tomy tube for respiratory and nutritional support. Over 2 months in along-term care facility, she was weaned off the ventilator. She thenpresented to acute rehabilitation, and on examination, was tetraplegicand had poor oral and head control. She had significant atrophy of herbilateral tibialis anterior and gastrocnemius muscles and had a Cush-ingoid appearance. Subsequent electromyography and nerve con-duction studies (EMG/NCS) demonstrated critical illness poly-myopathy and critical illness polyneuropathy, but no evidence ofsteroid-induced myopathy. Steroid treatment was continued andthe team optimized her rehabilitation program by avoiding resis-tance exercises to decrease the chance of muscle fiber loss. Inapproximately 5 weeks, the patient was able to slightly move herright upper extremity with gross movements at the shoulder,which helped her in using a power wheelchair.Program Description: A 39-year-old woman.Setting: Tertiary care rehabilitation center.Results or Clinical Course: EMG/NCS demonstrated criticalillness polymyopathy (CIPM) and critical illness polyneuropathy(CIPN) but not steroid-induced myopathy in a patient on long-termsteroids.Discussion: Tolosa-Hunt Syndrome is a rare disorder characterizedby severe and unilateral headaches with extraocular palsies and im-paired vision if there is a delay in treatment. This is the first reportedcase, to our knowledge, of a patient with Tolosa-Hunt and locked-insyndromes who developed critical illness polyneuropathy and criticalillness polymyopathy. Optimization of her acute inpatient rehabilita-tion therapeutic and medication program was possible by identifyingthe cause of her weakness and atrophy with EMG/NCS.Conclusions: EMG/NCS is an important means of identifying theetiology of weakness in a patient who has visual impairment withTolosa-Hunt syndrome who had been on long-term steroid therapyand locked-in syndrome with additional bilateral pontine infarct.

Poster 112Isolated Median Neuropathy after PercutaneousTransluminal Angioplasty: A Case of MedialBrachial Fascial Compartment Syndrome.Amit Dholakia (Northeastern Rehabilitation Associates,P.C., Wilkes-Barre, PA, United States); Zach Broyer, MD;Theodore D. Conliffe, MD; Dennis N. Nutini, MD.

Disclosures: A. Dholakia, No Disclosures.Case Description: A 67-year-old woman with left arm pain andweakness.Program Description: A 67-year-old woman with a history ofmesenteric arterial stenosis who presented with complaints of lefthand weakness and discomfort for 4 months after a percutaneoustransluminal angioplasty with stent placement in the superior mes-enteric artery. The left brachial artery was used as the access site.After the procedure, she had bruising and pain of the left upper armwith weakness and paresthesias in her left hand. She followed upwith her vascular surgeon a week later who felt there was nosustained arterial damage. She continued to have neurologic deficitsand was eventually referred for a physiatric evaluation. Initial phys-ical examination revealed sensory deficits of the first three digits ofher left hand as well as significant weakness. She underwent elec-trodiagnostic study for further evaluation.Setting: Physiatry private practice.Results or Clinical Course: Nerve conduction studies of theleft median motor and sensory nerves were unobtainable. EMG

revealed acute denervation and poor motor unit activity of thepronator teres, flexor carpi radialis, and abductor pollicis brevis.The left delotoid, biceps, triceps, extensor indicies proprius, flexorcarpi ulnaris and first dorsal interosseus were normal.Discussion: Medial Brachial Fascial Compartment (MBFC) syn-drome is an uncommon condition that has been reported as acomplication from percutaneous brachial arterial puncture. MBFChas been described as a tunnel surrounded by the medial intermus-cular septum and a tough brachial fascia that extends from the axillato the elbow. This tunnel includes contents of the axillary andbrachial arteries, branches of the brachial plexus, and the axillarysheath surrounding the neurosvascular bundle. The mechanism ofinjury of the MBFC syndrome is due to hematoma formation result-ing in compartment syndrome which can lead to peripheral nerveinjury within the MBFC. MBFC syndrome is underrecognized assymptoms maybe delayed. Successful management of this compli-cation is based on early recognition and prompt surgical manage-ment. In our case, this condition was not addressed ahead of time.Conclusions: This is a case of an isolated median neuropathy asa result of MBFC syndrome. MBFC is a rare complication of angio-graphic access.

Poster 113Suprascapular Neuropathy Following TotalShoulder Arthroplasty: A Case Report.Anupam Sinha, DO (Rothman Institute, Philadelphia,PA, United States); Madhuri Dholakia, MD.

Disclosures: A. Sinha, No Disclosures.Case Description: A 75-year-old woman with a history of bilat-eral glenohumeral arthritis, status post left total shoulder arthro-plasty 6 months prior, presented with complaint of persistent weak-ness and lack of range of motion in the left shoulder. She denied anyneck pain or upper extremity radicular symptoms. She did reportparesthesias in both hands. She denied any bowel or bladder dys-function. She denied any shoulder weakness prior to the surgery.Physical examination was unremarkable except for weakness notedin the left shoulder abductors and external rotators, along withpainful passive range of motion in both shoulders. Musculoskeletalultrasound of the left shoulder revealed rotator cuff tendinosis alongwith moderate atrophy of the rotator cuff muscles.Setting: Outpatient orthopedic practice.Results or Clinical Course: Electrodiagnostic studies of the leftupper extremity showed evidence of denervation in the left su-praspinatus muscle with absent recruitment; the supraspinatusmuscle was found to be normal. There was also evidence of bilateralcarpal tunnel syndrome. There was no evidence of cervical radicu-lopathy or brachial plexopathy. A diagnosis of left suprascapularneuropathy was made.Conclusions: The most common complications following totalshoulder arthroplasty include prosthetic loosening, glenohumeralinstability, periprosthetic fracture, rotator cuff tears, infection, neu-ral injury, and deltoid muscle dysfunction. Here we present a case ofinfraspinatus syndrome following total shoulder arthroplasty. Thesuprascapular nerve is vulnerable to entrapment at the superiorscapular notch and the spinoglenoid notch. Selective involvementof the suprascapular nerve at the spinoglenoid notch results in theisolated atrophy and weakness of the infraspinatus muscle thatcharacterizes infraspinatus syndrome. Mechanisms of injury during

S228 PRESENTATIONS

surgery may include nerve traction, nerve compression secondary totaut ligaments and nerve transection.

Poster 114Multifocal Acquired Demyelinating Sensory andMotor (MADSAM) Neuropathy Secondary toInfliximab Infusion: A Case Report.Anupam Sinha, DO (Rothman Institute, Philadelphia,PA, United States); Madhuri Dholakia, MD.

Disclosures: A. Sinha, No Disclosures.Case Description: A 69-year-old man with a history of ulcer-ative colitis, status post C4-C7 fusion (secondary to myelopathyover 10 years ago), presented with a 1-year history of right upperextremity pain and paresthesia. Recent MRI of the cervical spineshowed evidence of a well-healed fusion from C4-C7 with findingsof degenerative changes at C3-4 and C7-T1. The patient did have anMRI of the brachial plexus, which was unremarkable. The patientdenied any lower extremity symptoms; however, he did have someparesthesias in the sole of his feet. The patient noted that most of hissymptoms began after infliximab infusion therapy for ulcerativecolitis. His last infliximab infusion was 8 weeks prior to this ap-pointment. He denied any bowel or bladder dysfunction. On phys-ical examination, the patient was neurologically intact, except forexcept for 4/5 strength in the right hand intrinsics. There were noupper motor neuron signs.Setting: Outpatient spine practice.Results or Clinical Course: Electrodiagnostic studies of theupper and lower extremities showed prolonged latencies, dimin-ished amplitudes and conduction velocities, in multiple nerves in anon-focal distribution. Diminished recruitment and polyphasic po-tentials were found in the majority of muscles in the upper andlower extremities. The patient was diagnosed with multifocal ac-quired demyelinating sensory and motor (MADSAM) neuropathy.He was referred to neurology where he was advised to beginintravenous immunoglobulin (IVIg) therapy.Discussion: Multifocal acquired demyelinating sensory and mo-tor (MADSAM) neuropathy is defined clinically by a multifocalpattern of motor and sensory loss, with nerve conduction studiesshowing conduction block and features of demyelination. Alsoknown as Lewis-Sumner syndrome, this neuropathy is a rarelyreported complication in patients undergoing treatment with theantitumor necrosis factor � (TNF-�) monoclonal antibody inflix-imab. Symptoms may resolve after cessation of the antibody treat-ment; however IV Ig infusion therapy is the treatment of choice ifsymptoms persist.Conclusions: We present a rarely reported case of MADSAM, orLewis-Sumner syndrome, following infliximab treatment. Clini-cians should be aware that electrodiagnostic studies are essential inthe diagnosis of this complex neuropathy.

Poster 115Improving Electrodiagnostic Medicine Skills &Competency in Physical Medicine andRehabilitation Residents Utilizing a Peer to PeerTeaching Module.Brite J. Chalunkal, DO, DPT (NYPH Cornell/ColumbiaUniversity, Yonkers, NY, United States); ChristopherVisco, MD.

Disclosures: B. J. Chalunkal, No Disclosures.

Objective: This project sought to determine the effectiveness of apeer to peer EMG hands-on training course as an educationalmodule including evaluation methodology to instruct residents inelectrodiagnostic evaluation and to quantify acquired competenciesin those electrodiagnostic skills through objective evaluation meth-odology.Design: One-way repeated measure ANOVA.Setting: Level 1 trauma center.Participants: 14 PM&R residents: 7 PGY2s and 7 PGY3s.Interventions: Fourteen residents participated in a course inwhich the senior third-year residents were assigned to teach thejunior residents through technical training concepts. Prior to thehands-on course all residents were required to take a 36-questionwritten examination, which tested basic aspects of EMG and clinicalanatomy. All of the residents also completed a 20-questionhands-on pre-course practical. After delivery of the educationalmodule, knowledge acquisition and skill attainment were measuredin clinical skill in diagnostic procedures via a procedure checklistand written exam.Main Outcome Measures: Objective measures compared res-ident pre and post course written and practical scores in electrodi-agnostics (EDX) before and after institution of the comprehensiveEDX competency module.Results: 14 of the 14 residents (100%) successfully demonstratedproficiency in every segment of the evaluation element of theeducational module by the end of the electrodiagnostic course.There was a statistically significant difference in pre and post scoresin both the written and practical overall with a P score less than .05. In the PGY2 group N(7) there was an improvement of practicalscore from 27.5 � 10 to 77.5 � 15 (P�.0005) and an improvementin written from 41.6 � 4 to 63.43 � 11.3 (P�.0016). In the PGY3group N(7) there was also an improvement of practical scores from70.8 � 11 to 98.3 �3 (P�.01) and an improvement in written from45.8 � 7to 74.75 � 9.6 (P�.00012).Conclusions: The standardized educational peer to peer moduleand evaluation methodology provide a potential frame work for thedefinition of baseline competency in the clinical skill area of EDX.

Poster 116Riche-Cannieu Anastomosis Masquerading asSevere Median Neuropathy: A Case Report.Christopher J. Hess, MD (University of Virginia, Charlot-tesville, VA, United States); Jeffrey G. Jenkins, MD.

Disclosures: C. J. Hess, No Disclosures.Case Description: A 45-year-old woman presented with insid-ious onset of right upper extremity pain over 8 months. She hadbeen diagnosed with acute severe right-hand median neuropathyfound on EMG/NCS performed 2 months after symptom onset byan outside provider. Specifically, the electrodiagnostic reportshowed severe reduction in median compound motor action poten-tial (CMAP) amplitude and 3� fibrillation potentials in the abduc-tor pollicis brevis. The patient was referred for continued symptomsthat were refractory to carpal tunnel injection. It was noted onexamination that her thenar musculature was well preserved; thiscalled into question the diagnosis of severe median neuropathy,prompting referral to our lab for repeat testing.Setting: Academic outpatient electromyography lab.Results or Clinical Course: Repeat EMG/NCS performed 8months after symptom onset showed the following: Findings- 1.

S229PM&R Vol. 4, Iss. 10S, 2012