmia that often precedes it.

 Paroxysmal autonomic instability with dystonia and rehabilitation outcome – After severe traumatic brain injury: A case report



Amra Saric

Case Diagnosis: Severe traumatic brain injury with paroxysmal autonomic instability with dystonia. Case Description: 29 year old male sustained subdural, subarachnoidal hemorrhage, diffuse axonal injury, multiple depressed skull fractures. During acute care he developed intermittent episodes of tachycardia, tachypnea, diaphoresis, extensor or flexor posturing with dystonia. Investigation for triggers revealed empyema, treated with antibiotics, and chest tube and was diagnosed with right upper extremity DVT. EEG was done to rule out seizure activity. Episodes of autonomic instability persisted despite improvement of other medical issues. Rehabilitation team was consulted for management of spasticity and autonomic dysregulation. The patient was placed on Propranolol, Clonidine and Gabapentin. Discussions: This case report describes a 29 year old male with history of severe traumatic brain injury who presented with paroxysmal autonomic instability and dystonic movements during his stay at acute hospital. Paroxysmal autonomic instability with dystonia (PAID sy) appears to be distinct syndrome that occurs as an uncommon complication of traumatic brain injury, intracerebral hemorrhage, anoxic brain injury, hydrocephalus, meningoencephalitis. Pathophysiology of PAID syndrome likely involves dysfunction of the diencephalic autonomic centers (thalamus and hypotalamus) or disruption of their connection to other brain regions. Cortically provoked release of catecholamines may contribute to hypertension, tachycardia and tachypnea. Differential diagnosis include seizures, sepsis, malignant hypertermia, autonomic dysreflexia, serotonin syndrome, and agitation. The use of Beta adrenergic blockade and alpha 2 adrenergic agonist are proven clinically useful in reducing some of the features. Conclusions: Paid syndrome remains poorly understood and under-recognized rare condition that is associated with severe traumatic brain injury. Early diagnosis, proper diagnostic work up, and pharmacological management of this complication had significant impact on patient neurological outcome, ability to be transferred out of intensive care unit and starting inpatient rehabilitation treatment. Further research into pathophysiology and combination of pharmacotherapy is needed in order to reduce associated morbidity and increase therapeutic efficacy.

 Partial anterior spinal artery syndrome: A case report



Thomas Hordt

Case Diagnosis: Partial Anterior Spinal Artery Syndrome. Case Description: 74-year-old Caucasian male that presents to the outpatient clinic with primary complaint of 6-7 month history of worsening balance, left lower extremity weakness and roughly 1-2 year history of bilateral distal foot numbness. His balance impairment first presented following a surgery to relieve small bowel obstruction in 2/2018. Post bowel surgery he began limping and was soon using a cane for ambulation. His weakness improved some but the impaired balance persisted. Physical exam findings were positive for dorsiflexion and EHL weakness with decreased sensation to pinprick and vibration in bilateral distal lower extremities. On electrodiagnostic evaluation, patient had a distal and symmetrical sensorimotor axonal polyneuropathy. More concerning was a separate process involving a significant loss of anterior horn cells, as evidenced by diffuse spontaneous activity. Findings were just as marked proximally as distally, with markedly increased motor unit action potentials parameters suggesting reinnvervation via axons that survived the primary event. Discussions: The most likely etiology reproducing his overall picture would be a partial anterior spinal artery (Artery of Adamkiewicz) syndrome. This would likely be the result of a transient drop in perfusion pressure during his most recent bowel surgery. Conclusions: Anterior spinal artery syndrome does not have to be an all or nothing event. However, evidence exists supporting a partial ischemic event resulting in primary motor neuron loss involving multiple root levels.

 Patient recovery after West Nile virus encephalomyelitis



William A. Rieck, Lori M. Grafton, Justin S. Hong

Case Diagnosis: West Nile Encephalomyelitis. Case Description: 59-year-old healthy female presented to an outside hospital with 3 day history of rash, fever, and mild headache. Due to concern for exposure to Rocky Mountain spotted fever, she was treated with Doxycycline; however, due to development of hallucinations and tremors, treatment was broadened to include antibiotic and antiviral medications and she was transferred to a higher level of care. Her neuro ICU stay was significant for respiratory failure, EEG consistent with encephalopathy, lumbar puncture revealed 646 WBC with neutrophil predominance and positive West Nile Virus (WNV), and positive serum WNV IgM. Remainder of extensive testing for alternative etiologies was negative. MRI showed signal abnormality from the lower medulla to the C2 level. Patient was diagnosed with West Nile Encephalomyelitis and discharged to acute rehab. At discharge, she was supervision-to-independent level for mobility/ADL's and moderate-to-maximum level for cognition. She was discharged home with family supervision, outpatient therapies and no driving/work. Discussions: WNV is thought to affect the neurologic system of approximately 1% of infected patients. The functional prognosis of this population sub-set is not well documented in the literature. Approximately 10% of West Nile Encephalitis cases result in fatality. One manuscript reported that only 37% of patients infected during the New York City outbreak in 1999 made full recovery after one year. In clinic follow-up, this patient progressed functionally and was discharged from outpatient therapies with a home program. Neuropsychological battery completed 4 months post-diagnosis revealed complete resolution of cognitive deficits. She returned to driving and work without issue. Conclusions: This case presents a positive functional outcome for one patient diagnosed with West Nile Encephalomyelitis.

 Patient specific function-focused outcome measures lead to better utilization of botulinum toxin in combination with physical therapy



John A. Donovan, Deborah McCowan, Everett Hills

Objectives: Determine if physical therapists and physiatrists using the Patient Specific Functional Scale (PSFS) can produce quantifiable clinically significant improvement in a patient's ability to perform self-selected tasks via targeted botulinum toxin injections followed by physical therapy. Design: Retrospective chart review of patients ( >18 years old) with chronic neurological disorders producing spasticity referred for outpatient physical therapy by a physiatrist. Patients were administered the PSFS at initial evaluation by the physical therapist. The PSFS consists of the patient self-identifying three tasks considered important but difficult or unable to currently perform. The patient then rated the current level of ability to perform each task on an 11-point scale with “0” representing “unable to perform” and “10” representing “able to perform at prior level or anticipated functional goal.” Based on individual clinical assessments, the physiatrist and physical therapist discussed and confirmed the muscles for targeted denervation by botulinum toxin injections. The patients then underwent the botulinum toxin injections followed by physical therapy that averaged 10 visits. The PSFS was administered on discharge. Results: 28 patients with baseline and discharge PSFS scores and who had received targeted botulinum toxin injections guided by recommendations from the physical therapist were identified. Initial PSFS scores: Mean: 2.83, Median: 2.84; Final PSFS scores: Mean: 6.41, Median: 6.66; Improvement in PSFS scores: Mean: 3.58, Median: 3.82. Conclusions: The utilization of patient specified goals along with physical therapist and physiatrist assessments to guide targeted botulinum toxin injections followed by physical therapy was determined to produce clinical significant improvements based on the PSFS scores before and after combined interventions. Prior research showed that in the PSFS, a minimally clinically important difference (MCID) >3.00 demonstrated a clinically meaningful functional improvement. Based on this study, we recommend incorporating PSFS scores and close collaboration between physical therapists and physiatrists when treating spasticity in chronic neurological disorders.

 Pattern of traumatic spinal cord injury in a tertiary rehabilitation center of Northern India



Anil K. Gupta, Dileep Kumar, Mohit K. Srivastava, Sudhir Mishra, Ganesh Yadav

Objectives: To assess the epidemiological pattern and clinical profile of traumatic spinal cord injury and determine gender-wise association with clinical profile. Design: A cross-sectional study was conducted in department of PM&R. King George Medical University, Lucknow and 68 patients of traumatic spinal cord injury were enrolled. The sociodemographic information and clinical profile of the patients was collected with the help of a pre-designed tool and all relevant data was gathered accordingly. Results: The most common age group affected in traumatic spinal cord injury in our setting was 15-30 years (39.7%). majority (83.2%) of the study participants were males and fall from height (73.5%) was the most common cause of injury. most of the patients (55.9%) were of AIS Grade A. 68.4 percent males and 100 percent females had fall from height as the most common cause of injury and this association was statistically significant (P< 0.05). Conclusions: The study has revealed the epidemiology and clinical profile of traumatic spinal cord injury which will be beneficial in planning and executing strategies for its prevention.

 Patterns of urodynamic abnormalities in patients with traumatic spinal cord injury



Musab Bin Noor

Objectives: To determine types and frequency of Lower Urinary Tract abnormalities utilizing Urodynamic Studies in traumatic Spinal Cord Injury patients in an indoor Spinal Cord Injury Rehabilitation ward of a tertiary care rehabilitation hospital in Pakistan. Design: A 1 year PROSPECTIVE Study was carried out using non-probability consecutive sampling of patients at Spinal Injury Ward Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan. Subjects of both genders were chosen after informed consent, with a history of Traumatic Spinal Injury for at least 3 months. The 3 month cutoff was selected to cater for resolution of Spinal Shock. The American Spinal Injury Association or ASIA impairment scale was used to classify patients in terms of neurological level and severity. All patients underwent Urodynamics testing in Electrodiagnostics Department, AFIRM on Pico Smart 3000 manufactured by Medica, Italy. Patients with Urinary Tract Infections, asymptomatic bacteriurea and renal, ureteric or vesical calculi were excluded from the study. Recorded data were analyzed using statistical program IBM SPSS V 23. Results: 73 patients were included in the study. The mean age was 33, (SD + 12.4). Males were 62 (84.9%) while females were 11 (15.1%). Thoracic injury was seen in 63 patients (86.3%), Cervical in 8 (10.9%) and Lumbar in 2 (2.73%) patients. Injuries were complete in 49 (67.12%) cases. The commonest bladder abnormality was Detrusor Sphincter Dyssynergia (DSD) with Terminal Detrusor Overactivity in 38 (52%) cases, followed by DSD with Phasic Detrusor Overactivity in 16 (21.9%) and Acontractile Bladder in 15 (20.5%) cases. 4 cases (5.47%) showed Normal Bladder studies. Conclusions: Urodynamic evaluation in SCI patients is crucial in identifying and managing various types of Lower Urinary Tract dysfunction. My study reveals that Spinal Cord Injury does not result in a single, uniform pattern of neurogenic bladder, but can cause a spectrum of lower urinary tract abnormalities.

 Perceived facilitators or barriers to adapted sport for poststroke individuals



Lisiane A. Maia, Elgison L. dos Santos, Maria de Fátima F. Vara, Ana Paula C. Loureiro

Objectives: In the current literature it is well established that physical exercise plays a fundamental role in the prevention and recurrence of noncommunicable chronic diseases such as stroke. Adapted sport (educational, participatory or paralympic) has emerged as an important complementary means in the recovery of people with disabilities as individuals after stroke. The aim of this study was to evaluate the participation rate of chronic stroke patients in paralympic modalities and / or participation sport. Design: A descriptive study was conducted with post-stroke patients who were undergoing physical therapy, using the ICF Activity and Participation component through questions formulated for this study: 01) How much your family motivates you in relation to the practice of a sport activity? 02) Have you ever been encouraged by your physiotherapist to do some kind of sport? 03) Do you participate in any government-sponsored sports health promotion program? The respective equivalences of the data obtained for the qualification used in the ICF were performed, which ranges from 0-4. Results: The study included 52 individuals after stroke; average age 58 ± 15 years; post-stroke time 42 ± 51 months, residents of the city of Curitiba-Brazil. None of the patients perform any kind of sport. Regarding motivation 25% of the sample reported never having been motivated by the family and 50% reported no motivation from their physiotherapists to participate in sports activities, both in participation and paralympic modalities. Regarding the participation of activities offered by the government (11%) do not participate because of accessibility and (36%) reported not knowing any health program focused on sports. Conclusions: There is a need for greater dissemination of participation sports and sports so that professionals know and encourage the inclusion of this population as a means of inclusion, socialization, mortality prevention, risk of comorbidities and recurrence of stroke.

 Peripheral nerve degeneration early after acute, motor complete spinal cord injury



Christopher White, Oksana Sayko

Objectives: Describe the temporal electrophysiologic changes in the peripheral nervous system (PNS) following an acute, motor complete SCI to determine best time of intervention to preserve the PNS. There has been research aimed at discovering treatments to repair spinal cord after SCI. Less research has gone into understanding the peripheral nerve degeneration and how nerve function can be preserved. Studies in chronic SCI have shown degenerative findings, but little is known of when exactly the degeneration starts and how to prevent it. Design: Three patients with cervical and thoracic spine motor complete injuries (American International Standards A and B) were recruited. Serial EMG/NCS at one, three, six, and nine months post injury were performed with the purpose to characterize nerve and muscle electrophysiological changes within the first year after the SCI. EMG/NCS included fibular and tibial motor nerve conductions, stimulated single fiber (SSF) EMG, and needle EMG of selected lower extremities muscles. Results: Nerve conduction studies showed consistent amplitude drop of the tibial and fibular nerves by nine months post injury in all subjects. SSF EMG had normal jitter analysis. Abnormal spontaneous potentials were present as early as one-month post injury and continued to 9 months post injury. Conclusions: Data is consistent with previous studies of chronic SCI patients showing degenerative changes of the PNS distal to the SCI. This study determines that degenerative changes in peripheral nerves and muscle denervation below the level of SCI start as early as one month post injury; spontaneous potentials indicate active denervation to nadir around 3-6 months post injury. These findings indicate that treatment interventions to preserve the peripheral nerves should be introduced as early as 1 month after injury.

 Peripheral neuropathy induced by ciprofloxacin improved with goal directed inpatient rehabilitation



Neha Shah, Noel Rao, Shaheen Jadidi

Case Diagnosis: Ciprofloxacin induced peripheral neuropathy. Case Description: 67-year-old female with history of recurrent pseudomonas pneumonia, on chronic supporessive therapy with ciprofloxacin for one year, presented with gradual onset bilateral lower extremity weakness associated with parasthesias. She required total assistance for standing trial. She had decreased proprioception, and diminished light touch/pinprick perception below her knees, bilaterally. History reveals chronic low back pain controlled with oral NSAIDs. Patient reportedly took celebrex 200mg BID. Imaging was remarkable for cervical canal stenosis, but did not account for presenting symptoms. Ciprofloxacin was discontinued, and patient underwent 14 days of intensive inpatient rehabilitation. Weakness gradually improved. She made improvements with gait and transfers. She regained some sensation in her lower extremities, though persisted to have sensory deficits. At discharge she was able to walk 150' with a rolling walker, with bilateral AFOs. She was safely discharged home to family at modified- independent level. Discussions: We report a case of ciprofloxacin-induced persistent peripheral neuropathy. Our patient had been on ciprofloxacin for several months before onset of neuropathy. This is in contrast to data suggesting that neuropathic symptoms usually occur within 1 week after the start of treatment. Patients aged over 60 with renal disease have decreased clearance of fluoroquinolones. Our patient did not have decreased renal function, but did have chronic low back pain for which she took NSAIDs regularly. Neurologic adverse effects with ciprofloxacin have been described with concomitant use of NSAIDs. All NSAIDs, except acetylsalicylic acid, enhance GABA receptor inhibition that has been attributed fluoroquinolones. Fluroquinolone induced neuropathy can be improved with goal-oriented intensive inpatient rehabilitation, utilizing various modalities including adaptive equipment, bracing, and physical therapies. Conclusions: Fluoroquinolone-use related peripheral neuropathy symptoms can be debilitating but improved with an intensive rehabilitation program. Physiatrists should be aware of fluoroquinolone-induced peripheral neuropathy and association of concomitant use of NSAIDs when prescribing medications.

 Persistent ataxia and apraxia in a patient with legionella encephalitis following legionnaires disease: A case report



Mina K. Shenouda, Brian D. Greenwald, Sara Cuccurullo

Case Diagnosis: The patient is a 30-year-old previously independent, healthy woman who developed legionella encephalitis characterized by behavioral disturbances, ataxic/apraxic movement disorder, and dysarthric speech following Legionnaires disease. Case Description: Patient initially presented to an acute care hospital where she was treated for bilateral pneumonia. Urine legionella antigen was positive and cerebrospinal fluid studies showed elevated legionella immunoglobulin. Magnetic resonance imaging (MRI) brain showed possible infarct in the corpus callosum, and repeat MRI showed resolution of previous lesion with new possible microhemorrhages in cervical spine. The course was complicated by thrombocytopenia, transaminitis, and rhabdomyolysis leading to renal failure requiring hemodialysis. Patient was stabilized and was discharged to acute inpatient rehabilitation facility and found to be dependent for transfers, activities of daily living, and ambulation. She was managed by a multidisciplinary rehabilitation team. Despite comprehensive treatment, patient's ataxic motor dysfunction persisted, and the patient was discharged to a long term extended recovery unit. Discussions: Legionnaires disease is an acquired gram negative infection of the lung. Neurologic sequelae are noted in the literature to include confusion, ataxia, encephalopathy, and demyelinating encephalomyelitis. Exact pathophysiology is unclear; however, it is thought to be endotoxin or immune mediated, responsible for micro-hypoperfusion of brain tissue. Reversible lesions on MRI were also described, contributing to the intricacy of the disease. In this case, corresponding brain lesions causing the ataxia and apraxia are difficult to demonstrate using MRI, and therefore would be attributed to the Legionella encephalitis. Patients require swift diagnosis, and optimized medical and rehabilitation care. Conclusions: Neurologic sequelae of legionnaires disease can vary greatly and are poorly understood. Our patient's unique presentation of legionella encephalitis with persistent ataxia, apraxia, and dysarthria will contribute to the medical knowledge and understanding of this debilitating condition.

 Persistent hemichorea-hemiballismus induced by nonketotic hyperglycemia and hemorrhagic strokes: A case report



Eytan Rosenbloom, Steven J. Mann, Getahun Kifle

Case Diagnosis: Persistent Hemichorea-Hemiballismus Induced by Non-Ketotic Hyperglycemia and Hemorrhagic Strokes. Case Description: 63-year-old female with a past medical history of hypertension and type 2 diabetes presented with profound right sided hemichorea-hemiballismus. She was admitted two months prior for hemichorea-hemiballismus induced by non-ketotic hyperglycemia and hemorrhagic stroke. Initially, these movements were limited to the right shoulder; however progressed to involve the entirety of the right upper limb, lower limb and jaw. MRI on prior admission showed a hyperintense signal in the left caudate and lentiform nucleus, subacute right cerebellar hemorrhage and multiple remote microhemorrhages in the basal ganglia, thalamocapsular region and cerebral hemispheres. This admission, MRI revealed a hyperintensity of the left caudate head and lentiform nucleus, more prominent than on prior admission. Throughout hospitalization, glucose levels were adequately controlled and HgbA1C improved from 15 to 10 in less than two months. Symptoms failed to completely resolve with haloperidol, diazepam, quetiapine and tetrabenazine. The patient was subsequently transferred to an acute rehabilitation unit. Discussions: Hemichorea-hemiballismus is a rare hyperkinetic, irregular, wide amplitude movement disorder of the limbs. Strokes followed by non-ketotic hyperglycemia represent the most common etiologies of this condition. While hyperglycemic induced hemichorea-hemiballismus is generally benign and resolves with adequate glycemic control, recovery time after stroke is often more variable and dependent on the nature and location of the lesion. Anti-dopaminergic medications are considered effective first-line agents for symptomatic relief. This patient's symptoms were surprisingly refractory to both anti-dopaminergic medications and improved glucose regulation. This case uniquely allows the study of recovery time and prognosis in hemichorea-hemiballismus when induced by both non-ketotic hyperglycemia and stroke. Conclusions: Though hemichorea-hemiballismus induced by non-ketotic hyperglycemia generally resolves with adequate glycemic control, concomitant extensive cerebrovascular disease may impede its recovery and worsen the prognosis.

 Persistent limb paralysis after herpes zoster infection: A rare complication



Mona M. Ahmad

Case Diagnosis: Postherpetic upper extremity paralysis. Case Description: This patient is a 75 year old male who presented to our clinic with right arm pain and weakness. Three weeks prior to presentation while playing with his grandson he noticed pain in the right shoulder which continued to worsen. Two weeks later, patient noted increasing weakness in the right shoulder. Exam revealed decreased strength in right shoulder abduction and elbow flexion. No signs of tendon impingement were present. Right biceps and brachioradialis reflexes were hypoactive. Sensation was intact. Skin inspection revealed vesicular eruption in the right C4 dermatome. Cervical spine MRI was significant for spondylosis and mild canal stenosis at C6/C7. Shoulder MRI was unrevealing. EMG revealed evidence of denervation in C5/C6 distribution. Varicella zoster virus (VZV) titers were positive for infection. Diagnosis was consistent with cervical radiculopathy secondary to herpes zoster. Discussions: VZV infection is associated with development of varicella (chickenpox) and herpes zoster (shingles). VZV becomes dormant within sensory ganglia after primary infection and reactivation leads to herpes zoster. Motor paralysis upon reactivation is rare as the virus is found in sensory ganglia, and only 3-5% of cases show motor findings. Generally 50% of patients have complete recovery in strength with physical and occupational therapy and antiviral therapy. Despite receiving these therapies, our patient has persistent paralysis and pain of the right deltoid muscle more than 10 months after initial presentation. Presentation after resolution of skin findings would have made diagnosis more challenging. Conclusions: Though rare, herpes zoster infection can lead to acute onset of limb paralysis and pain. Careful history taking and exam are crucial in making this diagnosis, and VZV should remain part of the differential in patients with this presentation. Early intervention and initiation of antiviral therapy as well as physical and occupational therapy are necessary to improve outcomes.

 Persistent thiamine deficiency after repletion causing functional decline



Rosa M. Pasculli, Malaka Badri, Raj Panchal, Anna Weingart, Jung Ahn

Case Diagnosis: Persistent thiamine deficiency after bariatric surgery causing ataxia and functional decline. Case Description: A 21 year old female six weeks status post sleeve gastrectomy presented with one week of blurry vision, bilateral lower extremity weakness, and impaired gait. Initial exam was significant for horizontal nystagmus and wide, ataxic gait. Brain MRI was consistent with Wernicke's encephalopathy and high dose IV thiamine was started; thiamine level was 32 nmol/L (normal 70-180). After nine days of parenteral repletion, repeat level was 188. Patient was admitted to acute rehab on oral thiamine, ambulating 100 feet with assistive device (AD) and contact guard assist. With therapies, ambulation improved to 600 feet without AD and supervision. On day 12, patient had functional decline to 80 feet ambulation with increased unsteadiness. High dose IV thiamine was resumed given concern for persistent malabsorption; repeat thiamine was 89. Her functional status improved with parenteral thiamine and therapies; upon discharge she ambulated 400 feet independently. Discussions: Bariatric surgery can precipitate micronutrient deficiencies in vitamin B12, iron, and thiamine, which may cause altered mental status, peripheral neuropathy, and ataxia. These can contribute to functional deficits and may warrant an acute rehabilitation stay. These patients are at risk for malabsorption and can return to a deficient state even after repletion. Given the parallel rise in obesity and bariatric surgeries, it is essential for rehab providers to recognize these vitamin deficiencies, which are not described in the rehabilitation literature. Early symptoms of thiamine deficiency include nausea and constipation, but can progress to Wernicke's encephalopathy (confusion, ataxia, ophthalmoplegia); this may manifest as a change in functional status. Concomitant vitamin repletion and participation in therapies is key to ensuring return of function. Conclusions: In patients with functional deficits related to vitamin deficiency, immediate recognition of symptoms, vitamin repletion, and consistent participation in therapies are vital for patient recovery.

 Physical activity prior stroke is of importance for stroke outcome



Katharina Stibrant Sunnerhagen, Malin Reinholdsson, Annie Palstam

Case Diagnosis: Physical inactivity is considered a pandemic. Regular physical activity seem to lead to a less severe stroke and better long-term outcome. There is a gap in knowledge if pre-stroke physical activity (PA) influences cognition after stroke. The hypothesis of this study is that pre-stroke PA could have a positive impact on cognition early after stroke. The objective is to investigate if age, sex, smoking, diabetes, pre-stroke PA, new and previous atrial fibrillation, previous TIA and protective treatments such as statin or hypertension treatments could predict normal cognition in patients with first stroke during their stay at the stroke-unit. Case Description: Physical activity pre-stroke in Gothenburg (PAPSIGOT) is a cross-sectional study. Data were retrieved from two Swedish stroke registers; the National Swedish Stroke Register (Riksstroke) and a local stroke register (Väststroke). To link the two registries together, the Swedish personal identification numbers were used and anonymous data were received. Discussions: The study included 1397 patients with a mean age of 71 years (range 20-99), 42.2% women and the majority with ischemic stroke (92.3 %). Cognition was impaired (MoCA≤25) in 57.3 %, although 87.2% of the patients had a mild stroke (NIHSS 0-5). Almost half (44 %) were physically inactive. The binary regression analyses concluded the result where higher PA (OR=1.58), younger age (OR=0.96), no diabetes (OR=0.65) and no atrial fibrillation (OR=0.74) could predict 12.3% of the cases of preserved normal cognitive function after stroke. Conclusions: The results suggests that PA and younger age could result in not only in less severe stroke but also preserved cognitive function. In this study, PA - such as walking at least 4 hours/week, was beneficial. PA not only protects from stroke but also increases the chance having a less sever stroke.

 Physical activity and exercise recommendations for older people living with HIV: A protocol for a scoping review



Levin Chetty, Saul Cobbing, Verusia Chetty

Case Diagnosis: Older people living with HIV (OPLWH) are expected to live longer in the era of antiretroviral treatment, but they are at risk for developing various health complications. Because senescence is an inherent process that can be accelerated by HIV, it is important to identify strategies that can modify this phenomenon. Emerging data suggests that physical activity can have a positive impact on viral replication and immune system of people living with HIV. Case Description: The study is a scoping review based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) methodology. It will be guided by the research question validated by the amended population-concept-context framework according to the Joanna Briggs Institute methodology for scoping reviews. Relevant peer reviewed primary studies will be extracted from various electronic databases. The Mixed Method Appraisal Tool (2018) will be applied to assess the quality of the studies. Discussions: The findings gathered will provide an overview of the research together with than an assessment of the quality of studies. The authors will produce a narrative report which will summarize the extracted data. It will also be depicted in the final write-up using a thematic approach that allows for flexibility in the capturing of data, because it may be possible for the review to yield unknown concepts. Gap identification will detect areas, such as countries that lack data on outcomes for OPLWH, and if there is a paucity of data on significant physical activity prescription guidelines for OPLWH. Conclusions: The evidence gathered from the selected studies will be discussed in relation to the research questions using a narrative to identify and explore emergent themes. The review will provide a baseline of evidence on exercise and physical activity interventions for OPLWH. It will highlight gaps regarding the use of exercise and physical activity as an effective rehabilitation tool for OPLWH.

 Physical disability, a mark of cain? The impact of disability stigma on access to rehabilitation services



Elohor I. Jete

Case Diagnosis: More than a billion people worldwide live with a disability. The barriers to rehabilitation – funding, family support and staff availability are well known but Stigma is often not spoken about despite it negatively affecting every facet of life of people with disabilities. The effects of stigma on a person's view of their physical disability, how it acts as a barrier to accessing rehabilitation services and how these barriers can be overcome are discussed. Case Description: The database PubMed and SAGE journals were used in order to include a comprehensive literature review. The author also uses her mother's personal experiences to provide examples of how stigma affects a person's view of their physical disability. Discussions: Concealment for fear of being stigmatised causes people to miss opportunities and support. Stereotyping and wrong perceptions of people with disabilities as 'helpless', an economic drain on society, or as a sign of ill omen associated with witchcraft or punishment from God contributes to stigma. Stigma associated with devices that signify a loss of function and stigma patients experienced from healthcare professionals acts as a barrier to accessing rehabilitation services. Patients who fail to respond to treatment can be unpopular with healthcare professionals and therefore treated differently. To overcome stigma the media and care professionals should use words that empower people with disabilities who should be seen as functional members contributing positively to society. Conclusions: Education is crucial to change attitudes that promote stigma and conscious or unconscious biases. There is more need to be focussed on what people with disabilities can do rather than what they cannot do. Rehabilitation medicine should embrace the biopsychosocial model more to reduce stigma, negative views and misconceptions.

 Physician perceptions of battle field acupuncture in the North Florida/South Georgia VA healthcare system



Gail Castaneda, Sergio Romero, Mi Jung Lee, Jaewon Kang, Stephen Mudra, Ted Gingrich, Charles Levy

Objectives: To assess the attitudes of active and non-active physician providers regarding battlefield acupuncture and integrative medicine at a single VHA facility. Design: Cross-sectional study design. Results: Sixty-six of 87 physicians responded to our survey (76% response rate). Of these, 37 (57%) were providing BFA at the time of the survey (active providers). Active providers treated an average of 121 (SD = 208) patients with BFA in the previous year and estimated that 71 % of their patients experienced meaningful pain relief. Sixty-five percent of providers believed that the duration of pain relief is two weeks or less; however, 81 % of providers are scheduling return appointments at intervals of 3-4 weeks or greater. Physicians reported their attitudes toward integrative medicine prior to BFA training and after training (time of the survey). Initially, 5% described themselves as highly skeptical, 18% were skeptical, 17% were neutral, 38% were enthusiastic, and 23% were highly enthusiastic. At the time of the survey, none were highly skeptical, 2% were skeptical, 12% were neutral, 52% were enthusiastic, and 35% were highly enthusiastic. Conclusions: Exposure to BFA training and experience practicing BFA resulted in reduced skepticism and increased enthusiasm to integrative medicine as a whole. Although active providers feel that 71% of their patients get pain relief from BFA, a majority thinks this lasts no more than two weeks, while a majority is scheduling follow up appointments at 3-4 weeks or later. BFA is an alternative treatment for pain management that many VA physicians deem useful and effective, but there appears to be a disconnect between the duration of effect and the frequency of appointments.

 Polyneuropathy, organomegaly, endocrinopathy, monoclonal proliferative disorder, skin changes syndrome masquerading as chronic inflammatory demyelinating polyneuropathy in HIV: A rare case report



Yashesh A. Parekh, Vivek Nagar, Apoorva Jayarangaiah, Michelle Stern

Case Diagnosis: 49-year-old male with a history of HIV, on antiretroviral treatment with undetectable viral load, presented with a four-month history of progressive weakness and paresthesias. Case Description: Prior to admission, the patient regressed from independent ambulation to ambulation with a rollator. Preliminary workup was remarkable for thrombocytosis and an abnormal SPEP. EMG showed severe, demyelinating, sensorimotor polyneuropathy. A team of neurologists, hematologists, and physiatrists, established that his weakness was due to chronic inflammatory demyelinating polyneuropathy (CIDP) versus POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal proliferative disorder, skin changes) syndrome. He was transferred to acute inpatient rehabilitation and given IVIG treatment for 4 days, which was ineffective. At this time bone biopsy revealed abundant plasma cells and VEGF levels were elevated. The diagnosis of POEMS syndrome was made. He was given steroids for 4 days and has now started chemotherapy while awaiting a stem cell transplant. Discussions: As both POEMS syndrome and CIDP present as rare etiologies of chronic progressive polyneuropathies with sensorimotor involvement, electrodiagnostic studies can aid in accurately differentiating between these rare syndromes. In this context, POEMS syndrome shows an overall greater amplitude reduction of distal motor and sensory potentials, more severe involvement of peroneal nerves, and less alterations of conduction shown with normal distal latencies. Additionally, POEMS syndrome in the setting of HIV is an exceedingly rare etiology of polyneuropathy. As variants POEMS syndrome have been found to have a worse prognosis with an associated HIV infection, a multidisciplinary approach to management should be considered. Conclusions: Treatments effective for CIPD (i.e. IVIG and plasmapheresis) are ineffective in treating POEMS syndrome. Electrodiagnostic testing is a key consideration in differentiating these rare etiologies for polyneuropathy. Correspondingly, a prompt and accurate diagnosis significantly contributes to early treatment as well as better neurophysiologic recovery and functional outcomes, especially considering the poor prognosis of POEMS syndrome with comorbid HIV infection.

 Pompe disease related to polyneuropathy, about a clinical case in Colombia



Nel D. Lara Arroyo, Carlos Rangel Gómez

Case Diagnosis: Glycogen storage disease type II or Pompe disease, is an autosomal recessive metabolic disorder which damages muscle and nerve cells. It is caused by an accumulation of glycogen in the lysosome due to deficiency of the lysosomal acid alpha-glucosidase enzyme. It has two forms: infantile-onset disease, and a late-onset type of Pompe disease, usually related to myopathy. The alteration of nerve fibers is not typical of this disease, however there are some reported cases of co-existence of polyneuropathy in Pompe disease. Case Description: Our case is a 50-year-old female patient, with a clinical history of distal weakness, with difficulty walking, weakness of dorsiflexers and atrophy, extending to upper limbs with motor and sensory alterations. In the presence of these symptoms electromyography and neuroconduction studies were conducted, which resulted in decrease in motor amplitudes, altered nerve conduction velocities and absence of sensitive potentials regarding a mixed polyneuropathy, with the presence of myopathic units in some proximal muscles. Discussions: Due to the incidence of pompe disease in the Colombian population, and the presence of some cases reported with polyneuropathy, we decided to perform a filter paper test for Pompe disease, obtaining altered Results that showed a deficiency in the acid alpha glucosidase enzyme. We also carried out tests on leukocytes with samples of 0.08 (nmol / mgprot / h) with reference values of (0.4 - 1.43), and abnormal GAA gene sequencing analysis, (Exon 9 c.1375G >A). Conclusions: Enzyme replacement therapy was initiated with stabilization of the disease evidenced in functional tests: time up and go test, getting up and sitting 5 times, and calculating speed in 10 meters, without finding significant changes in 6 months of evaluation. Our Results support the theory of involvement of nerve cells and perineurium in some patients with pompe disease, which may present with polyneuropathy.

 Popliteal entrapment syndrome: A case of proximal tibial neuropathy after isolated popliteus muscle overuse injury



Yeocheon Yun, Jong Ha Lee, Hee-Sang Kim, Dong Hwan Yun, Jinmann Chon, Yunsoo Soh, Myung Chul Yoo, Yong Kim, Yun Kyung Seo, Seona Chae

Case Diagnosis: Popliteal Entrapment Syndrome: A Case of Proximal Tibial Neuropathy after Isolated Popliteus Muscle Overuse Injury. Case Description: A 75-year-old man visited hospital for left foot pain and weakness started about four months ago. Before the pain started, he played “Jegi-chagi”, a Korean traditional game, for one week with his left leg. He had a left popliteal painful swelling. The pain at left plantar foot started around one month later. At the time of visiting hospital, the left calf was generally soft and had no tenderness. Left plantar foot pain scored 7 in visual analog scale. The light touch sensation was diminished on his left plantar foot. He had 4 of 5 strength of big toe dorsiflexion and 2 of 5 strength of 2nd to 5th toes flexion and abduction. Discussions: Magnetic resonance imaging (MRI) of left knee showed edema and enlargement of the left popliteus muscle with diffuse high signal intensity at T2-weighted image. MRI of left ankle showed unremarkable findings. Nerve conduction study showed decreased compound muscle action potential (CMAP) amplitude and delayed CMAP latency in the left tibial nerve. The amplitude of sensory nerve action potential was unobtainable in the left medial plantar nerve and lateral plantar nerve. The needle electromyography study showed abnormal spontaneous activities and discrete recruitment patterns at left abductor digiti quinti, abductor hallucis and tibialis posterior. Under the basis of these Results, we confirmed his diagnosis with proximal tibial neuropathy caused by isolated popliteus muscle injury. Isolated popliteus injury typically occurs after external rotation of slightly flexed knee or a twisting injury. Conclusions: Playing “Jegi-chagi” consists of repetitive motion of internal rotation of the tibia on the femur. It might cause overuse of popliteus muscle. Our case is rare and unique in that proximal tibial neuropathy was caused by compression related to mass effect from the enlarged popliteus muscle.

 Posterior reversible encephalopathy syndrome and acquired myotonia following Roux-en-Y gastric bypass



HeeRak Kang, Margaret A. Turk, Shernaz K. Hurlong

Case Diagnosis: Posterior Reversible Encephalopathy Syndrome And Acquired Myotonia Following Roux-en-Y Gastric Bypass (RYGB). Case Description: 41 year old patient with RYGB surgery 8 months prior who presented with lower extremity weakness, truncal ataxia, and no cognitive changes to indicate Wernike Encephalopathy. On exam there was decreased strength in her lower extremities bilaterally, percussion myotonia, a wide based gait and truncal ataxia. Labs showed vitamin deficiencies of vitamins A, D, thiamine, and pyridoxine. All other levels were normal. An MRI showed bioccipital subcortical FLAIR signal, right more than left, suggestive of PRES. Electrodiagnosis was done to evaluate progressive lower extremity weakness in the setting of pain and muscle cramping that showed electrophysiologic evidence of myotonic discharges without neuropathy. Genetic testing for neuromuscular disease was negative. During her inpatient rehabilitation facility (IRF) admission the patient progressed with mobility and coordination to discharge home but continued to have truncal ataxia and percussion myotonia. Discussions: PRES with coexisting acquired myotonia after RYGB has not been reported and may be related to multiple vitamin deficiencies. She had no history of hypertension or hypertensive episodes prior to findings of PRES. Her bypass had been complicated by pouch stenosis and inability to eat, eventually requiring total parenteral nutrition (TPN). She reported compliance with multivitamins but had inadequate absorption of water and fat soluble vitamins. TPN alone was not sufficient to replete her deficiencies and she required additional IV and IM supplementation to make functional progress. There was no evidence on EMG to indicate any usual vitamin deficiency neuropathy associated with RYGB. Conclusions: PRES should be in the differential for patients who present with central neurologic deficits after RYGB. Electrodiagnosis is helpful in delineating underlying abnormalities related to vitamin deficiency. This patient responded to comprehensive therapeutic interventions offered in IRF level of care.

 Posterior reversible encephalopathy syndrome presenting with prolonged left hemiparesis due to isolated brainstem lesion



Jason Lou, Marika Greiff

Case Diagnosis: Posterior Reversible Encephalopathy Syndrome (PRES). Case Description: This is a 30-year-old female with a history of HTN and migraine headaches who presented to the ED with headache, speech difficulties, and left-sided weakness. Her systolic blood pressure was noted to be 200+; MRI showed non-hemorrhagic enhancing midbrain/pontine lesion. Infectious, rheumatologic, and inflammatory workup returned unremarkable for a specific cause. After her blood pressure was controlled, repeat MRI brain showed decreasing size of brainstem ischemia. Given her history of HTN and radiologic improvement with blood pressure management, diagnosis of Posterior Reversible Encephalopathy Syndrome (PRES) was made. She was admitted to acute rehabilitation at a minimum assist level for ADLs, utilizing a rolling walker for ambulation due to 0 strength for dorsiflexion at the left ankle. She had continued left hemiparesis after completing rehabilitation, however was discharged home at a modified independent level for her mobility, transfers, and self-care. Discussions: This is a rare case of a non-traumatic brainstem injury secondary to PRES, which falls into a group of poorly-defined radiologic/clinical syndromes that also includes Reversible Posterior Leukoencephalopathy Syndrome (RPLS) and Hyperperfusion encephalopathy. PRES typically involves lesions in the posterior cerebral hemispheres, with symptoms of headache, confusion, visual symptoms, and seizures. Supporting diagnostic features include resolution of radiologic findings with blood pressure management. Pathogenesis is thought to be related to cerebral auto-regulatory failure and endothelial dysfunction. Conclusions: This is an atypical case of PRES presenting with isolated brainstem lesion, focal neurologic deficits, and prolonged disability greater than 6 weeks from onset. Prognosis for PRES is typically good, with symptoms being fully reversible within a period of days to weeks.

 Posterolateral knee pain due to exostosis resulting in nerve impingement: A case study



Sonia Thakur, Jennifer Paul, Victoria Kung

Case Diagnosis: Fibular head exostosis with common peroneal nerve entrapment in a 56 year old male with a history of hereditary exostosis, right lateral meniscal tear and knee osteoarthritis. Case Description: A 56 year old male presented for evaluation of new onset right posterolateral knee pain. His exam was notable for point tenderness and allodynia over the posterolateral aspect, and absence of strength and sensory changes. Work up resulted in a right knee radiograph, which was revealing for a large exostosis involving the fibular head. Subsequent MRI of the right knee revealed merged proximal and fibular osteochondromas at the proximal tibiofibular joint posteriorly. In addition he underwent viscosupplementation to elucidate the contribution of knee osteoarthritis to his pain pattern. It did not result in improvement of posterolateral knee pain, although chronic diffuse knee pain improved. Eventually he underwent a radical resection of the right fibular exostosis which resulted in the resolution of his pain. It is notable that intraoperatively, neurolysis of the common peroneal nerve was performed to release it from the surrounding mass. Discussions: The differential for posterolateral knee pain usually encompasses knee osteoarthritis or meniscal tear. A common peroneal nerve entrapment is often not a consideration. However, our patient's relatively common presentation led to a unique diagnosis after imaging revealed exostoses with location congruent with his pain. Conclusions: Work up for knee pain, while considering arthritis or meniscal injury should also take into account possibility of a local mass effect due to the presence of exostoses and subsequent nerve entrapment.

 Postural orthostatic tachycardia syndrome secondary to traumatic brain injury: A case report



Matthew Puderbaugh, Mahmood Alatbee, Michael V. Nguyen, Min Jeong P. Graf

Case Diagnosis: Postural Orthostatic Tachycardia Syndrome secondary to Traumatic Brain Injury. Case Description: 40 year old male with a past medical history with a mild traumatic brain injury (TBI) approximately 3 years prior with good recovery, who was involved in a motor vehicle collision. No loss of consciousness or amnesia. The patient had immediate sensation of head pressure and fatigue. He also developed decreased concentration, word finding difficulty, vertigo, disequilibrium, visual overstimulation, photophobia, phonophobia, sleep impairment, and mood changes. While he was participating with TBI interdisciplinary program, he was noted to have difficulty with body temperature regulation, exertional activity intolerance and mild elevations of his blood pressure and pulse. He was referred for Autonomic Electromyography which showed an increase of his heart rate of 29 beats per minute with head tilt test followed by vasovagal syncope, suggestive of Postural Orthostatic Tachycardia Syndrome (POTS). Endocrinology lab work up was negative. His exercise tolerance improved gradually with POTS exercise program and gradual return to activity. Discussions: POTS is a form of dysautonomia characterized by a heart rate increase of 30 or more beats per minute within the first 10 minutes of standing, in the absence of orthostatic hypotension. Many of symptoms related to POTS overlap with TBI symptoms and can be overlooked for patients with persistent TBI symptoms. Approximately 11% of pediatric patients with POTS reported sustaining a mild TBI within 3 months of developing their symptoms of POTS. It has been suggested that POTS is a poor prognostic factor in mild TBI recovery. Autonomic dysfunction including hyperadrenergic states or autonomic neuropathy caused by TBI may explain the POTS symptoms. Conclusions: This a case of POTS secondary to a mild TBI due to a motor vehicle collision. POTS can be considered as a type of autonomic dysfunction caused by mild TBI for patients with persistent symptoms.

 Predictive factors of neuro-orthopedic-disorders occurrence among vascular hemiplegics



Meryem Frigui

Objectives: The Neuro-orthopedic disorders (NOD) are the main complications in stroke progression. However, they haven't been enough studied in the literature. The main objective of our work is to determine the predictive factors of NOD occurrence. Design: This is a cross-sectional study over a period of 2 years from January 2017 to January 2019, including patients referred to the Department of Physical Medicine and Rehabilitation of Mahdia for a vascular hemiplegia. A multivariate analysis was used to determine the predictive factors of NOD occurrence. Results: Data were collected for124 patients with an average age of 60.79± 12.58 years and a sex ratio of 1.2 (M/F). Stroke was ischemic in 74% of cases and hemorrhagic in 26% of cases. The median time to stroke was 6 months (1-150) and the median duration to management in Physical Medicine was 3 months [1-9]. The NOD frequency in our population study was 66.9%. They are located at the upper limb level in 60.5% of cases and at the lower limb in 44.4% of cases. Predictive factors of NOD were: age 65 (OR=6.136; CI=2.147-17.535; p=0.001), the non- achievement of rehabilitation (OR=13.731; IC=4.687-40.223; P10-3), the presence of spasticity (OR= 4.423, CI=1.564-12.514, p=0.005) and persistence of bladder disorders (OR=3.62, CI=1.235-10.611, p=0.019). Conclusions: Our study, despite its limitations, is one of the few studies that have focused on the NOD among vascular hemiplegics. Also to our knowledge, no study has determined the predictive factors of their occurrence. Hence the originality of our work.

 Predictors of functional recovery after hight ICU for serious cranial trauma patients: A prospective study



Fernando Z. Arêas, Brenda Oliveira, Bruna Inocente, Roger Walz

Objectives: This study aimed to evalued which predictors are linked to the functional improvement of these patients after 72 hours of ICU discharge. Design: Prospective, transversal, observational study was carried out in two hospitals in Florianópolis, Santa Catarina, Brazil. Where data on patient characteristics and clinical data from 206 victims of severe TBI (Glasgow < 8) were collected. Having as inclusion criteria: patients admitted to the ICU with severe TBI. As exclusion criterion other neurological diseases associated. Results: Of the 206 patients, we had 96 (46.60%) deaths. The predictors of functional recovery were not related to age, gender, subarachnoid hemorrhage, pupil, injury prevalence, other associated trauma, GCE, delirium and GOS. Tendency to total functional dependence with predictors of Marshall Classification in type II lesion (p = 0.07) and ICU time (p = 0.07). Functional dependence was higher in patients who did not undergo neurosurgery (p < 0.05), traffic accident trauma (p < 0.05), ICU admissions for more than 30 days (p = 0.005) and patients who did not undergo surgery. had ICU physical therapy (p < 0.05). Conclusions: Submission to neurosurgery, trauma from traffic accidents, ICU stay for more than 30 days and physiotherapy in the ICU are predictors associated with the level of functional dependence of patients with severe TBI after 72 hours of ICU discharge.

 Predictors of pain disability among patients with chronic pain



Amanda McIntyre, Shannon Janzen, Swati Mehta, Jerome Iruthayarajah, Mitch Longval, Eldon Loh, Robert Teasell

Objectives: Chronic pain has been known to disrupt various aspects of a patient's life; the impact of chronic pain on life activities is often captured using the Pain Disability Index (PDI). The objective of this study was to identify predictors of pain disability in a sample of patients with chronic pain. Design: Individuals with chronic pain were recruited from a clinic in Ontario, Canada. Using a cross-sectional design, sociodemographic data and clinical health information were collected from patients. Additionally, the following outcome measures were completed: PDI, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder 7 item (GAD-7), Brief Pain Inventory (BPI) severity and interference, CAGE substance abuse screening tool, Anxiety Sensitivity Index (ASI), and Acceptance and Action Questionnaire (AAQ). Associations between all variables and the PDI were determined using stepwise linear regression modelling. Results: A total of 218 individuals (140 females) were recruited who had a mean age of 52.9±11.9 years and mean time since injury of 14.2±10.3 years. Time since injury, education, living arrangement, use of non-opioids, and substance misuse were not correlated with pain disability. In the subsequent stepwise model, only BPI pain interference (R2 change=0.532; p< 0.001) and age (R2 change=0.015; p=.015) were significant predictors of pain disability whereas gender, type of pain, pain severity, employment, cannabis use, morphine equivalent, GAD-7, PHQ-9, ASI and AAQ were not. The overall model fit was R2=0.542 (p=0.015). Conclusions: Clinicians should consider pain interference and age when treating chronic pain patients, as these were shown to significantly impact pain disability.

 Predictors of quality of life among individuals with spinal cord injury



Shannon Janzen, Amanda McIntyre, Swati Mehta, Sarah Caughlin, Eldon Loh, Robert Teasell

Objectives: The objective of this study was to identify predictors of quality of life (QoL) in a sample of individuals with SCI. Design: Individuals were recruited from a SCI outpatient clinic in Ontario, Canada. Sociodemographic data and clinical health information was collected. The following outcome measures were completed: Euro Quality of Life (EQ-5D) – overall health item; Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder 7 item (GAD-7); Rosenberg Self-Esteem Scale (RSE), Adult Dispositional Hope Scale (ADHS), Anxiety Sensitivity Index (ASI), and Acceptance and Action Questionnaire (AAQ). Associations between all variables and QoL were determined using stepwise regression modelling. Results: The sample consisted of 80 individuals (35 females) with a mean age of 59.4±13.2 years and mean time since injury of 12.3±13.3 years. Simple linear regressions demonstrated that all variables were significantly correlated with QoL except for time since injury (p=.944) and gender (p=.623). Significant sociodemographic variables were entered first in the stepwise regression model, followed by the outcome measures. The model showed that only PHQ-9 (R2 change=0.186; p=.001) and ADHS (R2 change=0.059; p=.039) were retained in the model as significant predictors of QoL whereas GAD-7, RSE, ASI, and AAQ were not. The overall model fit was R2=0.245 (p=.039). Conclusions: The results underscore how both depression and dispositional hope is associated with one's QoL. Continued research on interventions that reduce depression and increase hope may improve QoL in the SCI population.

 Prevalence of frailty and associated risk factors among Saudi community-dwelling older adults



Bader Alqahtani, Aqeel Alenazi

Objectives: To investigate the prevalence of frailty, and associated risk factors among Saudi older adults. Design: This is a cross-sectional study. A total of 486 community-dwelling older adults aged ≥60 years living in the Riyadh region were included in the study. This study took place from January 2018 to August 2019. Frailty prevalence was assessed with the Fried's frailty phenotype. Cognitive function was assessed by the Arabic Mini-Mental State examination. A multinomial logistic regression model was constructed to examine the association between sociodemographic characteristics and clinical risk factors and frailty. Results: The overall prevalence of pre-frailty and frailty were 47.3% and 21.4%, respectively. Frail participants were older, were more likely to live alone, had more chronic conditions, and had lower cognitive function. Conclusions: The prevalence of frailty the Riyadh region in Saudi Arabia was high compared to other populations. Future research should examine the consequences of frailty in this population.

 Prevalence of physical disability in patients with leprosy in the municipality of fernadópolis, SP



Paula M. Lucas, Flávio Henrique N. dos Santos, Amanda Oliva Spaziani, Talita Costa Barbosa, Raissa Silva Frota, Patrícia Michelassi Carrinho Aureliano

Objectives: To identify the degree of disability in patients with leprosy, infectious and chronic disease caused by Mycobacterium leprae, using the World Health Organization disability classification system in Fernandópolis, São Paulo, Brazil. Design: This is an epidemiological, descriptive and retrospective study, conducted through information collected in the database of the Notification of Disease Information System, also known as SINAN. Results: 208 cases were reported between 2012 and 2016, predominantly female (55.76%); white race (72.11%); age group from 43 to 60 years old (40.38%); educational level prevailed high school (55; 26.44%); urban dwellers (206; 99.03%); multibacillary form (170; 81.73%); In the diagnosis, the evaluation of the degree of physical disability was grade I (98; 47.11%), therefore being the most prevalent. The clinical dimorphic forms had a higher number of carriers (155; 74.51%). Conclusions: in the evaluation of the therapeutic scheme, the predominance of multidrug therapy / 12 doses (169; 81.25%) was observed. Treatment increased the proportion of people with World Health Organization grade 0 disability from 40.86% to 49.72%. Discussion: Leprosy is a kind of chronic, contagious disease that extends over a long time and is difficult to control. In addition, it may persist even after the end of treatment and is of great public health importance because of its disabling power. Leprosy is an infectious and chronic disease caused by Mycobacterium leprae, a mandatory intracellular parasite that has affinity for skin cells and peripheral nerves. The research was extremely important because it allows the characterization of the behavior of leprosy in the Brazilian city.

 Prevalence of spatial neglect poststroke: A systematic review



Peii Chen, Grigoriy Shekhtman, Emily Esposito

Objectives: To establish the prevalence of spatial neglect (SN) based on the side of brain damage and recovery stage post stroke. SN impedes rehabilitation progress, increases fall risks, slows functional recovery, and increases stress and burden in family caregivers. However, the estimation of SN prevalence varies widely across studies, ranging from 10% to 80%. Design: We conducted a systematic literature search in February 2019 using PubMed, CINAHL, PsychINFO and Web of Science databases. Search terms included “spatial neglect” OR “visual neglect” OR “hemineglect” OR “visuospatial neglect” OR “unilateral neglect” OR “spatial inattention” for “Title” OR “Abstract”. Studies selected for inclusion met predetermined criteria: (1) including stroke patients with right brain damage (RBD) as well as those with left brain stroke (LBD), (2) specifying numbers of individuals with SN after right brain vs. left brain stroke, (3) observational research (excluding intervention studies), (4) original research (excluding reviews or meta-analysis studies), and (5) full article available in English. Results: A total of 45 studies were identified for inclusion through the detailed search strategy. The total numbers of RBD vs. LBD patients were 3783 vs. 3362, and among them 23.1% had SN (left-sided vs. right-sided neglect = 31.7% vs. 14.5%). SN was most common (29.8%) in the acute care (14 studies) and rehabilitation hospitals (22 studies). Both settings showed 41.0% of RBD patients had left-sided neglect and 18.1% of LBD patients had right-sided neglect. SN was least common (16.6%) among community-dwelling survivors more than 1 year post stroke (1 study; left-sided vs. right-sided neglect = 20.0% vs. 12.5%). Conclusions: The present study established the overall prevalence of SN across sides of stroke, settings, and recovery stages post stroke to be 23.1% (31.7% after RBD stroke and 14.5% after LBD stroke). The prevalence rate decreases as time post stroke increases.

 Profound bilateral vertical gaze palsy in artery of Percheron stroke



Nitin Prabhakar, Priya Varma, Henry Huie

Objectives: Artery of Percheron Stroke. Design: A 52-year-old female without significant past medical history presented to an acute care hospital with sudden onset vision loss and dizziness and NIHSS score of 29. CTH and CTA were negative, but MRI of the brain revealed acute bilateral thalamic infarcts. She was treated acutely with tPA, aspirin and statin for secondary stroke prophylaxis. She was subsequently admitted to acute rehabilitation and noted to have a profound vertical gaze palsy, torsional nystagmus, dysarthria, and memory impairments. Based on imaging findings and clinical presentation, she was diagnosed with a cryptogenic Artery of Percheron (AOP) stroke. focused on memory, vestibular, and visual awareness strategies, and she made functional gains in both physical and cognitive domains by the time of discharge. Results: Bilateral thalamic strokes are a rare but well described phenomenon, and AOP occlusion has a reported incidence of 0.1% to 0.3% in ischemic strokes. Understanding the 4 major patterns of thalamic infarction can be useful in understanding the wide range of cognitive and motor impairments present in these patients. In AOP, there is a single dominant artery supplying bilateral medial thalami with variable contribution to the rostral midbrain. Vertical gaze palsies usually suggest some midbrain involvement due to lesion of the oculomotor nucleus and the rostral interstitial nucleus of the medial longitudinal fasciculus. Rehabilitation approaches focused on improving visual scanning and compensation may be helpful in improving gaze palsy deficits. Conclusions: There is a wide spectrum of clinical presentations in bilateral thalamic strokes. We present a case characterized by profound vertical gaze palsy due to AOP occlusion in acute rehabilitation. In this rare stroke syndrome, it is important to identify a patient's specific deficits and focus on targeted rehabilitation strategies.

 Prognosis and functional outcomes of white cord reperfusion syndrome following cervical fusion



Satyum Parikh, Anita Kou, Gaurish Soni

Case Diagnosis: White Cord Reperfusion Syndrome. Case Description: A 30 year old male with previous history of immune dysfunction underwent elective anterior corpectomy discectomy and fusion at C5-6 for symptomatic cervical stenosis originating from remote motor vehicle collision. No intraoperative complications were noted. Post operatively, however, the patient developed sudden onset bilateral lower extremity weakness and generalized hyperesthesia along with saddle anesthesia and signs of neurogenic bladder. Immediate MRI findings were grossly unremarkable and he was subsequently taken to operating room for hardware revision. The patient underwent hardware removal and re-implantation, again without intraoperative complications. His symptoms of lower extremity weakness persisted and repeat MRI findings then demonstrated White Cord Reperfusion Syndrome. Physiatry was subsequently consulted. He was recommended comprehensive inpatient rehabilitation after his deficits were noted to be consistent with C6 ASIA Impairment Scale D spinal cord injury. After a two week acute rehabilitation course, the patient was discharged home at a supervision level. Discussions: White Cord Reperfusion Syndrome is a rare but significant consequence of elective spinal procedures. Its etiology is based on rapidly increased blood supply to a chronically underperfused area. This complication may often mimic other conditions such as hardware failure or cord compression. In this particular case, hardware revision did not ameliorate symptoms of hyperesthesia, saddle anesthesia, or lower extremity weakness.There are few reported cases of white cord reperfusion syndrome, and these are centered upon diagnosis. There are currently no reported cases that document a patient's overall functional outcomes. Conclusions: This case furthers the literature involving white cord reperfusion syndrome after spinal procedures. The consequences, including the subsequent spinal cord injury demonstrated by this patient, have long term implications impacting overall functional quality of life. Treatment requires prompt diagnosis and long term follow up. The nuances and benefits of rehabilitation for these patients are indicated in this case.

 Program for the measurement of facial asymmetry



Javier González Damián, Gabriela Flores Mondragón

Objectives: The most recognized scale for the classification of Bell's palsy is the House Brackmann (HB) scale. The advantages of the HB scale are its reliability and short time of application that allows its use in the clinical context, the disadvantages are that it has high interobserver variability and low sensitivity to change. Although there are several scales for the classification of facial paralysis, it is necessary to have one with quantitative assessment, easy to use and practical for clinical application. In this work, a software for the analysis of facial asymmetry was programmed using a previously described method. Design: Prior authorization by informed consent and approved by the institute's ethics committee and following national standards of personal data security, photographs were taken of 40 controls and 40 patients with Bell's palsy (clinically diagnosed). Measurements of angular and radial asymmetry were obtained using a program developed in Matlab (The MathWorks, INC. 2017). The program requires the manual selection of 8 anatomical landmarks, in order to make the evaluation. Three different users were requested to perform the measurements and these measurements were also performed manually. Results: The interobserver variability was less than 1%, which is comparable to the intrinsic error of the facial asymmetry of the control group. The average time for the selection of the anatomical landmarks and obtaining the results was less than one minute. The difference between manual and semi-automatic measurement was about 5% and was not significant (p < 0.01). Reproducibility of the measurements using the software was near 98%. Conclusions: An easy-to-use Matlab program was developed to measure facial asymmetry in patients with Bell's palsy. Good reproducibility, high inter-rater reliability and adequate internal validity make it an appropriate method to assess facial asymmetry.

 Proprioceptive functional vibration stimulation essential therapeutic tool in spasticity management of jump gait pattern in children with cerebral palsy



Andra Pintilie, Liliana Padure, Andrada Mirea, Corina Sporea

Objectives: Cerebral palsy or CP, a neurological disorder determined by a multitude of conditions (congenital, pre/natal/postnatal causes), with a prevalence of 2-2.5/1000 births, is characterized by motor and function loss, with the most frequent motor element represented by spasticity, and last but not least, by hypotonia, and secondary gait impairment. The purpose of our work is to follow up and assess the effects of proprioceptive functional vibratory stimulation (PFVS) on the jump gait pattern of spastic diplegic gait in children with cerebral palsy. The child with jump gait has equinus foot, genu flexum and coxa flecta, related to spasticity on the gastrocnemian and soleus, hamstrings and psoas muscles. In order to obtain spasticity decrement on the main muscle groups involved in jump gait and improve motor control, we advance the proprioceptive functional vibratory stimulation procedure, as part of the rehabilitation program. Design: Functional vibratory stimuli were applied using a mobile unit commercial medical device for bedridden and standing patients, on the lower limb antagonist muscles, associated with physical therapy, once a day for two weeks, in a group of 5 children with jump gait and cerebral palsy. Ashworth Modified Scale and 10 meters test were used as evaluation tools for spasticity intensity and establishing improvement or decrement of gait pattern. Results: The obtained results show a moderate amendment in gait pattern, with slightly softening of the targeted muscles, thus improving the gait pattern, in the subjected group of patients. Conclusions: In non-CP children gait is expected to be attained between 12 to 18 months, gait disorders being among the primary reasons for medical presentation in CP patients. In order to improve quality of life in young patients through rehabilitation procedures, by considerate attenuation of jump gait pattern, we recommend proprioceptive functional stimulation as adjuvant among other procedures.

 Prospects for a new swallowing evaluation method



Nobuyuki Arai, Kozo Hanayama

Objectives: We investigated whether a newly developed method for evaluating bolus movement during swallow (Pulsed-Fluoroscopy Swallow Study: Arai-Method) could be applicable for a patient with cranial nerve palsy after several microvascular decompression procedures. Design: Subject: a case with cranial nerve palsy after several microvascular decompression procedures: Pulsed-Fluoroscopy Swallow Study: Arai-Method Image acquisition: The subject was seated in the upright posture with the face fixed with a specially designed locking device. Two cups of material were prepared: one containing 10 mL of pure water and another containing 10 mL of a radiocontrast solution. The subject swallowed each liquid at once. A series of lateral view of digital X-ray images at 7.5 frames per second were recorded. Image analysis: To extract only the bolus image, the water-swallow image was subtracted from the radiocontrast solution-swallow image. The pathway of the bolus was divided into 15 anatomical sections. The size of the bolus in each section measured as the total gray value. The multidimensional information on bolus size, position and time were plotted as a contour graph (”swallow chart”). Results: No obvious aspiration was observed during the swallow. The swallow chart showed a total of three peaks located in the oropharynx, the hypopharynx, and the esophagus orifice. Conclusions: The Arai-Method was applicable for the current case. This case showed a swallow chart pattern which is different from that of healthy subjects. This swallow chart pattern, especially the peak in the oropharyngeal region was presumed to have occurred from intentionally avoided aspiration. It was considered this method could show a new aspect of the bolus movement evaluation during swallow.

 Protective headgear to prevent traumatic brain injury in surfers: A systematic review



Barbara Kozminski, Conan So, James B. Meiling, George Raum, Mary Showstark

Objectives: To review the literature to examine the incidence of traumatic brain injury (TBI) in surfers and elicit the need for protective headgear in surfing. Head injuries are the most common injury among surfers, composing well over one-third of surfing-related injuries. However, surfers are doing little to mitigate the risk of head injury with a low incidence of helmet use. Design: A systematic review of the MEDLINE database was performed in July 2019. Search terms included surfing, TBI, and headgear. Studies were included if they were in English, and examined the incidence of TBI in the setting of surfing or investigated the role of protective headgear while surfing. Cohort characteristics, methods of injury, and use of protective headgear were extracted. Results: 7 eligible studies were identified with 6245 patients and 4478 total injuries. Risk factors for head injuries included older age, competitive status, surfing greater than 6.5 hours per week, and performing aerial maneuvers. 26% of the injuries were head injuries (n=1178), with an overall incidence of 3.8% for concussions (n=162). Only 7.2% (n=196) of surfers wore protective headgear or helmets. The most common method of head injury was direct trauma from striking their own surfboard. Conclusions: Surfing poses a high risk of head injuries, particularly concussions. Although surfers recognizing the high risk of TBI and acknowledging that headgear is protective, many prefer to surf without them due to discomfort and effect on balance. Even though helmets have been adopted in other high impact water sports such as rafting, there remains a need in the surfing community to prevent head injuries.

 Proximal neuropathies in patients with poststroke shoulder pain



Tarek Shafshak, Mowaffak Abdel-Hamid, Marwa A. Amer

Objectives: Poststroke shoulder pain (PSSP) could be due to proximal neuropathy or upper trunk brachial plexus lesion. The aim of this study was to detect any electrophysiological abnormality in the proximal nerves supplying shoulder structures that could contribute to PSSP. Design: A cross-sectional study at a university hospital, tertiary level of clinical care. Materials and Methods: nerve conduction studies of the axillary, musculocutaneous, suprascapular, and lateral antebrachial nerves were done on both sides. In addition, electromyography of the deltoid, biceps brachii and infraspinatus on the hemiplegic side was performed on 30 stroke survivors with PSSP. Results: Axillary and musculocutaneous motor nerve latencies on the hemiplegic side were significantly prolonged compared with the normal side (P=0.012, 0.029, respectively). Moreover, axillary and suprascapular nerve amplitudes on the hemiplegic side were significantly lower than those on the normal side (P=0.008, 0.002, respectively). Twelve (40%) patients had electrophysiological abnormalities. Upper trunk brachial plexopathy was the most common abnormality which occurred in six (20%) patients. In addition, isolated axillary or suprascapular nerve lesion occurred at a similar frequency (10%). Conclusions: Proximal nerve lesions are not uncommon in PSSP patients and may occur subclinically.

 Platelet rich plasma therapy delays cartilage loss and improves function in a preclinical model of posttraumatic osteoarthritis



Prathap Jayaram

Objectives: Platelet rich plasma (PRP) is an emerging therapeutic strategy for treatment of osteoarthritis (OA); however, preclinical and clinical evidence for its efficacy is lacking and the mechanism of action is unclear. In the current study, we utilized leukocyte poor-PRP (LP-PRP) and leukocyte rich-PRP (LR-PRP) formulations to mimic clinical point of care formulations and assessed their potential to alter disease pathogenesis in a mouse model of post-traumatic OA. Design: Three-month-old wild-type male FVB/N mice received destabilization of the medial meniscus (DMM) surgery to induce OA. To assess the efficacy of LP-PRP and LR-PRP, mice received intra-articular injections at 2-,7- and 28-days post-surgery. Mice were then assessed at 5, 9, and 14-weeks post-surgery for changes in chronic pain using the hot plate nociceptive assay. At 14-weeks post-surgery, OA pathogenesis was evaluated using histology and phase-contrast mCT. Results: Treatment with LP-PRP preserved cartilage volume and surface as measured by phase-contrast mCT and histological scoring compared to PBS-treated controls (n= 8-10 per group, p < 0.05). While the effects of LR-PRP on cartilage loss were intermediate, it was not statistically better than treatment with PBS. On the other hand, LR-PRP but not LP-PRP protected against disease-induced thermal hyperalgesia (n= 8-10 per group, p < 0.05). Conclusions: The results of this study demonstrate that PRP therapy can delay progression of post-traumatic OA. Specifically, leukocyte-poor preparations protect from structural changes in diseased joints, and an increased leukocyte concentration in PRP imparts analgesic effects but may compromise chondroprotection.

 Psychometric properties of the spinal cord injury pressure sore onset risk screening (SCI-Presors), A novel instrument for pressure injury screening



Jude Delparte, Jackie Wright, Carol McAnuff, Heather Flett, Carol Scovil, Anthony Burns

Objectives: The Spinal Cord Injury (SCI) Pressure Sore Onset Risk Screening (SCI-PreSORS) instrument is a novel approach for pressure injury (PI) screening. The SCI-PreSORS is for individuals participating in inpatient SCI rehabilitation; and is comprised of four yes/no items (PI history, mobility, transfers, toileting) incorporated into a decision tree. This study prospectively determines test-retest, inter-rater reliability (IRR), and concurrent validity (Braden scale) of the SCI-PreSORS. Design: Ninety-nine individuals participating in inpatient SCI rehabilitation completed three study visits. Outcomes included the SCI-PreSORS and the Braden scale. Individuals with a Braden scale score ≤ 16 are considered at risk. Study intake was completed within 12 to 21 days of admission (median 16). Retest assessments were completed within four to eight (median 7) days whereas a second rater completed assessments (n=50) within one to six days (median 1). Interim test-retest reliability and IRR analyses were completed using percentage agreement. Results: Agreement for the level of PI risk (high vs low) at intake was 77%; determined using the Braden scale and the SCI-PreSORS. Test-retest reliability for PI risk was excellent (92%) for the SCI-PreSORS and good (87%) for the Braden scale. Inter-rater reliability was comparable for the SCI-PreSORS (83%) and the Braden scale (85%). For individual items, test-retest reliability ranged from 87% to 95% for the SCI-PreSORS and from 67% to 86% for the Braden scale. IRR for Braden scale items ranged from 43% to 83%. Due to the decision tree format of the SCI-PreSORS, IRR analysis was not possible for individual items. Conclusions: The SCI-PreSORS demonstrates good IRR and excellent test-retest reliability. Ongoing data collection and pending analyses will provide insight into additional metrics such as Cohen's kappa, as well as sensitivity and specificity. This will define the ultimate utility of the SCI-PreSORS for PI risk screening during inpatient SCI rehabilitation.

 Publication language and the estimate of effects of physical therapy on balance and postural control after stroke in meta-analysis of randomized controlled trials



Aurelien Hugues, Julie Di Marco, Michel Cucherat, Isabelle Bonan, Francois Gueyffier, Gilles Rode

Objectives: To compare treatment effect estimates (TEE) between studies published in a non-English language (SPNEL) and studies published in English language (SPEL) in a meta-analysis assessing the effects of physical therapy on balance and postural control after stroke (Hugues et al., 2019). Design: Medline, Embase/Scopus, Cochrane Central Register of Controlled Trials, PEDro, Pascal, and Francis databases were searched until January 2019. Two independent reviewers selected randomized controlled trials, extracted data, and assessed risk of bias according to the risk of bias tools from the Cochrane Collaboration. We conducted subgroup meta-analyses according to the language of study publication, then compared TEE between SPEL and SPNEL. Results: From 13,123 records, 132 SPEL (n=5219) and 13 SPNEL (n=693) were included. The weight of SPNEL in TEE was significantly lower than that of SPEL (mean: 8.2% versus 91.8%, p< 0.001). Compared to SPNEL, SPEL had both significantly lower risk of bias (studies judged as having a low risk of bias 48% versus 0%, p=0.002) and better quality of reporting for blinding of outcome assessment (studies judged as having an unclear risk of bias 42% versus 100%, p< 0.001); and a significantly better quality of reporting for incomplete outcome data (27% versus 77%, p< 0.001). The precision (inverse of variance) of TEE was significantly higher in SPEL than SPNEL (mean: 8.8 versus 4.3, p=0.003). TEE were not significantly different between SPEL and SPNEL (Standardised mean difference -0.16, 95% confidence interval [-0.53; 0.22], heterogeneity I2=78%). Conclusions: The restriction of the search to SPEL only did not change the meaning of results for 8 out of 9 outcomes. SPNEL had a worse methodological quality, reporting quality and precision of TEE but did not over-estimate TEE compared to SPEL. Therefore, sensitivity analyses should be performed to assess on a case-by-case basis the impact of SPNEL on estimates.

 Pulmonary cement embolism following vertebroplasty



Rosa Rodriguez, Kevin Dalal, Earl Biag, Mukti Gandhi

Case Diagnosis: T7 Metastatic Melanoma. Case Description: A 30-year-old male with a past medical history of metastatic melanoma, was admitted to the university hospital and was found to have a T7 metastatic tumor with pathologic fracture and epidural spinal cord compression. Patient underwent T6-T8 laminectomies, transpedicular decompression of the spinal cord, and corpectomy of T7 for tumor removal. The orthopedic surgeon also performed instrumented fusion with cement augmentation from the T5 through T9 levels. A postoperative Chest CT angiogram showed several hyperdense intraluminal filling defects in the segmental pulmonary arteries of the lingula and left lower lobe, compatible with cement emboli. Patient was started on Enoxaparin for deep vein thrombosis prophylaxis. On the tenth post-operative day, patient was cleared by Neurosurgery to begin an inpatient rehabilitation program. Discussions: Pulmonary cement embolism has an incidence rate of 23% after percutaneous vertebroplasty. The risk of embolism is often related to insufficient polymerization of the polymethyl methacrylate during injection, and leakage into the inferior vena cava. Though there are not clear treatment guidelines, reported cases were treated with anticoagulation, with embolectomy being the definitive treatment. Conclusions: This case presents a potentially fatal complication of percutaneous vertebroplasty. It illustrates the importance of routine post-operative chest imaging and close monitoring of patients undergoing inpatient rehabilitation after vertebral augmentation. It also emphasizes the need for clear therapeutic guidelines even in asymptomatic patients.

 Quality of life in spinal cord injured patients



Vinay Goyal, Sucheta Saha, Nonica Laisram

Objectives: Spinal Cord Injury (SCI) is a major setback in life of an individual. SCI patients often have a low quality of life. WHO defines “ Quality of life (QOL) as individual perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. Beyond the neurological deficits QOL is affected by Physical Health, Psychological, Social Relationships and environment. The present study was planned to study QOL using WHO QOL BREF Questionaire. Design: Descriptive and Quantitative study was planned from March 2015 to March 2016. Only adults of either sex with Spinal cord injury of more than one month duration was included in the study. After collecting Demographic data and Clinical examination WHO BREF questionnaire containing 26 items in local language was given to patients and they were asked to answer the questionnaire based on last two weeks. Patients who could not read it was read to them and answer was sought. Data was maintained on excel Sheet and analyzed in SPSS version 16. Results: Majority of patients were adult males with Male: Female ratio of 2:1. Paraplegics (88.9%) with dorsal dorsal vertebral injury (51%) with fall as most common cause. Mean of Physical Health, Psychological Health, Social Relationships and environment were 31.51, 39.22 . 40.07 and 33.92 respectively. Conclusions: Adult males experiencing fall from height constitutes most common group of Spinal Cord injured individual. Low scores in all domains shows low quality of life in Spinal Cord Injured patients.

 Quality of life of parents who have children with disabilities in Morocco



Hajjioui Abderrazak, Mohammed Elbaidouri, Nourelhouda Fares, Maryam Fourtassi

Objectives: Parents who have children with disabilities are often reported to have physical and psychological distress related to caring for their children, thus affecting their quality of life (QOL). This study explored the QOL among moroccan parents who have children with disabilities. Design: A total of 559 parents who have Children With Disabilities were recruited for the study using convenience sampling. The Participation and Quality of Life (PAR-QoL) tool-kit was used to measure the QOL among the parents. The socio-demographic data, financial conditions and family background were also recorded. Results: 83.5 % of the interviewed parents were mothers and 94% were married. 85.8% of the mothers were housewives. Results showed that having a child with Disabilities affects their parents' quality of life (average total score of 47.31). This alteration is more marked in the emotional domain than in the adaptive domain. We found significant associations between the Quality of Life alteration and the age of parents, the marital status, the health coverage, the place of residence, the age of the child, the nature of the disorder and the type of disability. Conclusions: This study indicates the need for parental support when providing intervention to their children with disabilities.

 Quantifying muscle co-contraction after brain injury



Ian J. Baguley, Hannah L. Barden

Objectives: Botulinum Toxin A (BTX-A) is the treatment of choice for positive motor features of upper motor neuron (UMN) syndromes, however, there is little research evidence to help clinicians select which combination of muscle injections will maximize outcome for any affected individual. A major issue in this regard is the inability of current measures to quantify patterns of “overflow” of normal proprioceptive information from one moving muscle that modulate muscle movement patterns (here defined as muscle co-contraction). We have previously shown the effectiveness of Dynamic Computerized Dynamometry (DCD) to provide ratio level data to quantify positive UMN features following acquired brain injury (ABI). This pilot case series extended the DCD protocol to investigate the cumulative impact of co-contraction from proximal upper limb movements pre and post BTX-A. It was hypothesized that motor control and spasticity would deteriorate in a stepwise fashion with increasing complexity of the task. Design: Individuals with post-ABI upper limb spasticity were assessed using the DCD protocol in five conditions (bipedal standing: arm beside hip (1), 90o elbow flexion (2), 90o shoulder forward flexion (FF)(3), maximum shoulder FF (4), single leg stance at 90o FF (5)). Data was analyzed for maximum force generation (known as Fmax), between-cycle spasticity (known as Fmin) and other published contraction/relaxation cycle parameters. BTX-A muscle selection was determined by the injector in line with patient-derived goals. Data were compared descriptively. Results: Pilot data was broadly consistent with the concept of increased hand spasticity with more complex tasks, with Fmin increasing by a maximum of 40 to 400%, depending on the person. Inter-cycle spasticity also increased as more muscles were required for task completion. Conclusions: This pilot data supports the hypothesis, quantifying the extent of forearm muscle spasticity and co-contraction wind-up as exacerbated by movements of ipsilateral proximal upper limb muscles and lower limb/trunk muscles.

 Racial differences in obesity in individuals with spinal cord injury: An urban-rural comparison



Huacong Wen

Objectives: To compare racial differences in obesity between urban and rural areas for people with spinal cord injury (SCI). Design: This is a cross-sectional analysis of survey data from National SCI Database linked with neighborhood data from American Community Survey and US Department of Agriculture Economic Research Service by Census tract. 3,385 participants (non-Hispanic white, 66.5%, non-Hispanic black, 22.5%, and Hispanic, 11.0%; men, 79.1%; mean age, 44.3 ± 15.6y; tetraplegia, 54.0%; complete injury, 45.3%; mean duration of injury, 8.3 ± 9.9y) who completed a follow-up assessment during 2006 - 2017 and resided in 2,934 census tracts. Urban tract was considered if a census tract with a population of ≥ 2,500; all other tracts were rural tracts. After controlling for demographic, injury-related and neighborhood (concentrated disadvantaged index) factors, logistic regression analyses were conducted separately for urban and rurual groups to estimate odds ratio (OR) of being obese (body mass index ≥ 30.0 kg/m2) in non-Hispanic black and Hispanic relative to non-Hispanic white. Results: of 3,385 participants, 23.1% were obese, and 76.2% were from urban area. Within urban group, Hispanics had the greatest obesity prevalence (30.6%), followed by non-Hispanic blacks (23.5%) and non-Hispanic whites (21.3%; p= .001). After controlling for demographic, injury-related and neighborhood factors, Hispanics were 56.1% more likely to be obese relative to non-Hispanic whites (OR, 1.56; 95% CI, 1.2-2.1), and obesity was not significantly different between non-Hispanic blacks and non-Hispanic whites. However, there was no significant racial differences in obesity for rural group. Conclusions: Racial differences in obesity exist among people with SCI from urban areas. Findings could help health care professionals to target groups for obesity prevention and management to reduce racial health disparities for SCI population.

 Rare case of vertebral body infarction associated with conus medullaris ischemia of unknown etiology: A case report



Varun Y. Goswami, Justin Virk, Raymund Millan, Jonathan D. LeCrone

Case Diagnosis: Vertebral Body Infarction associated with Conus Medullaris Ischemia. Case Description: A 56-year-old male with no significant past medical history presented with acute onset paraplegia with loss of bowel and bladder function. These symptoms rapidly progressed within an hour while patient was at work. Angiogram studies ruled out aortic dissection and aneurysm. Hypercoagulable panel was negative. Inflammatory markers were within normal limits, excluding a vasculitis process. Cerebrospinal fluid studies were grossly abnormal but cultures were negative. Thoracic magnetic resonance imaging (MRI) revealed an abnormal T2 signal in the T12 vertebral body with edema as well as abnormal enhancement within the conus medullaris. These findings were consistent with T12 vertebral body bone marrow infarction and conus medullaris ischemia. Discussions: Upon admission to rehabilitation, patient was functionally limited due to his diagnosis of complete T4 ASIA A spinal cord injury. Initially, he required moderate to maximal assistance with bed mobility and transfers. He worked intensively with physical and occupational therapy for four weeks, significantly benefitting from seated ergometer, truncal strengthening, and locomotor gait training. Upon discharge, the patient progressed to modified independent with wheelchair mobility, manually propelling 1,000 feet. The presence of vertebral body infarctions are very rarely found along with spinal cord infarctions due to regional arterial anastomosis. Conclusions: This patient was found to have a conus medullaris infarct adjacent to the T12 vertebral body. Symptoms often include back pain, paresthesias, paraplegia, radiculopathy, bowel and bladder dysfunction, and gait imbalance. It is imperative to thoroughly review MRI imaging for surrounding anatomical infarctions in patients who suffer from spinal cord infarctions. Vertebral body infarctions are directly related to increased pain and debility in the paraplegic population. Although rare, it should always be on the differential diagnosis as early recognition allows for timely evaluation and initiation of secondary preventative therapies.

 Rare co-existence of epidermoid tumor and meningioma: Rehabilitation management



Manasa Vasireddy, Riley Smith, Vivan Shah, P. Tyler Roskos

Case Diagnosis: Rare co-existence of Epidermoid tumor and Meningioma - Rehabilitation Management. Case Description: A 38-year-old female presented with symptoms of left side facial twitching, gait instability and blurry vision. She also reported chronic bi-frontal headaches. On admission, magnetic resonance imaging (MRI) of the brain revealed a non-enhancing 5.5 x4.2 cm posterior cranial fossa tumor invading the 4th ventricle and pushing the brain stem into foramen magnum, as well as second supra-tentorial tumor, just right to the posterior midline of the splenium of corpus callosum. She underwent subsequent sub-occipital craniotomy with cerebellar tumor resection and a staged biopsy confirming an epidermoid tumor. Based on its appearance, the homogenously enhancing mass posterior to corpus callosum was deemed to be a meningioma. The patient was admitted to inpatient rehabilitation and measures were taken to prevent pressure ulcers and deep venous thrombosis due to prolonged immobility. Emphasis in therapy was placed on maximizing the activities of daily living (ADLs), cognition, communication, and mobility. Discussions: The incidence of epidermoid tumors is only 1% of all primary brain tumors. Additionally, the coexistence of epidermoid tumor and meningioma has rarely been reported. The primary intervention is typically surgical and in this case, most of the epidermoid tumor was removed operatively. Rehabilitation care played a significant role post-operatively for this patient to enhance recovery, specifically focused on improving independence, balance, pain management and quality of life. Conclusions: This case report is significant because of the uncommon brain tumor type and co-existence of epidermoid and meningioma tumors. It also supports the efficacy of rehabilitation in post-surgical management of patients with rare brain tumors. Early rehabilitation care can enhance functional outcomes in these patients.

 Rare dual diagnosis – Primary anoxic brain injury with subsequent idiopathic spinal cord ischemia resulting in ASIA a paraplegia: Rehab and recovery, a case report



Joseph L. Graham

Case Diagnosis: Primary Anoxic Brain Injury with Subsequent Idiopathic Spinal Cord Ischemia Resulting in ASIA A Paraplegia. Case Description: The patient initially presented to the acute hospital with severe anoxic brain injury from overdose of Benzodiazepines and Fentanyl patches. She was stabilized, but meaningful recovery was deemed unlikely. The family decided to withdraw care and place the patient in hospice. However, after terminal wean from ventilator, the patient slowly began to show recovery. She regained purposeful movement in her upper extremities; however, her lower extremities remained flaccid. Upon evaluation for rehabilitation by PM&R, MRI of her spine was requested. Imaging showed long segmental central cord restricted diffusion and hyperintensity in paraspinal musculature, concerning for spinal cord infarct with associated denervation of paraspinals. Upon admission to acute rehabilitation hospital, ASIA exam showed T10 complete spinal cord injury. Patient participated in six weeks of rehabilitation working to upgrade independence with mobility at the wheel chair level, coordination of upper extremity movements, cognition and memory related to her severe brain injury. Discussions: The patient participated in an intensive program to regulate neurogenic bowel/bladder, manage lower extremity spasticity, and improve truncal support at and below the level of her spinal cord injury. After her inpatient rehabilitation course the patient progressed to ModI with eating, Supervision for ADLs, ModI with wheel chair locomotion, moderate assistance for transfers and supervision for cognition. Some studies report as high as 60% of primary diagnosis SCI patient have a concomitant brain injury, however the incidence of primary brain injured patients with secondary idiopathic spinal cord injuries are much less common and are a rare challenge in rehab.Conclusions: This rare dual diagnosis presented a unique challenge to our rehab team. However, through collaboration between PM&R specialists in Brain Injury and Spinal Cord Injury, this patient's rehab plan was tailored to overcome these challenges.

 Rare fluid collection in the subcutaneous pocket of an intrathecal baclofen pump identified



Michael Dove, Lauren T. Shapiro, Chane Price

Case Diagnosis: Extraperitoneal location of ventriculoperitoneal (VP) shunt catheter with migration into the subcutaneous pocket for intrathecal baclofen (ITB) pump. Case Description: A 54 year old man with history of severe traumatic brain injury and hydrocephalus status-post VP shunt placement underwent placement of an ITB pump for management of his spasticity. Two months following pump implantation, he was noted to have a palpable fluid collection overlying the implantation site. Abdominal x-ray revealed a lucency noted adjacent to the baclofen pump. Fluid from this site was aspirated and sent for analysis; culture was without growth but beta-2 transferrin was detected. Computed tomography (CT) demonstrated the VP shunt catheter had migrated into the pocket created for the ITB pump implant. While awaiting revision of the VP shunt catheter, he was found to have extensive proximal right lower extremity deep vein thromboses, and was unable to undergo the surgery for six months while receiving anticoagulation. During this time, his head CTs remained stable, his arousal improved, and his spasticity continued to respond to ITB therapy. Discussions: Distal catheter migration in the abdominal wall is a very rare complication of VP shunt placement. When the end of the shunt is displaced, fluid accumulates at the site and may cause shunt malfunction. Risk factors for shunt migration include elevated intra-abdominal pressure and the availability of “dead space” near the catheter. This patient had chronic constipation, and the establishment of the ITB pump pocket likely provided a low resistance pathway through which the catheter traveled. Conclusions: If a fluid collection exists at the baclofen pump site in a patient with a VP shunt, migration of the VP shunt catheter should be suspected and the fluid should be tested for cerebrospinal fluid. These patients are vulnerable to device malfunctions and require close follow up in order to prevent complications.

 Rare multifocal intraparenchymal hemorrhages following spinal surgery: A case report



Kathy Chou, Allison Averill

Case Diagnosis: Rare multifocal intraparenchymal hemorrhages following spinal surgery. Case Description: The patient with past medical history of anxiety and hypertension underwent elective lumbar laminectomy for resection of asymptomatic intradural schwannoma. Several days after surgery, she developed a headache followed by right-sided hearing loss, intermittent diplopia and left hemiplegia. Computed tomography and magnetic resonance imaging (MRI) head demonstrated right frontal and left parietal intraparenchymal hemorrhages, intraventricular and diffuse subarachnoid hemorrhages. MRI lumbar spine revealed a pseudomeningocele suggestive of cerebrospinal fluid (CSF) leak, and she subsequently underwent dural repair. Angiogram of the head/neck and repeat imaging were negative for arteriovenous malformations, aneurysms or mass. She was admitted to acute inpatient rehabilitation for left hemiplegia secondary to multifocal hemorrhagic strokes. On admission to acute rehabilitation, she had preserved strength on the right but no movement in left proximal arm and lower extremity. Two weeks into acute rehabilitation, she regained antigravity strength in distal left upper and lower extremities. Discussions: Intracranial hemorrhages after spinal surgery are extremely rare and are attributed to incidental or purposeful durotomies with a CSF leak. It is suspected that the negative intracranial pressure that develops with CSF leaks applies tension on cerebral blood vessels, nerves and meninges. The most severe consequences have poor prognoses and include reversible coma, cerebral herniation and infarction. Few intracranial hemorrhagic cases after spinal surgery have been reported, and most were cerebellar or subdural hematomas. This is the first case, to our knowledge, of multifocal and intraparenchymal hemorrhages following spinal surgery. Conclusions: Physiatrists need to be aware of the rare sequelae after spinal surgery. New neurologic findings following spinal surgery should prompt evaluation for dural tear and possible consequent intracranial hemorrhages.

 Rare occurrence of radiation-induced lumbar plexopathy in a medically complex cancer patient



Alyssa Mixon, Jasmine Zheng

Case Diagnosis: Identifying ways in which acute manifestations of symptoms following chemotherapy and radiation therapy can be differentiated in the cancer population with a focus on a rare diagnosis of radiation-induced lumbosacral plexopathy in a medically complex cancer patient. Case Description: A literature review was performed for a case report involving the rare occurrence of radiation-induced lumbar plexopathy in a medically complex cancer patient. Discussions: Literature reveals the diagnosis of radiation-induced lumbar plexopathy is not common and for our patient, given such a low dose with an acute presentation, rare. Building a strong differential diagnosis can help with identification and management of patients to ensure the pathology is not missed. Conclusions: When treating cancer patients, one must account for not only cancer pathology but also treatment dose, timing, and side effects in addition to new and pre-morbid conditions. This involves coordinating care among a variety of specialties to create an integrated healthcare team, with the ever-growing need for experts in the cancer rehabilitation field.

 Rea-val: Study screening pilot oropharyngeal dysphagia in neurosurgical-intensive care unit



Remi Mallart, Bertrand Dureuil, Eric Verin

Objectives: There are various tests that can be used to screen oropharyngeal dysphagia (OPD) depending on the populations studied. Post-extubation dysphagia is being explored more and more in the face of the increase in morbidity and mortality, the medical and financial consequences it brings. However, there is no screening test for these disorders in patients with brain injury in neurosurgical-intensive care unit (ICU). The purpose of this pilot study was to conduct a feasibility study of a new OPD screening test in this population. Design: A prospective analysis was performed in brain-injured patients hospitalized in neurosurgical-ICU, intubated for more than 72 hours. Screening for OPD at 24 hours from extubation with a new analysis protocol in bedside patients was performed. The protocol consisted of associating a V-VST, a recognized and validated test in the OPD in patients with stroke, to a GuSS-ICU, Designed for the population in ICU except neurological-ICU. Sociodemographic and clinical data was collected to highlight predictive factors of dysphagia. Results: Among the 55 hospitalized patients, about 25% of patients were eligible. 70% of the examined patients had OPD at 24 hours, contraindication per os, with a risk of major complications. Contrary to the service protocole in which 20% couldn't be examined, the others were examined between 1 to 5 days after their extubation. We were able to screen them all at 24 hours, by all the staff, without any complication. Conclusions: We propose a feasible, secured protocol. It is necessary to continue the study with patient follow-up in order to have a sensitivity analysis, and favoring factors, which were not analyzed in this study. This test doesn't replace a specialized evaluation but could answer the question of refeeding if it is normal, and the thoughtful realization of an instrumented exploration in case of failure.

 Recovery from left cerebellar hemorrhage, as a complication of right pericallosal aneurysm clipping: A case report



Sonia Thakur, Kyle Smith, Heather M. Ma

Case Diagnosis: Acute cerebellar hemorrhage following elective bifrontal craniotomy for pericallosal aneurysm clipping in a 68-year-old man with a history of intracranial aneurysms, paroxysmal A-fib, and prior left basal ganglia hemorrhage. Case Description: A 68-year-old male presented for elective bifrontal craniotomy and right A2-A3 pericallosal aneurysm clipping. His procedure utilized peri-operative lumbar drain placement and intracranial Brainlab navigation, with no documented intraoperative complications. Postoperatively, the patient had altered mental status. A head CT showed bilateral fronto-temporal SAH and left cerebellar hemorrhage of unclear etiology. No venous thrombus was seen on CT venogram. Work up including INR and thromboelastography was inconsistent with coagulopathy. The cerebellar bleed was managed with intravenous antihypertensives and corticosteroids. His acute hospital course was complicated by status epilepticus, MRSA pneumonia, paroxysmal sympathetic hyperactivity, and unsuccessful extubation trials. The patient was discharged to acute inpatient rehabilitation 51 days after admission, where he continued to show functional and cognitive improvements with therapies, sleep optimization, and neurostimulant initiation. His functional deficits were primarily due to cerebellar ataxia and executive function impairment. He was eventually discharged home after 19 days of acute inpatient rehabilitation. Discussions: Remote cerebellar hemorrhage is a rare, infratentorial complication which may occur after supratentorial surgery. Intracranial hypotension and coagulation disorders are possible risk factors, but the patient had none of these. Postoperative suction drainage and intraoperative CSF loss could also result in parenchymal shifts or changes in trans-tentorial pressure gradients, contributing to spontaneous hemorrhage. Despite a prolonged stay in the Neuromedicine ICU, this patient was discharged home, requiring only minimum to contact guard level of functional assistance. Conclusions: Remote cerebellar hemorrhage is a rare, but significant, complication of a supratentorial intracranial aneurysm clipping. Acute inpatient rehabilitation plays an essential role in achieving improved functional outcomes in these patients.

 Recovery of muscle fiber force with tamoxifen after spinal cord injury in rats



Maria E. Santiago, Jorge Monserrate, Iris Salgado, Aranza Torrado, Sebastian Bernaschina, Mariely Nieves, Jorge Miranda, Walter Frontera

Objectives: Spinal cord injury (SCI) results in early loss of skeletal muscle mass and function suggesting that any interventions must be started very soon after injury. The main objective of this study was to test the effects of Tamoxifen (a neuroprotective agent) on single muscle fiber size and function after SCI. Design: Adult female rats were randomly assigned to either 7 days-sham (SHAM; n=5), 7 days-post-injury (7DPI; n=5), or Tamoxifen (TAM; n=4) group. SHAM animals were sutured after laminectomy. 7DPI rats received a contusion with an NYU impactor. Tamoxifen pellets (0.7mg daily) were implanted subcutaneously. Diameter and cross-sectional area (CSA) of chemically skinned soleus single muscle fibers were measured. Maximum force (Po), and specific force (Po/CSA) were determined by the slack test procedure using high calcium concentrations. 179 fibers were tested (69 SHAM; 55 7DPI; 55 TAM). Means + SD were calculated and values analyzed using ANOVA. Results: Diameter was significantly (p< 0.001) smaller after 7 days in 7DPI (75 mm) and in TAM (81 mm) rats compared to SHAM (95 mm). Similar results (< 0.001) were seen for CSA (SHAM=3760 mm 2 ; 7DPI=3030 mm 2 ; TAM=2980 mm 2 ). Maximal force was significantly lower (p< 0.001) at 7DPI (83 mN) but there was no difference between SHAM (138mN) and TAM (110 mN) suggesting a beneficial effect of the drug. No difference among groups was seen in specific force (p=0.11; SHAM=5.5 N/cm 2 ; 7DPI=4.3 N/cm 2 ; TAM=5.3 N/cm 2 ). Conclusions: Our results showed that muscle fiber size is smaller and single fiber function impaired in the acute phase. The reduction in force is due to muscle fiber atrophy only because single fiber specific force was similar in all three groups. Drug interventions such as tamoxifen after SCI can restore maximal force when implemented very early after injury.

 Recreational psychosocial proposals to go through processes of prolonged hospital stay



María F. Colón, Mariela Tamburrini, Miriam A. Weinberg, Juan P. Sole, Sabrina Martínez, Gabriela Colacchio, Soledad Gimenez, Emilce Schenk

Objectives: Objetivos generales: Desarrollar estrategias de RPS para favorecer el proceso hacia la salud durante la enfermedad; para beneficiar la atención y la atención de los participantes hospitalizados durante el período noviembre de 2018 - mayo de 2019. Evite sobrecargar al familiar acompañante o amigo de los pacientes hospitalizados durante el período de noviembre de 2018 a mayo de 2019. Objetivos específicos: Genere una agenda de actividades semanales de RPS para aumentar las propuestas ofrecidas. Fomentar una actitud de autocuidado en los familiares y amigos que lo acompañan, un espacio para escuchar y reflexionar sobre sus experiencias como cuidadores. Fomentar y profundizar el vínculo entre el equipo de salud y los participantes. Fomentar las habilidades motoras y de procesamiento. Design: The following work is descriptive. Tools: Planning of activities. Register of: Direct observation in field notebook. Assistance and participation in RPS activities. Resources: Agenda of ephemerides and celebrations. Group dynamics. Fun recreational activities. Results: Period evaluated: November 2018 – May 2019 Quantity of RPS activities: 117 Participation of patients: 74% in November 18 – 94% in May 2019; Participation of accompanying family members and friends: 2% in November 2018 – 9% in May 2019. Conclusions: Through this experience we have observed and accompanied singular trajectories of which varied responses in attitude have arisen when faced with the RPS proposals. Motor skills and processes such as memory, attention, the resolution of problems, executive functions and socialization were stimulated. This proposal encouraged the process of rehabilitation enabling the participants to get to know each other and form relationships from another point. We worked on the potentialities of the persons providing them with tools which would assist the going through a process of health-illness at any time of life.

 Recurrent meningitis and posterior fossa syndrome from a persistent pseudomeningocele, a challenging rehabilitation diagnosis



Chase J. Smith, Blessen C. Eapen

Case Diagnosis: Recurrent meningitis, secondary to post-operative pseudomeningocele following posterior fossa mass resection. Case Description: A 22-year-old female with past medical history of posterior fossa subependymoma was admitted to an inpatient rehabilitation unit status-post mass resection complicated by Enterobacter cloacae meningitis. After completing 3-weeks of culture sensitive cefepime, the patient still exhibited a post-operative pseudomeningocele within normal limits per referring neurosurgeon. Rehabilitation progress was complicated by nausea, headaches, and cerebellar signs with slowly enlarging pseudomeningocele. A MRI of the brain revealed a persistent fistula between CSF and pseudomeningocele allowing for suspected seeding of bacteria, confirmed by lumbar puncture. The patient underwent 6-weeks of meropenem, maintaining stable systemic inflammatory markers. However large volume lumbar punctures and eventual ventriculoperitoneal shunt placement was required for refractory hydrocephalus. Despite negative shunt cultures, MRI and CSF flow studies revealed persistent meningitis in the caudal brain with extensive adhesions, CSF loculations and 4th ventricle isolation. Posterior fossa revision was required to address isolated infection and CSF impediment through accompanying post-obstructive changes. Discussions: Post-operative meningitis is an undesirable but occasional complication of neurosurgical intervention, however, recurrent meningitis is rare and not commonly encountered by physiatrists. This case demonstrated a diagnostic challenge in the rehab setting, as a well described posterior fossa syndrome delivered a more common explanation for enduring nausea, ataxia, cranial nerve deficits and other cerebellar signs after mass resection. Rather these symptoms were a herald for recurrent meningitis from pseudomeningocele, which is not a well identified source for persistent bacterial infection in the current literature. Conclusions: Physiatrists on inpatient rehabilitation wards should always be suspicious that infection may mimic common post-operative symptoms, even well described syndromes as in this case. Recurrent bacterial meningitis from persistent pseudomeningocele is rare. However, expedited diagnosis was achieved through comprehensive daily history and physical examinations, with emphasis on interdisciplinary and interspecialty communication.

 Reducing length of stay on an inpatient rehabilitation brain injury unit through improved behavioral management



Ashley Kakkanatt, Erika Trovato, Rachel Feld-Glazman

Case Diagnosis: Decrease length of stay on an acute inpatient brain injury rehabilitation unit by one day by improving behavior management. Case Description: An interdisciplinary team was assembled to address behavioral management challenges in three domains: environment, staffing, and behavior monitoring. Changes were put into effect beginning in November of 2017. Environmental modifications made include creation of a locked and secured unit dedicated to patients with brain injury and installation of a centralized video monitoring system. Staff were encouraged to complete non-violent crisis intervention (NCVI) training to be more equipped to handle patients with PTA. A consistent inpatient psychiatry consultation service was implemented. Agitated Behavior Scale (ABS) tracking was initiated for all patients at admission. Interdisciplinary behavior rounds were instituted five times per week to adjust medications, reduce restraint use, improve team communication and recognize triggers to agitation. Discussions: In 2018, 491 patients were discharged from the inpatient brain injury rehabilitation unit with an average length of stay of 20.03 days. Compared to an average length of stay of 21.75 days in 2017, there was a reduction by 1.72 days. There was also a reduction in patient falls, elopements, and restraint use. There was a 350% increase in NCVI-trained staff. Conclusions: Through an improved interdisciplinary approach to behavioral management, there was a reduction in average length of stay on the acute inpatient brain injury rehabilitation unit by over one day from 2017 to 2018.

 Rehabilitacion en sindrome de hiperlaxitud articular



Veronica Matassa

Case Diagnosis: El Sindrome de Hiperlaxitud articular se presenta con dolor osteomioarticular; que pueden ser generalizadas o no, y acompañarse de signos inflamatorios y degenerativos articulares. Hay diferentes grupos de criterios diagnósticos, como los de Beighton PH en el cual se aplican diferentes maniobras (9) a las que se les asigna un punto por cada maniobra positiva siendo con valor de 4 puntos o mas, Hiperlaxo. Case Description: Paciente de 45 años de edad con con dolores articulares multiples, multiples cirugias (columna, rodilla, hombro), diagnosticada como Fibromialgica, colon irritable, cefaleas recurrentes. Se inicia la evaluación comprobandose hiperlaxitud articular (criterios de Beighton con 5 puntos), deficit propioceptivo con alteración del balance (BESS), deficit de concentracion y fatigabilidad. Presentaba historial de tratamiento con diferentes Aines sin respuesta, EVA 8/10, trastorno del sueño por dolor mixto. Se inicia tratamiento de rehabilitacion interdiciplinaria con objetivo de fortalecimieto muscular, mejora propioceptiva y cuidados articulares. Se inicia tratamiento farmacologico llegando con parches de buprenorfina a dosis de 10mg con paracetamol 1g cada 8 horas, pregabalina 75mg, lactulon jarabe 30cc. Se obtuvo mejora funcional global (FIM y Barthel), manejo del Dolor EVA 4 y reconstitucion del descanso nocturno mejorando deficit mnesico y concentración. Discussions: Esta paciente tuvo un diagnóstico definitivo a sus 45 años de edad luego de 5 intervenciones quirúrgicas, tratamientos por fibromialgia, depresion, fatiga crónica, cefaleas sin resultados. Refiere alivio no solo de encontrar un tratamiento efectivo que le permite realizar sus actividades sino ademas de saber que le pasa y como cuidarse. Conclusions: La identificación de esta patologia, el manejo adecuado del dolor y su rehabilitacion interdiciplinaria con objetivos claros acorde a la misma mejora la calidad de vida de estos pacientes que en ocacione pelegrinan largamente con diagnósticos erróneos y permiten realizar los controles preventivos de las complicaciones.

 Rehabilitation challenges in an individual with self-inflicted burn injury in a suicide attempt: A case report



Jenna Ji, Elizabeth A. Fierro, Ashley Kakkanatt, Michelle Stern

Case Diagnosis: Partial and full thickness burns over 50% of total body surface area (TBSA). Case Description: A 47-year-old male with past psychiatric history of bipolar disorder and polysubstance abuse, presented with partial and full thickness burns over 50% of TBSA after self-immolation. After acute burn care, patient was admitted for acute inpatient rehabilitation. On presentation he had diffusely decreased muscle strength in the lower extremities and significant restriction in range of motion of the upper extremities due to axillary skin contracture. During the course of his physical rehabilitation patient was non-compliant with wound care and airplane splinting, requiring psychiatric consultation and use of quetiapine. Patient non-compliance led to delay in rehabilitation and exacerbation of complications however there was moderate improvement in compliance after psychiatry consultation services were involved in his care. Discussions: Psychiatric co-morbidities in an individual with burns after a suicide attempt pose a complex array of challenges for the rehabilitation process. Premorbid psychiatric conditions are risk factors associated with depressive symptoms after burn injury. This patient was actively depressed prior to admission and his continued anhedonia led to poor compliance and cooperation in medical treatment and therapy sessions which precipitated contraction formation. Studies have shown that self-immolation patients with burns have increased need for surgery, delayed wound healing, and poor cooperation. Conclusions: This case illustrates the potential for delayed rehabilitation and worsening of complications due to premorbid psychiatric conditions and the value of a multi-disciplinary approach. More rapid functional improvement may occur when the patient's active psychiatric issues are made central to the rehabilitation process with close psychiatric and social work follow up.

 Rehabilitation challenges of a medically complex patient with a ruptured cryptogenic brain abscess: A case report



Yevgeniya Sergeyenko, Richa Lamba, Ning Cao

Case Diagnosis: Previously independent 72-year-old male with acute ventriculitis and generalized meningitis in the setting of ruptured cryptogenic brain abscess of unknown etiology. Case Description: The patient developed multiple complications, including hydrocephalus status post ventriculoperitoneal shunt, arterial and venous thrombi, and multiple acute strokes in the posterior circulation territory. Upon admission to AIR, his low arousal, waxing/waning mental status, dysphagia, left hemineglect and left hemiparesis posed significant hurdles to his rehabilitation care. Multidisciplinary treatment approach included arousal protocol, cognitive therapy, adaptive equipment, mobility, and ADL training. Concurrently, pharmacologic treatment was optimized by decreasing seizure medication and adding high dose modafinil. Thiamine supplementation was also added for possible Wernicke Korsakoff in the setting of nutritional deficiency. The patient responded well to treatment, with notable improvement in his level of alertness and participation. Discussions: The patient's functional status began to improve with improvement in his level of alertness and participation after 20 days of acute inpatient rehabilitation training. At discharge, he required minimum assistance for feeding and grooming and moderate assistance for upper extremity dressing. He also showed improving oral management/transfer of chewable solids. He was able to be safely discharged to sub-acute rehabilitation to make further progress. Cryptogenic brain abscess is a rare diagnosis, and rupture of an abscess into the ventricle is associated with a high rate of mortality. However, in this case, medical management combined with multidisciplinary rehabilitation treatment in the AIR setting reduced mortality risk and helped to maximize the patient's functional recovery. Conclusions: Achieving functional recovery goals is complicated in a medically complex patient with a ruptured cryptogenic brain abscess and requires medical optimization as well as a multidisciplinary approach to rehabilitation treatment.

 Rehabilitation course after spinal cord infarction due to cervical epidural injection: A case report



Kathryn Altonji, Margaret Mandato, Ki H. Kim

Case Diagnosis: Quadriplegia and ventilator dependence due to spinal cord infarction after cervical transforaminal epidural steroid injection. Case Description: This is a 27-year-old male who developed anterior spinal cord and basal ganglia infarction after C6/C7 transforaminal epidural steroid injection with methylprednisolone and lidocaine. At admission to inpatient rehabilitation he had 0/5 strength in all extremities, ventilator dependence and severe dysphagia. Rehabilitation interventions included functional electrical stimulation, Lokomat training, mouth stick use, cervical strengthening, upright tolerance training and spasticity management. He has demonstrated motor return of the right lower extremity to 1-2/5 strength and intermittent activation of some upper extremity muscles. The upper extremities are flaccid and lower extremities are spastic. Light touch is mostly intact and pin prick is impaired below C3/C4. Voluntary anal contraction is absent. He progressed to a regular diet with thin liquids and tolerance of leak speech. Five months after spinal cord injury he developed spontaneous respiration with vital capacity of 100-150 milliliters, phrenic nerve study with bilateral response and is planning for diaphragmatic pacer. Discussions: There is literature identifying cases of quadriplegia due to the rare complication of spinal cord infarction after cervical epidural steroid injection. However to our knowledge, none have described the rehabilitation interventions and course. Conclusions: We describe the rehabilitation course for a case of quadriplegia and ventilator dependence due to spinal cord infarction after cervical epidural steroid injection. The patient continues to require total assistance for all ADLs however has demonstrated return of some right lower extremity motor function, improvement in dysphagia to regular diet, and spontaneous respiration with plan for diaphragmatic pacer.

 Rehabilitation following valproic acid-induced hyperammonemic encephalopathy in a patient with intractable epilepsy



Dan Nguyen, Ann Ikonne, Se Won Lee

Case Diagnosis: Valproate is a widely used anticonvulsant utilized for the treatment of seizures. Its use has been linked to Hyperammonemic Encephalopathy; a rare complication characterized by decreased levels of consciousness, focal neurologic deficits, cognitive slowing, drowsiness and lethargy. Case Description: We present a case of a 29-year-old African American male with intractable epilepsy secondary to a remote history of a left frontal CVA with associated right hemiparesis and traumatic brain injury that was initially admitted to the hospital with complaints of headache, confusion, weakness and multiple seizures. He continued to experience seizures in acute care despite treatment with 5 different antiepileptic medications. On admission, the ammonia levels were found to be elevated and peaked at 108. Discussions: Valproate was discontinued. He was started on Lactulose, Rifaximin, and Clobazam was added. Ammonia levels improved to 43 at the time of admission to inpatient rehabilitation facility (IRF), and he remained seizure free for 2 days. Initial course in rehabilitation was complicated by recurrent seizures leading to a short return to acute care. However, upon readmission to IRF, he continued to have intermittent seizures leading to ongoing neurologic insult hindering his progress. On day 9, the patient's seizures subsided and significant progress was made with extensive rehabilitation. Over his 14 day stay, comprehensive physical, occupational, and speech therapies lead to meaningful improvement in FIM scores (51 to 87). Conclusions: This case demonstrates the unique challenges of a patient with intractable epilepsy with a complex and carefully balanced medication regimen complicated by continued neurologic insult during his rehabilitation course.

 Rehabilitation for patient with prion disease



Eugene Palatulan, Akinpelumi Beckley, Frank Schirripa

Case Diagnosis: Creutzfeldt-Jakob disease. Case Description: A 65-year-old man with hypertension presented with progressive functional decline for two months with subacute paranoia, abulia, ataxia and myoclonus. Patient's initial workup for autoimmune encephalitis and post-infectious cerebellitis were unrevealing. MRI study revealed bilateral diffusion restriction and FLAIR hyperintensities in bilateral caudate, putamen, and pulvinar nuclei. Pan CT scan showed no malignancy. On admission, patient was noted to require max assistance for bed mobility and transfers with severe truncal ataxia. Neurological workup completed during acute inpatient rehabilitation course revealed positive LP results for 14-3-3 proteins and real-time quakin-induced conversion (Rt-QuIC) study making diagnosis of sporadic Creutzfeldt-Jakob disease (CJD) overwhelmingly positive. As this is known to be an irreversible and terminal diagnosis, goals of admission were transitioned to caregiver training as opposed to functional rehabilitation. Involvement of palliative care was essential in providing resources for home support and equipment. Discussions: Creutzfeldt-Jakob disease is a neurodegenerative disorder under the umbrella of prion diseases with long incubation periods and progress inexorably once symptoms appear. CJD is extremely rare, approximately 1 case of sporadic CJD per 1,000,000 population per year detected by Rt-QuIC test. Prognosis is poor and there is no known effective treatment. Rehabilitation medicine plays crucial role in ensuring that patients can effectively return home with the necessary equipment and support. As patient is rendered total dependence by this devastating disease, reducing caregiver burden becomes a very important goal especially in patients and family who choose to go home with hospice. Conclusions: CJD is a rare neurodegenerative disease. It results in devastating outcome of mental deterioration, hypokinesia, myoclonus and cerebellar signs of nystagmus and ataxia. From onset of symptom to end is unrelenting and renders a fully functional and independent person to total dependence. Rehabilitation medicine plays crucial role in reducing caregiver burden and facilitating safe return home.

 Rehabilitation in a patient with transverse myelitis secondary to acute lymphoblastic leukemia



Gilbert Siu, Jonathan Lee

Case Diagnosis: 23-year-old male with no past medical history presented with acute leg weakness, paresthesias, and fatigue. MRI of the spinal cord revealed hyperintense lesions at T7 and T8. Laboratory studies also showed abnormally elevated white count. Physical examination demonstrated flaccid lower limbs, areflexia, and sensation loss with pinprick and light touch below T7 level. This patient's functional status examination was maximum assistance for mobility and activities of daily living (ADL). Case Description: Further testing reviewed that the patient was diagnosed acute lymphoblastic leukemia (ALL). The MRI results were also consistent with transverse myelitis involving T7 and T8 spinal cord levels. The patient was started on chemotherapy and then transferred to acute inpatient neurologic rehabilitation hospital. With continued chemotherapy, the patient was started on comprehensive spinal cord rehabilitation program. After four weeks of rehabilitation, the patient ultimately progressed to a Modified-Independent level for functional wheelchair mobility and ADL. Discussions: Acute lymphoblastic leukemia is an uncommon cause of transverse myelitis. Multiple leukemia cases have shown causes of transverse myelitis after chemotherapy, bone marrow transplant and radiation, but not from ALL alone. This is the first reported case, to our knowledge, of rehabilitation course in a patient in this type of patient. Conclusions: Although acute lymphoblastic leukemia causing transverse myelitis is rare, this case highlights the importance of rehabilitation for the functional recovery of the patient.

 Rehabilitation of chronic poststroke spastic paresis: Impact of guided self-rehabilitation contracts on gait at the cardinal paul emile leger national center for rehabilitation of persons with disabilities of Yaoundé-Cameroon



Kambou Sinforian, Alex Moyou, Vincent Ombede, Etienne Tsafack, Michael Temgoua, Callixte Kuate

Objectives: Spastic paresis is a syndrome observed in many conditions including stroke. It arises after lesions of central motor pathways involved in motor command execution. This syndrome combines in order of appearance: stretch-sensitive paresis, soft tissue contracture and muscle overactivity. The current study aimed to evaluate the impact of Guided Self-Rehabilitation Contracts on gait of patients with chronic post stroke spastic paresis. Design: This was a randomized controlled trial. The intervention arm performed Guided Self-Rehabilitation Contracts based on prolonged self-stretching postures during 10 minutes for each selected muscles of the affected lower limb and motor exercises to be done in 15 seconds every day at home. All the work done was reported by patients on logbook which was verified at every weekly follow-up visit. The control arm underwent Conventional Rehabilitation sessions. Initial and final assessments took place ten weeks apart. Outcome measures included 10 meters walking test at comfortable and fast speed, passive range of motion (XV1), angle of catch (XV3, Tardieu) and active range of motion (XA). We used Student T test and Mann Whitney test for statistical analysis. Results: Ten patients were included in each arm. Baseline characteristics were similar in both groups. At the end of intervention, participants undergoing Guided Self-Rehabilitation Contracts presented greater improvement of comfortable and fast walking speed about 40% and 11%, respectively. Compared with controls, the intervention group reported higher reduction of coefficient of shortening with a significant difference between the two arms (p=0,047). Conclusions: Guided Self-Rehabilitation Contracts improved soft tissue contracture and walking speed more than Conventional Rehabilitation in patients with chronic post stroke spastic paresis. This method can be a good rehabilitation strategy for physical therapists particularly in low income countries.

 Rehabilitation of neurological manifestations of Legionnaires' disease



Deborah Pacik, Maria Jouvin-Castro

Objectives: Legionnaires' Disease. Design: A 36 year-old male maintenance worker with no significant medical history presented with vomiting, AKI, rhabdomyolysis, liver dysfunction, hyponatremia, ataxia with wide stance, dysmetria, dysarthria, poor short-term recall, clonus, and pronator drift. MRI showed corpus callosum changes consistent with an infectious process. Urine culture was positive for legionella. Pneumonia seen on imaging was asymptomatic. On admission to acute inpatient rehabilitation, he required a rolling walker for ambulation, demonstrated poor static and dynamic balance, working memory deficits, and required maximum assistance with activities of daily living (ADL). He made rapid progress with physical, occupational, and speech therapy. Three weeks after discharge, he had almost complete resolution of his symptoms with residual clonus and mild pronator drift. Results: This is a rare and complicated presentation of Legionella with multi-organ involvement but without pulmonary symptoms. Legionella is a gram-negative bacteria found in human-made water sources that is best known to cause atypical pneumonia. The incidence of infection increases in warm, humid environments and during summer months. It is associated with poverty and occupations such as maintenance, security, and construction. Neurological involvement is thought to be caused by microglial invasion in the CNS. There are published case reports describing one or two extrapulmonary symptoms but few reports with such a complex presentation and none documenting the benefit of acute inpatient rehabilitation. This patient presented with significant neurological deficits and difficulty with ADLs but made rapid progress with intense therapy. The findings of clonus and pronator drift after discharge, indications of continued CNS involvement, did not interfere with his functional ability. Conclusions: Extrapulmonary Legionnaires' disease should be considered in the differential diagnosis with acute ataxia, speech deficits, and difficulty with ADLs. Disability related to the neurological manifestations of legionella may improve rapidly with acute rehabilitation.

 Rehabilitation of persistent posthypoxic myoclonus (lance-adams syndrome): A case report



Elizabeth Aguila, Stuart Yablon

Case Diagnosis: Lance Adams Syndrome (Chronic Posthypoxic Action Myoclonus). Case Description: A 34-year-old female sustained hypoxic brain injury due to airway obstruction of uncertain duration. When found, cardiopulmonary resuscitation (CPR) was initiated for 7 minutes before return of spontaneous circulation. She was intubated, received a brief course of mechanical ventilatory support and then weaned from the ventilator. By day 11 of her acute care hospital stay, she was conscious, but manifested upper and lower extremity hypertonia with action myoclonus observed in all limbs and trunk. Diagnostic evaluation included magnetic resonance imaging (MRI) of the brain and cervical spine, vascular imaging, and electroencephalography (EEG). No acute abnormalities were observed. She experienced worsening action myoclonus and diaphoresis, despite oral benzodiazepines, baclofen and high-dose levetiracetam. At 4 months postinjury, she was admitted to IPR. Divalproex sodium and primidone were added to her treatment regimen. Action myoclonus and diaphoresis then improved, facilitating standing for short periods of time, and initiating transfers with less physical assistance. Discussions: Lance-Adams syndrome (LAS) is a rare complication of hypoxic brain injury, presenting with action myoclonus, postural imbalance and ataxia. The pathophysiology of LAS is incompletely understood. Pharmacotherapy is the mainstay of treatment for LAS and includes antiepileptic drugs and benzodiazepines. While there are few studies addressing the benefit of coordinated multidisciplinary rehabilitation for LAS, in this patient clinical improvement coincided with concurrent modification to drug therapy during IPR. Conclusions: LAS can cause severe motor impairment. A combination of pharmacotherapy with coordinated multidisciplinary rehabilitation may optimize functional improvement. Further study is warranted, especially in cases with severe LAS that persist despite pharmacologic interventions.

 Rehabilitation outcome of patients suffering from posterior reversible encephalopathy syndrome



Zeev Meiner, Yonah Ofran, Elior Moreh, Jeanna Tsenter, Isabella Schwartz

Case Diagnosis: PRES is an increasingly recognized clinicoradiologic syndrome caused by dysfunction of the brain capillary endothelium resulting in vasogenic edema mainly in the occipital lobes. The etiologies of PRES include acute hypertension, eclampsia, immunosuppressive therapy and renal disease or following surgical procedures. The main symptoms are related to the visual system including hemianopsia, visual neglect or cortical blindness. Case Description: 4 patients, 1 male and 3 females age 71, 65 and 60, 40 years old respectively, with PRES were treated in our department in the last years. PRES was diagnosed according to clinical and radiological findings in MRI. 3 patients developed PRES after surgeries and one following streptococcal pneumonia. CT scan demonstrated symmetric occipital lesions and MRI revealed symmetric, hyperintense lesions on T2 weighted images, involving posterior white matter regions of the brain characteristic of PRES Rehabilitation and cognitive outcomes were evaluated using the motor and cognitive FIM. A fMRI using specific paradigms for activating the visual cortex was done in 3 patients. All patients showed significant functional and cognitive improvement as noted by the improvement in FIM as well as other cognitive tests however little improvement was found in visual functions. Discussions: The mechanism behind PRES remains controversial and unproven. Severe hypertension leading to a blood pressure that exceeds the upper limits of autoregulation, with subsequent forced hyperperfusion, has been suggested. Conversely, vasculopathy and hypoperfusion have been reported, and the PRES imaging appearance resembles a watershed distribution. According to our study although patients with PRES syndrome improved significantly in rehabilitation in most of cognitive and ADL functions, they are left with severe visual field disturbances affecting their independence. Conclusions: It is important to recognize the symptoms of PRES early in order to prevent unnecessary interventions and to initiate specific rehabilitation treatments.

 Rehabilitation post Lance Adams syndrome: Case report



Zainab J. Al Lawati, Amra Saric

Case Diagnosis: Management of movement disorders requires multidisciplinary approach. With the advances in rehabilitation medicine and its multimodal approach Physiatrists are able to troubleshoot complex movements disorders and be an essential part in the multidisciplinary approach to provide better care. Case Description: 45 years old man attempted suicide via hanging in 2018. It was reported he was apneic for 10 seconds and then resumed breathing. Once he regained consciousness he had persistent myoclonus. He was reviewed by Neurology team who thought this is consistent with post- hypoxic myoclonus. He was admitted to the Rehabilitation facility to address his functional independence and manage his myoclonus. His medical management was optimized. He was educated how to manage when his unpredictable myoclonus occurs. After ensuring a safe home environment and independent ambulation he was discharged home. Discussions: Lance-Adams syndrome (LAS) was first described in the 1960s by Lance and Adams, who described 4 patients who developed myoclonic jerks within a few days following an episode of anoxia. After recovery of consciousness, the patients continued their abnormal clonicmovements, which were triggered by intentional action or external stimuli, and they were relieved at resting or during sleep. Although the pathophysiology of LAS has no been clearly defined, the prognosis is known to be quite good. With regards to treatment, substances like clonazepam, sodium valproate, piracetam, 5-hydroxytryptophan, fluoxetine hydrochloride and carbidopa showed positive influence on the action myoclonus. In addition to the medical management; Rehabilitation Medicine plays a vital role in optimizing patient's goals and quality of life using variable approaches. Implementing endurance exercises and cognitive strategies on top of balancing the sedative side effects of these anti-epileptics is successfully achieved with collaboration with Neurologists. Conclusions: This report illustrates the art behind the rehabilitation medicine in managing complex movement disorders improving patients' quality of life.

 Rehabilitation with complete decongestive therapy in a patient with aseptic meningitis secondary to relapsing polychondritis



Gilbert Siu, Jonathan Lee

Case Diagnosis: 42-year-old male with no past medical history presented with acute change in mental status, dizziness, and headaches. MRI of the brain revealed extensive leptomeningeal enhancement consistent of meningitis. Multiple laboratory studies, including cerebral spinal fluid, were unremarkable for infectious etiology. Physical examination demonstrated ataxia, diffuse hyperreflexia, and cognitive impairment along with right ear and nasal erythema and diffuse metacarpal joint swelling and tenderness. This patient's functional status examination was moderate assistance for ambulation and activities of daily living (ADL) with limitation in hand function due the joint swelling. Case Description: After a review of extensive laboratory testing with key physical examination features, the patient was diagnosed with relapsing polychondritis causing aseptic meningitis. The patient was given prednisone and then transferred to acute inpatient neurologic rehabilitation. The patient continued to receive prednisone during his rehabilitation course. The patient also received complete decongestive therapy (CDT) to the hands, which consisted of compression wrapping and manual lymphatic drainage. The patient's hand function, pain, and edema improved with the CDT. Ultimately, he progressed functionally to a modified-independent level and was discharged home. Discussions: Relapsing polychondritis is a rare and progressive inflammatory disease. While the pathogenesis is poorly understand, the inflammatory response affects the cartilaginous structures, predominantly the ears, nose, tracheobronchial tree, and peripheral joints. Neurologic manifestation represents only 3% of the patients and only a handful of cases present with aseptic meningitis. This inflammatory disease is treatable with corticosteroids. In this case the patient's functional and cognition status improved with rehabilitation, steroids, and complete decongestive therapy. This is the first reported case, to our knowledge, of acute rehabilitation with complete decongestive therapy in this type of patient. Conclusions: Although relapsing polychondritis with aseptic meningitis is rarely reported, this case report highlights that the importance of acute inpatient rehabilitation, and therefore this treatable disease should not be overlooked.

 Relative influence of personality tendencies on psychosocial functioning in patients with traumatic brain injury



Manabu Hashimoto, Takafumi Yamashita, Makiko Nishi, Hiroe Tsukahara

Objectives: To investigate how personality tendencies in patients with traumatic brain injury (TBI) influence their cognitive functions, behavioral and psychological symptoms, and psychosocial functioning. Design: Seventeen patients with TBI were examined (male: 15, female: 2). Personality was assessed using the Japanese version of the Minnesota Multiphasic Personality Inventory (MMPI). Cognitive functions were evaluated using the Wechsler Abbreviated Scale of Intelligence III (WASI-III), revised Wechsler Memory Scale (WMS-R), Rivermead Behavioral Memory Test (RBMT), Behavioral Assessment of the Dysexecutive Syndrome (BADS), Trail Making Test (TMT), Paced Auditory Serial Addition Test (PASAT), and modified Stroop test (mST). Behavioral and psychological symptoms were assessed using the Neuropsychiatric Inventory (NPI). Psychosocial functioning was evaluated by the Global Assessment of Functioning (GAF) scale. Statistical comparisons were made by employing the Kruskal–Wallis or Mann–Whitney U test (significance level: p< 0.05). Results: Three patterns were observed for the validity scales of the MMPI: V-shaped (”V”, n=7), inverse V-shaped (”IV”, n=5), and descending (”D”, n=5). Patients were also classified according to the MMPI T-score: i.e. whether they had normal scores on all ten of its clinical scales (≤70 pts; “N”, n=10), or at least one was elevated ( >70 pts, “E”, n=7). Although insignificant statistically, GAF scores were higher for the V group than the IV group (p=0.077). Additionally, the N group displayed better performance on the mST part 3 and the GAF scale than did the E group. Conclusions: Patients with TBI without personality tendencies that could pose clinical problems had significantly better psychosocial functioning (as measured by the GAF scale) than those with clinically significant personality tendencies. However, such tendencies exhibited no significant associations with cognitive functions or behavioral and psychological symptoms.

 Reliability and validation of the heckmatt scale for assessing muscle fibrosis in spasticity: A preliminary report



Alana Fleet, Rajiv N. Reebye, Ryan V. Sandarage, Marisa Moreta, Michael Munin

Objectives: Ultrasound-guided procedures, including botulinum toxin A injections, are increasingly used to visualize tissue targets. The Heckmatt scale is often referenced in spasticity studies to classify the degree of muscle fibrosis on ultrasound. However, this was originally designed and validated in patients with Duchenne muscular dystrophy. The aims of this study are: to validate the Heckmatt scale in patients with spasticity to assess fibrosis on ultrasound, examine reliability of the scale, and compare whether it varies with clinical experience. Design: Patients were recruited from outpatient clinics across two centres. 44 adult participants, diagnosed with spasticity in the upper (UE) and/or lower extremity (LE) and undergoing chemodenervation procedures were enrolled. 6 healthy adult controls were also included. The main variable was Heckmatt scale scores. Clinical and demographic data were also obtained for analysis. Ultrasound images were taken in a standardized approach for predetermined muscles of the UE and LE. Images were de-identified and reviewers blinded to participant characteristics. Two resident and two staff physicians were trained to assign Heckmatt ratings to 115 ultrasound images, separated over two time points. Additional comparisons were made between clinician and software-generated scores using quantitative grayscale software. Results: In assessing reliability of the Heckmatt scored images, there was good agreement within and between clinicians, with interclass correlation coefficients (ICC) intra-rater 0.81 and inter-rater 0.76 (p< 0.001). The relationship between clinician Heckmatt scored data and software-generated 'quantitative' scores showed a strong, significant correlation, with Spearman's rho = 0.829 (p< 0.001). Conclusions: Preliminary data suggests the Heckmatt scale is a valid and reliable tool for patients with spasticity to assess muscle fibrosis on ultrasound. Clinicians and researchers can apply it to future work using ultrasound in spasticity management, with potential to guide tissue targets in chemodenervation.

 Reliability of Chinese version of the walking index for spinal cord injury II



Xiaodan Ma, Weihong Qiu

Objectives: Ambulation is a primary goal of the individual who sustains a spinal cord injury (SCI). The Walking Index for Spinal Cord Injury II (WISCI II ) was cited as one of the most reliable measures of the function of walking in SCI clinical trials in the published guidelines developed by the International Campaign for Cure of Spinal Cord Paralysis. In China, there is still no research on reliability of the WISCI II . The purpose of this study is to translate the Walking Index for Spinal Cord Injury II into Chinese and to assess the reliability of the Chinese version of WISCI II in patients with spinal cord injury. Design: Thirty patients, with average age of 42.7 years. Level: 13 cervical,9 thoracic,8 lumber; ASIA (American Spinal Injury Association) impairment scale (AIS) grade: 27 D/3 C. Assessment of maximum WISCI II levels by two trained, blinded raters to evaluate test-retest and intra-rater reliability. Results: The intra-rater reliability was 0.991 for therapists A and 0.986 for therapists B, for the maximum WISCI II level. The test-retest reliability for the maximum WISCI II score was 0.984 on day 1 and 0.976 on day 2. Conclusions: The Chinese version of WISCI II has high test-retest and intra-rater reliability when administered by trained raters.

 Reliability of inertial sensor-based poststroke spasticity measurements



Sun Hyung Kim, Sang Yoon Lee, Seung Ho Jang, Shi-Uk Lee

Objectives: We investigated to compare the test-retest and inter-rater reliability of goniometer- and inertial measurement unit (IMU) sensor-based measurement of angle of catch (AoC). We aimed to describe individual variability of MAS grade 2 using IMU sensors. Design: A total of 23 stroke patients with 29 spastic (MAS 1 to 2) elbows were included. The test protocol based on the dynamic part of the mTS measurement were tested. Two examiners measured the spasticity using two instrumentations: 1) a digital goniometer and 2) an IMU-based system (Human Track, Rbiotech Co., Korea). Each limb was examined four times. Two IMU sensors tracked the motion during the tests, with a sample frequency of 100 Hz. The angles of full ROM and acceleration rate of the movements were calculated. AoC was defined as maximal deceleration point. Test-retest and inter-rater reliability of AoC measurement were calculated with Cronbach's α. From the time-angle curve, we classified the patterns of curve that correspond to the MAS grade 2. Results: Test-retest reliabilities using digital goniometer were excellent (Crohnbach's α = 0.970 and 0.968 for examiner A and B), but inter-rater reliability was acceptable (0.770). For IMU sensor method, both test-retest (0.964 and 0.949 for examiner A and B) and inter-rater reliabilities (0.933) were excellent. In 8 spastic elbows measured as MAS grade 2, patterns of AoC were as followings: (A) marked AoC point before a half of the full ROM; (B) marked AoC point after a half of the full ROM; (C) unapparent AoC during the full ROM, which means that spasticity classified as MAS 2 can be classified in detail according to AoC patterns measured with IMU based system. Conclusions: Post-stroke spasticity measurement using IMU sensors showed more reliable Results than digital goniometry. Spastic limbs with MAS grade 2 can be subclassified according to AoC patterns measured with IMU sensors.

 Repeated immunotherapy for the management of anti-NMDA receptor encephalitis: A case report



Jennifer M. Chui, Nicole Diaz-Segarra, Radhika Bapineedu

Case Diagnosis: Anti-NMDA Receptor Encephalitis. Case Description: A 40-year-old man presented with acute visual disturbances and headaches. He subsequently developed severe confusion and altered mental status. After extensive evaluation, cerebrospinal fluid revealed antibodies consistent with anti-NMDA receptor encephalitis and underlying etiology for paraneoplastic syndrome was negative. He underwent first-line treatment with intravenous immunoglobulin (IVIG) and steroids without significant clinical response. Additional treatment with rituximab resulted in symptomatic improvement. However, his hospital course was complicated by respiratory failure secondary to central ventilation syndrome and autonomic instability. After recovery, he was transferred to an acute rehabilitation facility. Upon admission, he was non-verbal, hypersexual, aggressive, and had generalized weakness. While motor recovery improved with therapy, his behavior worsened despite treatment with antipsychotic and sedative medications prompting repeat rituximab infusions. After repeat infusions, his cognitive function improved significantly, specifically speech and resolution of his hypersexual and aggressive behaviors. He was eventually discharged home and continued with outpatient cognitive therapy. Discussions: Anti-NMDA receptor encephalitis can present with a wide range of symptoms including visual or auditory distortions, speech and movement disorders, cognitive and behavioral disturbances, autonomic dysfunction, and central hypoventilation as described in this unique case. While the etiology of anti-NMDA receptor encephalitis is not completely known, one theory postulates an altered immune response to a neoplasm (paraneoplastic syndrome). First line treatments include removal of the neoplasm, IVIG, and steroids. However, immunotherapy such as rituximab can be used as a second line treatment for patients who are refractory to initial treatment. Additionally, multiple rounds of rituximab infusion may be necessary as re-emergence of symptoms can occur. Conclusions: Anti-NMDA receptor encephalitis is a serious life threatening disease and recovery is generally slow, occurring over months to years. With prompt diagnosis, proper medical management, and comprehensive therapy to address the cognitive, respiratory, and motor deficits, patients can have good recovery and prognosis.

 Representations of first and last, left and right in the brain: Lessons from multimodal spatial neglect



Lihi Isidora Mansano, Corrine Serfaty, Yaron Sacher, Nachum Soroker

Objectives: Unilateral spatial neglect (USN) is a common sequel of stroke associated with poor rehabilitation outcome. It results from impaired processing within a network that controls spatial attention, and is more frequent, long-standing and severe following right-hemisphere damage (RHD). Aim: To examine the importance of spatial location (left/right) vs. temporal order (first/last) parameters, in conditions where visual and tactile objects have to be reconstructed mentally following sequential presentation of their parts in mid-sagittal position. Design: Method: 35 first-event RHD stroke patients with left USN and 29 healthy controls were presented with pairs of 2D geometrical shapes for same/different judgment, in 3 testing conditions: a. 'visual static' [VS] – each object exposed in its entirety; b. 'visual dynamic' [VD] – objects moved horizontally (leftward/rightward) behind a central narrow slit exposing only part of the object at one time; c. 'tactile dynamic' [TD] – the upper contour of objects, similar in appearance to the visual objects, are palpated by the blindfolded participant in both rightward and leftward directions, with the index finger of the right hand. In tasks b and c the spatial representation has to be reconstructed mentally from partial, non-lateralized, sensory information. Results: In both VD and TD tasks patients demonstrated difficulty detecting a difference between the pair of shapes when it was located in the left part of the mentally reconstructed object, despite the fact that all shape parts where presented in midline position, eliminating the need for lateralized search. Recency benefitted judgement. Conclusions: Access to conscious awareness in USN depends on both the spatial and temporal tags of an object. Better understanding of the brain mechanisms underlying the variety of neglect manifestations is mandatory for development of efficient rehabilitation tools to reduce neglect-related disability.

 Results of the international spinal cord injury survey in Australia



James W. Middleton, Mohit Arora, Timothy Geraghty, Ruth Marshall, Andrew Nunn

Objectives: The Australian arm of the International Spinal Cord Injury (Aus-InSCI) Community Survey is part of a global cross-sectional study to describe the 'lived experience' of people with spinal cord injury (SCI) and identify key factors influencing level of functioning and independence, health, community participation and quality of life. Design: The Aus-InSCI study uniquely combined data from SCI units in four Australian states, a government insurance agency and three consumer organizations, using privacy-preserving data management, secure transfer and data-linkage processes, to create a representative, population-based, anonymized dataset of people with SCI. The Aus-InSCI questionnaire consists of 125 (international) and additional 68 (national) questions, including socio-demographics, SCI characteristics, body functions and structures, activities and participation, environmental and personal factors, and appraisal of health and well-being. Results: 1579 adults (18 years or older) with traumatic or non-traumatic SCI at least 12 months post-injury were recruited from March to December 2018. The mean age for the whole cohort was 58±14 years, with most participants being male (73%) with paraplegia (61%) and incomplete lesions (68%). The cohort had a wide range of 'lived experience' with time post-injury from under 5 years (23%) to more than 30 years (21%). Overall quality of life was rated by majority of respondents as being good (43.2%) or very good (19.1%). Twenty-nine percent were engaged in paid work activities (at mean time of 2.4±3 years). Compared to 1 year ago, general health was rated as better in 23%, about same in 55% and worse in 22%. The most common health issues included pain (85%), sexual dysfunction (79%), sleep disorders (78%), bowel (75%) and bladder (62%) problems. Conclusions: Aus-InSCI represents the largest and most comprehensive survey of health-related issues, functioning, social inclusion, economic participation and support needs ever conducted in Australia, providing a baseline for future comparison within Australia and international benchmarking.

 Right common carotid artery stump syndrome: A case report



Robert J. Maldonado, Shelly Gulhar, Rachna Malhotra

Case Diagnosis: 50 year-old male presented to the ED with weakness in the left upper extremity, left lower extremity and left face, found to have right common carotid artery (RCCA) occlusion. Case Description: The patient has a history of peripheral arterial disease and throat cancer status post chemoradiation. He had been experiencing intermittent L-sided weakness for a month. Neck CT showed a 3 cm thrombosis involving the proximal RCCA. Carotid duplex demonstrated occluded RCCA with patent retrograde flow in the right external carotid artery and antegrade flow in the right internal carotid artery. He was started on a heparin drip, aspirin, and high-dose statin. While in the ED, his neurological deficits resolved. The initial plan was for medical management however, he experienced intermittent episodes of transient left-sided weakness, left facial droop and slurred speech. He was taken for RCCA exploration, ligation, and division. A chronic appearing thrombus with a friable component was seen in the RCCA. His Postoperative hospital course was complicated by recurrent transient ischemic events (TIAs). Discussions: Typically, carotid stump syndrome is caused by an occlusion of the internal carotid artery which leads to periodic cerebral emboli. This is a rare case of common carotid stump syndrome with resultant cerebral ischemia. RCCA ligation was performed in order to prevent further cerebral emboli. Postoperatively the patient continued to have recurrent TIAs in the setting of normotension. At discharge, a systolic blood pressure goal of 170-180 mmHg was recommended in order to maintain adequate perfusion. Rehabilitation in these patients becomes particularly difficult due to recurrent TIAs and strokes. Therefore, it is important to emphasize the need to maintain blood pressure above the guidelines to ensure desired therapeutic outcomes. Conclusions: Further studies regarding the management of carotid stump syndrome are needed, in order to prevent further neurological damage and maximize the utility of therapeutic rehabilitation.

 RNA-Seq analyses of the effect of electromagnetic fields with different exposure time in mesenchymal stem cells during osteogenic differentiation



Xinping Li, Jiayuan Ou, Liming Bai, Pin Zhao, Wenfang Bai, Mingsheng Zhang

Objectives: Previous studies demonstrated that electromagnetic fields (EMF) could affect mesenchymal stem cells (MSCs) differentiation, and that effects of EMF on cells depend on the frequency, intensity, and exposure time, yet the underlying molecular networks associated with different exposure times of EMF on MSCs remain unexplored. We try to provide more information to determine the properly adjusted values of EMF. Design: In this study, MSCs were isolated from bone marrow and cultured with the conditioned media, then exposed to EMF at 50 Hz of frequency, 5 mT of flux densities for 30min, 1h, 3h, or 6h for 3 days. Then we used next generation sequencing to analyze gene expression profiles of EMF treated-MSCs by using the FANSe3 algorithm on the Chi-Cloud NGS analysis platform. Gene Ontology (GO) function and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis were used to analyze the molecular pathways, while qRT-PCR were used to validate the key expressed gene of the pathways. Results: When MSCs were treated with EMF for 30min, 1h, 3h, or 6h, a total of 31, 15, 313, or 177 genes, respectively, were differentially expressed compared to the control. Only 2 genes (Fam49a, Alox5) overlapped between EMF groups with different exposure time. GO and KEGG biological pathway analyses showed that the differentially expressed genes (DEGs) were enriched in biological process domain with different patterns, and in metabolic process for EMF with 3h and 6h exposure time. The DEGs were significantly enriched in 2~3 signaling pathways such as microRNAs in cancer, Rap1 signaling pathway, and Ras signaling pathway for 6h of EMF exposure. Conclusions: We provided evidence that EMF with different exposure time could alter MSCs gene expression profiles with different patterns, and continued EMF exposure has a risk of carcinogenesis in the osteogenic induction process of MSCs.

 RNA-Seq analysis identifies gene expression profiles in mesenchymal stem cells after 50Hz electromagnetic fields treatment



Xinping Li, Jiayuan Ou, Liming Bai, Pin Zhao, Mingsheng Zhang

Objectives: Several studies demonstrated that electromagnetic fields (EMF) could affect mesenchymal stem cells (MSCs) proliferation or differentiation depending on the frequency, intensity, and the exposure time, yet the underlying molecular networks associated with different exposure times of EMF on MSCs remain unexplored. Design: In this study, MSCs were isolated from bone marrow and cultured with the conditioned media, then exposed to 50 Hz EMF at 5 mT of flux densities for 30min, 1h, 3h, or 6h for 3 days. Then we used next generation sequencing to analyze gene expression profiles of EMF treated-MSCs by using the FANSe3 algorithm on the Chi-Cloud NGS analysis platform. Gene Ontology (GO) function and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis were used to analyze the molecular pathways, while qRT-PCR were used to validate the key expressed gene of the pathways. Results: When MSCs were treated with 50Hz EMF for 30 min, 1 h, 3 h, or 6 h, a total of 17, 54, 19, or 69 genes were differentially expressed compared to the control, respectively. one genes (HSPB7) overlapped between EMF groups with different exposure time. GO function analyses showed that the nitric oxide mediate signal pathway was the major pathway affected after 50Hz EMF treatment for 30min, 3h, and 6h. Enriched in the biological process related to cell motility and apoptotic process after EMF treatment for 1h were found. KEGG pathway analysis showed that DEGs enriched in biological processes at different time points exhibited a different pattern, and MAPK signaling pathway were enriched after EMF exposure for 30min and 3 hours. Conclusions: We provided evidences that EMF with different exposure time could alter MSCs gene expression profiles with different patterns, and EMF exposure might induce adaptive response after EMF treatment for 1h.

 Rod-cone dysfunction in blunt traumatic brain injury



Michael V. Nguyen, John P. Cassady, Amy Chang, Min Jeong P. Graf

Case Diagnosis: Rod-Cone Dysfunction in Blunt Traumatic Brain Injury. Case Description: A 41-year-old male presented status post motor vehicle collision at 30-40 MPH where he was restrained. Loss of consciousness was undetermined. Post-traumatic amnesia lasted less than 24 hours. GCS was 14, and head CT was negative. Patient reported occipital and posterior cervical pain, blurred vision, photosensitivity, night blindness (nyctalopia), mood instability, and cognitive symptoms. Patient had no history of prior traumatic brain injury (TBI) or family history of ocular disease. Developmental Optometry diagnosed moderate convergence insufficiency and retinal pigmentary changes. Patient was prescribed glasses with prism and tint and referred to Occupational Therapy for vision rehabilitation and to Ophthalmology. Electroretinogram performed by a Retina Specialist after a Neuro-ophthalmology evaluation demonstrated severe rod-cone dysfunction. His peripheral vision showed mild improvement with syntonic phototherapy. Discussions: Up to 90% of patients post-TBI report visual disturbance. This patient's visual complaint is consistent with post-TBI blurred vision, photosensitivity and visual fatigue. However, nyctalopia, constricted visual field and pigmentary changes are atypical and prompted Ophthalmology assessment. Low amplitudes on electroretinogram suggest severe loss of rod/cone function. The etiology of nearly all documented rod-cone dysfunction is related to genetics or autoimmune disease. This case demonstrates electrodiagnostic evidence of this diagnosis after blunt traumatic brain injury. Retinal trauma with photoreceptor degeneration is only reported in blast TBI animal model. In this case, trauma may be a possible cause leading to or exacerbating his rod-cone dysfunction. Blunt trauma resulting from motor vehicle collision may have caused eye injury with neuronal inflammation, leading to photoreceptors loss. Conclusions: Rod-cone dysfunction in TBI is a very rare occurrence. We describe one such case in a patient with no significant past history or family history of ocular disease following a blunt TBI. Rod-cone dysfunction may be considered as one of rare etiology to cause visual dysfunction after TBI.

 Role of electrophysiology in the diagnosis of human parechovirus-associated acute flaccid paralysis: A case report



Abigail V. Mendoza, Ephraim D. Gambito, Reynaldo R. Rey-Matias, Lyde M. Alday-Magpantay

Case Diagnosis: Non-Polio Enteroviruses (NPEVs) including Coxsackievirus, Echovirus and newly discovered Enteroviruses (EVs), which are implicated causes of acute flaccid paralysis (AFP), are emerging public health concerns after the Poliovirus has experienced significant stepwise reduction over the past few decades. Lately, the Department of Health in the Philippines announced an outbreak of Poliomyelitis nineteen (19) years after it was declared Polio-free. AFP-associated cases of human parechovirus (HPeV) infection in young children have been reported in literature since 2004. Confirmatory tests include stool analysis and neuroimaging of the central nervous system. While clinical and radiological features are identified in literature, descriptions of electrophysiological abnormalities are limited. Case Description: This is a case of a 1-year old Filipino boy who presented with initial focal flaccid limb weakness following a prodromal illness, which progressed asymmetrically with respiratory paralysis. Lumbar puncture results were normal, nasopharyngeal swab showed enteroviral antigens, and HPeV was isolated in stool samples. Cervical spine MRI initially demonstrated inflammatory changes in the C4 to C6 cord levels, but was normal on repeat testing after five months. Following the case definition of EV-D68 related AFM, these findings altogether led to diagnosis of AFP. Discussions: Nerve conduction study (NCS) of the upper limbs revealed normal sensory nerve action potential parameters, but the motor nerves exhibited reduced compound muscle action potential amplitudes with normal latencies and conduction velocities, indicating a pure motor axonal loss. Electromyography (EMG) was consistent with active partial denervation with patchy evidence of reinnervation process on all limbs. These findings of a diffuse axonal motor polyneuropathy are compatible with neurophysiological changes seen in limited published studies on enterovirus-associated AFP (specifically Enterovirus-D68). Conclusions: Electrophysiological studies are clinically useful as part of the multidisciplinary approach in diagnosing enterovirus-associated AFP. To our knowledge, this is the first electrophysiological description of parechovirus-associated AFP in Asia.

 Sacral level spina bifida plantar pressure analysis



Zachary J. Horwitz, Aaron Powell, Amy Bodkin, Richard Pimentel

Objectives: Individuals with sacral level Spina Bifida are known to have long term foot deformities, pain, wounds and functional decline. Plantar pressure evaluation may provide a relatively affordable and accessible way of risk stratifying children for longer term disability. The objective of this study was to compare the plantar pressures of children with sacral level Spina Bifida to able bodied controls to see if there are significant quantitative or qualitative differences. Design: The data was collected retrospectively from Children's Hospital Colorado's Gait Analysis Laboratory using a pedobarography mat. Quantitative data was analyzed using a Covariant T-Test comparing the 2 groups across 5 variables (foot progression angle, foot start location, foot end location, lateral pressure ratio, arch pressure ration). Qualitative analysis of foot shape and peak pressures was performed visually post data processing. Results: The 17 sacral level patients collected had an average age, height, and mass of 8.35 years, 123.8 cm, and 29.6 kg. The 18 control patients collected had an average age, height, and mass of 14.9 years, 161.5 cm, and 55.8 kg. All P values are listed as right foot and then left foot respectively. Foot progression angle 0.0242 and 0.116, lateral ratio 0.64614 and 0.00803, arch index 0.5436 and 0.182, start locations 0.3818 and 0.1834, and end locations 0.153 and 0.233. Qualitatively, there was much more variability in peak pressures and overall foot shape in the feet of children with spina bifida than those in the able bodied group. Conclusions: Comparative analysis reveals fundamental differences in the feet of children with sacral level spina bifida. While it is uncertain if pedobargraphy will yield information that can aid in clinical risk stratification and decision making for this population, it does show promise for future prospective research.

 Saddle pulmonary embolism in a hemorrhagic stroke patient on venous thromboembolism prophylaxis during acute inpatient rehabilitation: A review of current management options



Kevin Machino

Case Diagnosis: Saddle Pulmonary Embolism, Hemorrhagic Stroke. Case Description: A 56 year-old male with history of hypertension was admitted to acute inpatient rehabilitation (AIR) after an acute right pontine hemorrhagic stroke attributed to uncontrolled hypertension. He was continued on Heparin 5,000 units q12hrs for venous thromboembolism prophylaxis on AIR Day 1. He was functionally progressing well in all therapy sessions until AIR Day 15 when he reported new-onset shortness of breath during physical therapy. Initial SpO2 was 85% on room air in the therapy gym. Repeat SpO2 was 95% on 4L O2 nasal cannula. He was tachycardic (110 bpm) and normotensive (104/84 mmHg). He was immediately transferred to an acute care hospital ED and CTA chest revealed acute bilateral pulmonary emboli (PE) including a saddle pulmonary embolus. Discussions: The patient was started on a heparin drip and eventually underwent IVC filter placement. He was transitioned to Coumadin prior to being transferred back to AIR, where he completed his rehabilitation without complications. He was discharged home independent on all ADLs and modified independent for ambulation after a two-week AIR stay. The incidence of PE in post-stroke patients is less than 1%, with a higher rate of PE in hemorrhagic strokes compared to ischemic strokes. However, PE has a high mortality rate in post-stroke patients (up to 25%). Currently, there are no definitive guidelines on the management of acute PE in hemorrhagic stroke patients due to the high risk of rebleeding. This case sheds light on one of the few management options for PE in hemorrhagic stroke patients. Conclusions: Development of PE is possible in patients with hemorrhagic strokes despite receiving VTE chemoprophylaxis. This life-threatening condition should always be considered in patients presenting with acute-onset shortness of breath during inpatient rehabilitation. Early recognition of PE is crucial for approp