Effective Rehabilitation Management of Central Pontine Myelinolysis: A Case Study

PM&R Vol. 5, Iss. 9S, 2013 S159 multiple brain ischemic infarcts in the left thalamus, bilateral midbrain, left occipital lobe and right basal ganglia. On admission to Rehabilitation, physical examination showed flaccid quadriplegia with an isolated right thumb movement. Alertness was intact. The patient was able to communicate by opening and closing his eyes. Initial rehabilitation efforts resulted in minimal functional recovery. Around 12 weeks after surgery, volitional movements were noted and this was followed by an exponential gain in function. After 16 weeks of comprehensive rehabilitation, including robot-assisted walking therapy, the patient was able to speak short sentences, propel a wheelchair, don/doff his shirt and ambulate x 20 ft with moderate assistance. Setting: Pediatric Inpatient Rehabilitation Unit Results or Clinical Course: 11-year-old male with Locked-in syndrome for 12 weeks showed unexpected functional gains with comprehensive rehabilitation. Discussion: The most common mechanism of Locked in syndrome is a basis pontis infarction. Based on accepted literature, most functional recovery occurs within the first few weeks after the insult. This presentation reports on an unusual case when a genetic disorder resulted to a cascade of events that led to a pediatric patient in a locked-in state for 3 months. Expectations for appre- ciable functional recovery seemed unrealistic at that stage. A patient centered multidisciplinary approach with close communication with the parents seemed to have played a key role in the patient’s unexpected gain in function. Conclusions: 11-year-old male with Locked-in syndrome for 12 weeks showed unexpected functional gains with comprehensive rehabilitation. Poster 58 Bilateral Brachial Plexopathy: Differential Diagnosis of Amyloidosis? A Case Report. Susan Griffee (Mayo, Rochester, MN, United States); Ronald K. Reeves, MD. Disclosures: S. Griffee, No Disclosures: I Have Nothing To Disclose. Objective: Patient presented with complaints of long-standing bilateral hand numbness. Review of history revealed the numbness in her hands began approximately seven years prior. Despite undergoing bilateral carpal tunnel release, she continued to complain of numbness and pain in digits 1-5. Subsequently two years later, she continued with worsening hand numbness, but also developed extreme fatigue, dyspnea, and unrelenting nausea. Abdominal fat aspiration confirmed the diagnosis of amyloidosis, eventually requiring heart and liver transplant. After transplant, she was admitted to rehabilitation, her chief complaint bilateral hand numbness. Setting: Acute Rehabilitation Unit Participants: A 63-year-old woman with complaints of severe numbness in bilateral hands, with diagnosis of amyloidosis. Results or Clinical Course: Electromyography (EMG) was ordered. Results showed prolonged distal and significantly reduced amplitude of median motor studies. The ulnar motor amplitude was also reduced without focal conduction block or slowing. Needle exam showed florid fibrillation potentials and large complex motor unit potential in the first dorsal interossei, deltoid, triceps, and pronator teres. Clinical Interpretation concluded longstanding, smoldering patchy widespread bilateral brachial plexopathy Discussion: Amyloid neuropathy can affects up to 20% of diag- nosed amyloidosis. Amyloid neuropathy presenting sign most often involve small fibers that affect the lower extremity (similar to dia- betes mellitus) or isolated median neuropathy. In our case, the clinical and EMG findings were consistent with bilateral plexopathy secondary to amyloidosis. To our knowledge, no previous reported case of bilateral brachial plexopathy has been reported. Clinicians and electromyelographers evaluating EMG findings of bilateral brachial plexopathy could consider listing amyloidosis in the differential diagnosis. Conclusions: Amyloidosis should be considered in the differ- ential diagnosis when EMG and clinical symptoms correlate with bilateral brachial plexopathy. Poster 59 Effective Rehabilitation Management of Central Pontine Myelinolysis: A Case Study. Michael J. Ingraham, MD (Georgetown/National Rehabilitation Hospital, Washington, DC, United States); Cynthia G. Pineda, MD. Disclosures: M. J. Ingraham, No Disclosures: I Have Nothing To Disclose. Case Description: Patient is a 59-year-old woman who devel- oped central pontine myelinolysis (CPM) at an outside hospital. Initially she was believed to be merely deconditioned and slow to recover from a prolonged hospital stay on a ventilator for pneu- monia. However, her prolonged course and bulbar symptoms prompted investigation with further imaging. MRI revealed a large area of central edema and restricted diffusion in the pons consistent with central pontine myelinolysis. She presented to the acute rehabilitation hospital with tetraplegia. She was unable to ambulate or perform transfers. She had cognitive communication deficits which included dysarthria and decreased working memory. She had dysphagia and was restricted to a soft diet with nectar thick liquids. Other functional limitations included fatigue, decreased balance and endurance. Setting: Acute Inpatient Rehabilitation Hospital Results or Clinical Course: Patient had acute inpatient comprehensive rehabilitation with Speech Language Pathology (SLP), Physical Therapy (PT), and Occupational Therapy (OT) with medical, nursing, and psychology staff support. By time of discharge, her dysphagia improved and she was able to tolerate a regular consistency diet with thin liquids. Cognition and memory also improved and she did not require outpatient SLP. She was ambulating greater than 150 feet with a rolling walker and was able to perform activities of daily living (ADL) at supervision level. She was able to return home to family with PT and OT services. Discussion: CPM is a rare pathology that can result in lethargy, acute paralysis and bulbar symptoms from either over correction of hyponatremia or chronic alcoholism. Bulbar features such as dysphagia and dysphonia may be the defining feature. This pathology is not well represented in the physiatric literature, and further investigation into proper functional management is needed. Conclusions: This case describes that acute comprehensive inpatient rehabilitation is effective in promoting functional recovery of cognitive, paralytic and bulbar symptoms following osmotic damage in a patient with CPM. Outline placeholder Setting Results or Clinical Course Discussion Conclusions Bilateral Brachial Plexopathy: Differential Diagnosis of Amyloidosis? A Case Report Disclosures Objective Setting Participants Results or Clinical Course Discussion Conclusions Effective Rehabilitation Management of Central Pontine Myelinolysis: A Case Study Disclosures Case Description Setting Results or Clinical Course Discussion Conclusions