Poster 142: Palmar Fasciitis and Polyarthritis as a Paraneoplastic Syndrome Associated With Ovarian Carcinoma: A Case Report

ACADEMY ANNUAL ASSEMBLY ABSTRACTS

Outcome Measures: Treadmill walking time, Quebec Back Pain Disability Scale (QBPDS), Roland-Morris Disability Questionnaire (RMDQ), and the Swiss Spinal Stenosis Questionnaire. Results: Treadmill walking time improved significantly from baseline to 8-week follow-up in both groups 4 (control) and 2 (PT) (P⬍.05), with a trend for improvement in group 3 (combined ESI and PT). Selfreported functional status on the Roland-Morris Disability Scale demonstrated significant transient improvement in group 2 (PT) at 4 week follow-up; groups 1 and 3 worsened over time. Self-reported functional status on the QBPDS demonstrated a significant difference (P⬍.05) between groups 2 and 3 over group 4 (control) which demonstrated a worsening score over time. Conclusions: Subjects with lumbar spinal stenosis receiving therapeutic exercise (PT) improved function while subjects in the control group demonstrated worsening self-reported functional status over time. Key Words: Epidural steroid injection; Rehabilitation; Spinal stenosis. Poster 140 Optimizing Electromyography, Chemical Denervation, and Percutaneous Procedures of the Pelvic Floor With Magnetic Resonance Imaging-Based Schematics. Joseph S. Kass, MD, JD (Baylor College of Medicine, Houston, TX); Faye C. Chiou-Tan, MD; John S. Harrell, MD; Jessica S. Miller, MD; Katherine H. Taber, PhD. Disclosure: F.C. Chiou-Tan, Hanley and Belfus, receipt of royalties; Allergan, speakers bureau; Solstice, speakers bureau; J.S. Harrell, none; J.S. Kass, none; J.S. Miller, none; K.H. Taber, none. Objective: To provide anatomically accurate schematics of the pelvic floor with special attention to the muscles and their innervation. These schematics can be used to increase the accuracy of electromyography (EMG) and minimize complications when performing chemical denervation as well as percutaneous procedures such as sacral and pudendal nerve stimulator implantation. They will also aid in interpreting magnetic resonance imaging of the muscles, nerves, and cauda equina. Design: Cross-sectional schematics of the pelvic floor were drawn as they appear in imaging projections. The major nerves were clinically grouped into color-coded categories. The muscles and skin surfaces were labeled and assigned the color (or colors) of the appropriate nerves. Common anatomic variants were included. Interventions: Not applicable. Conclusions: An organized, comprehensive map of the motor innervation of the pelvic floor allows the physician to increase the accuracy, efficacy, and distribution of EMG pin placement, botulinum-A toxin injection for chemical denervation, and instrumentation for percutaneous procedures such as nerve stimulator placement. These procedures are performed to diagnose and treat incontinence, neurogenic bladder or bowel, and pelvic pain. This map may also assist the electromyographer in planning his/her study based on the detection of both neuronal injury and the pattern(s) of muscular changes in correlation with MR images. Key Words: Electromyography; Magnetic resonance imaging; Rehabilitation. Poster 141 Osteosarcoma of the Mid Femur Presenting as Lumbago in a Young Adult Recovering From Hallux Surgery: A Case Report. Geoffrey S. Keenan, MD (University of Virginia, Charlottesville, VA). Disclosure: G.S. Keenan, none. Setting: An outpatient musculoskeletal medicine clinic. Patient: A 24-year-old man with subacute low back pain (LBP). Case Description: The patient was referred from his orthopedist with right-sided LBP in the sacroiliac region that came on gradually over a period of 2 weeks. He was 1 month postoperative from a right bunionectomy, for which he had been placed in a CAM walking boot. He noted his

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lumbago was worse with ambulation and at the end of the day, and improved with swimming. There was 4 out of 5 strength in his right hip abductors and knee extensors. An X-ray of the right hip was negative for any bony abnormalities. His pain increased and required narcotics for partial control. A magnetic resonance image of the lumbar spine revealed a large broad-based bulge of the L4-5 lumbar disk, without neurologic impingement. He underwent a lumbar epidural steroid injection with no change in his pain levels. A psychiatry consult was obtained without an axis I diagnosis. A bone scan showed an area of significantly increased uptake in the proximal diaphysis of the right femur. Assessment/Results: A biopsy of the right femur was performed that revealed findings consistent with high grade osteosarcoma. Full body scanning did not reveal any metastases. He underwent a surgical resection of the tumor and adjuvant chemotherapy. Discussion: This case represents an unusual presentation of a rare cancer (approximately 750 cases/year in the U.S.). His recovery from hallux surgery and findings on examination suggested a benign musculoskeletal origin. Insidious onset pain is the most common symptom and its location involves the area affected by tumor. Swelling around the affected bone is the second most common clinical finding. Osteosarcoma, while primarily affecting the long bones of the body, typically is found in the distal femur at the knee. There are case reports in the orthopedic literature of hip pain, but not back pain, as a presentation of osteosarcoma. Conclusions: Physiatrists should be aware of atypical presentations of primary bone cancer when considering the differential diagnosis in patients with LBP. Key Words: Back pain; Femur; Rehabilitation. Poster 142 Palmar Fasciitis and Polyarthritis as a Paraneoplastic Syndrome Associated With Ovarian Carcinoma: A Case Report. Esther Pages, MD, PhD (Hospital Traumatologia & Rehabilitacion Vall d’Hebron, Barcelona, Spain); Amparo Cuxart, MD, PhD; Nuria M. Jou; Lluisa Montesinos; Isabel Rosell; Judith Sanchez-Raya, MD. Disclosure: A. Cuxart, none; N.M. Jou, none; L. Montesinos, none; E. Pages, none; I. Rosell, none; J. Sanchez-Raya, none. Setting: Rehabilitation unit in a tertiary care hospital. Patient: A 49-year-old woman with palmar fascitis and polyarthritis as a paraneoplastic syndrome associated with ovarian carcinoma. Case Description: The patient was admitted to our service in December 2007, with the suspicion diagnosis of complex regional pain syndrome type I, complaining of progressive painful swelling and stiffness in both hands, especially the palms, which were noted by the patient to have thickened progressively since September 2007. Pain and reduced range of motion gradually extended to involve shoulders and knees with no improvement after initial nonsteroidal antiinflammatory and corticosteroid treatment. She denied any previous joint diseases, Raynaud’s phenomenon, skin tightening, or trauma. Assessment/Results: Physical examination on admission was remarkable for symmetric swollen hands and fingers, painful on active and passive movement, and palmar fascial thickening with erythema. The fingers of the patient showed flexion contractures; making a fist was impossible. Examination also revealed markedly limited bilateral shoulder range of motion to 45° of abduction and 50° of flexion and limited knee flexion to 90° bilaterally. No evidence of skin sclerosis or arthritis in other locations was found. The patient’s symptoms were treated orally with a nonesteroidal anti-inflammatory and with a program of comprehensive rehabilitation. The immunologic laboratory investigation failed to show any specific abnormalities (rheumatoid factor, antinuclear antibodies, antistreptolysin titre). Radiography of both hands showed no signs of acute arthritis or osteoarthritis. Technetium-99mbone scan only showed a severe increased uptake in both wrists.Computed tomograArch Phys Med Rehabil Vol 89, November 2008

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ACADEMY ANNUAL ASSEMBLY ABSTRACTS

phy scans of the abdomen revealed a pelvic solid mass next to the uterus, suggesting an ovarian tumor. After the patient underwent total hysterectomy and anexectomy, the polyarthritis of the palms, shoulders, and knees showed a gradual spontaneous improvement, but the contractures in both hands persist despite extensive physiotherapy. Conclusions: The characteristic hand deformities of palmar fascitis and polyarthritis should alert the clinician to search for an underlying malignant disease. Key Words: Paraneoplastic syndrome; Rehabilitation. Poster 143 Pathologic Normoreflexia Due to Coexisting Upper and Lower Motor Neuron Conditions: Two Case Reports. Waqaas A. Quraishi, MD (Long Island Jewish Medical Center, New Hyde Park, NY). Disclosure: W.A. Quraishi, none. Setting: Tetiary care teaching hospital. Patients: Case 1 is a 71year-old woman seen for progressive leg weakness and balance impairments. Medical history was significant for long-standing Type II diabetes and scoliosis. In addition to proprioceptive deficits, physical exam revealed 2⫹ patellar and Achilles reflexes, Babinski signs, and clonus. Case 2 involved a 56-year old man, with a 43-year history of Type I diabetes; he presented with worsening pain in the neck and hands. Sensory deficits were noted with a stocking-glove distribution. Deep tendon reflexes at the knees and ankles were normative, with positive Babinski signs. Assessment/Results: In case 1, electrodiagnostic studies demonstrated bilateral sensorimotor peripheral neuropathy, consistent with her diabetic history. Magnetic resonance imaging (MRI) of the spine demonstrated severe dextroscoliosis and spondylosis with central stenosis. In case 2, nerve conduction testing revealed sensorimotor peripheral polyneuropathy and bilateral carpal tunnel syndrome. Cervical spine MRI demonstrated mild cord compression via spondylosis and disk disease. Analysis of both cases uncovered concomitant upper motor neuron dysfunction in addition to the expected lower motor neuron dysfunction. Conclusions: With myriad causes for hyper/hyporeflexia, the physician must be cognizant that normoreflexia does not automatically indicate normative neurologic function and that in the setting of anticipated abnormal reflexes, normoreflexia mandates further evaluation. Key Words: Diabetic polyneuropathy; Reflex; Rehabilitation. Poster 144 Pilot Study for Dual Radiofrequency Neurotomy in the Treatment of Sacroiliac Joint Dysfunction. Jonathan D. Burns, MD (The SMART Clinic, Sandy, UT); Scott Adelman, MD; Joseph G. Cunniff, DC, DO; Michael T. Giovanniello, MD; Angela M. Krull, MD. Disclosure: S. Adelman, Medtronic, speakers bureau; Richard Wolf USA, speakers bureau; Clarus Medical, speakers bureau; J.D. Burns, none; J.G. Cunniff, none; M.T. Giovanniello, Pfizer Celebrex, speaker, consulting fees, or other remuneration; Medtronic, clinical instructor, consulting fees, or other remuneration; A.M. Krull, none. Objective: To evaluate the effectiveness of dual radiofrequency neurotomy for sacroiliac joint (SIJ) dysfunction. Design: Pilot prospective cohort. Setting: Outpatient private practice. Participants: 9 patients with clinical evidence of SIJ dysfunction and previous positive response to intra-articular injection. Interventions: Conventional radiofrequency ablation of 3 target sites along the L5, S1, S2, and S3 lateral branches, followed by dual denervation between the 3 target sites, was performed on the symptomatic side. All denervations were preceded by sensory and motor stimulation. Main Outcome Measures: Patients’ perceived percentage improvement, patients’ satisfaction with procedure results, visual analog scale (VAS), and difference Arch Phys Med Rehabil Vol 89, November 2008

in subjects’ perceived function. Results: Patients were seen in follow-up between 2 weeks and 5 months following the procedure. Patients completed a subjective percentage improvement, VAS, and functional status questionnaire and were asked about their satisfaction with the procedure. Mean percentage improvement was 68.0%. 87.5% of patients were pleased with procedure outcomes. Average decrease in VAS following the procedure was 2.6, a decrease of 26%. Function increased an average of 20.8%. There were no observed complications. Some subjects experienced self-limited soreness for several days following the procedure. Conclusions: SIJ dysfunction is a significant etiology of low back pain. Variable innervation and biomechanics make treatment of this pain generator difficult. While intra-articular injections are diagnostic and sometimes therapeutic, denervation of sensory input to the SIJ offers more long-term relief. Strategies for SIJ denervation include intra-articular and targeting the sensory twigs off the lateral branches of L5, S1, S2, and S3 dorsal rami. In our study, conventional radiofrequency with subsequent dual radiofrequency neurotomy of these lateral branches represents a potential strategy for decreasing pain and improving function. A more extensive study is underway examining the physiology and long-term efficacy of this technique. Key Words: Low back pain; Rehabilitation; Sacroiliac joint. Poster 145 Plantar Fasciitis and Job Characteristics in a Working Population. Robert A. Werner, MD, MS (Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI); Nancy Gell, PT, MPH; Anne G. Hartigan, MD. Disclosure: N. Gell, none; A.G. Hartigan, UAW-GM, research grants; R.A. Werner, UAW-GM Health and Safety, research grants. Objective: To analyze the relationship between a diagnosis of plantar fasciitis and factors such as job characteristics and anthropometric properties of the foot. Design: Cross-sectional study. Setting: Automotive assembly plant. Participants: 407 employees from an automotive plant, including assembly, administrative, and skilled trades workers. Interventions: Not applicable. Main Outcome Measures: Diagnosis of plantar fasciitis based on questionnaire and physical examination. Results: Based on logistic regression, predictors for plantar fasciitis include pressure at the metatarsal heads, with a 3% increase in risk for every additional pound/square inch over the metatarsal heads (P⫽.02). Subjects with forefoot overpronation during gait were 3.3 times more likely to develop plantar fasciitis compared with those who do not overpronate (P⫽.002). Standing on a surface other than carpet was also a risk factor for plantar fasciitis. Subjects who rotated the number of shoes worn for work had a 40% decrease in risk of having plantar fasciitis (P⫽.03). Age, body mass index, and weight did not contribute significantly to the model, nor did type of job (assembly vs administrative), or perceived amount of time standing on the job. Conclusions: Factors that may predict plantar fasciitis include increased pressure at the metatarsal heads and increased forefoot pronation during gait. There was no relationship found between job factors such as perceived time spent standing and walking and a diagnosis of plantar fasciitis. Subjects who did not have symptoms of plantar fasciitis were more likely to rotate 2 or more pairs of shoes for work. Key Words: Occupational medicine; Rehabilitation.