He was discharged home following the small bowel resection butreturned to the emergency room within 48 hours for multiplesyncopal episodes. He then had progressive complications of diffuseautonomic failure including neurogenic bladder, anhidrosis, inabil-ity to make tears or saliva, pupillary dysfunction and eventualsignificant orthostatic and postprandial hypotension. He remainedin a tertiary care hospital for over 1 month resulting in considerabledeconditioning. The patient was eventually transferred to acuteinpatient rehabilitation facility with goals of regaining functionalindependence.Setting: Acute inpatient rehabilitation facility.Results or Clinical Course: The patient’s symptoms are con-sistent with a diagnosis of AAG that impacted his bowel, bladder,ability to perform transfers and activities of daily living (ADLs)safely.Discussion: AAG is considered a type of autoimmune neuromus-cular disorder. Patients with AAG develop antibodies to ganglionicnicotinic acetylcholine receptors located in the sympathetic, para-sympathetic and enteric ganglia resulting in symptoms of diffuseautonomic failure. There are very few documented cases of AAG,with no documented cases, to our knowledge, of rehabilitation forthese patients.Conclusions: Significant autonomic dysregulation caused byAAG can pose a unique challenge to the rehabilitation process.Successful achievement of independence in mobility, ADLs andbowel/bladder management can be accomplished with an inte-grated team approach incorporating pharmacological, mechano-physiologic principles and a progressive rehabilitation program.

Poster 326Ultrasound Guidance Utilized to Refill a ChallengingIntrathecal Baclofen Pump: A Case Report.John W. Rayburn, MD (University of Missouri, Columbia,MO, United States); Jane A. Emerson, MD.

Disclosures: J. W. Rayburn, No Disclosures.Case Description: A 16-year-old with mild cerebral palsy,hemi-dystonia, and autism with a recently implanted intrathecalbaclofen (ITB) pump presented for her initial refill. The patient wasobese and intolerant of deep palpation to her pump site. We couldnot palpate the pump or verify its position with X-ray. We decidedto utilize our clinic ultrasound in an attempt to verify positioning ofthe ITB port which negated the need for sedation or exposure toadditional radiation. The port was easily localized and the overlyingskin was marked with the open end of a pen. Images were capturedshowing the port on ultrasound. The refill was then performed withsterile technique utilizing a single injection, without redirection.Setting: Outpatient physiatry clinic.Results or Clinical Course: Diagnostic ultrasound was utilizedto successfully locate a baclofen pump in this challenging patient.This avoided the need for palpitation and repeated needle injectionswhich would have created stress for this patient. The patient toler-ated the procedure well and there were no complications.Discussion: ITB pumps are commonly used to treat patients withproblematic spasticity or dystonia. Refilling these pumps can bedifficult, depending on the patient’s body habitus and the positionof the pump, especially when the pump cannot be easily palpated.In certain patients, these refills are time consuming and stressful forboth the patient and the physician. An ITB refill was successfullyand easily performed utilizing ultrasound guidance.

Conclusions: Ultrasound provides a safe and easy mechanism tolocalize the refill port in patients with ITB pumps.

Poster 327The Role of Singing as a Rehabilitation Intervention.Joslyn John, MD (UMDNJ- Kessler, Newark, NJ, UnitedStates); Gautam Malhotra, MD.

Disclosures: J. John, No Disclosures.Objective: While there is ample research on the effects of musictherapy, there is only a limited amount of studies done on theintervention of singing. The objective of this paper is to review andanalyze existing research regarding singing as a medical interven-tion, and to consider its potential role as an adjunctive therapy invarious patient populations in rehabilitative medicine.Design: A comprehensive literature review was done on singingtherapy on PubMed. The bibliographies of these papers were thenreviewed. Articles that focused on melodic intonation therapy (adistinct therapy for aphasia), therapy for professional singers, andmedical issues pertaining to the voice were discarded.Setting: N/A.Results: Singing as an intervention was shown in the general popu-lation to significantly increase IgA, and have a positive effect on mood,energy, general well-being, stress reduction, lung capacity, and posture.It was also shown to increase FVC (although a statistical significancewasn’t reached). In the asthmatic population, improvements of pulmo-nary function were not statistically significant; however it was found tohelp health awareness, communication, and compliance among anindigenous people. For patients with COPD, singing classes signifi-cantly improved quality of life and anxiety levels as per surveys, al-though pulmonary function assessments in each study were varied;some studies showed significant improvements in expiratory function.Singing therapy also showed some improvement (not statistically sig-nificant) in expiratory function in multiple sclerosis patients. A pilotstudy done on Parkinson’s patients revealed significant changes inmaximum phonation time, functional residual capacity, maximal in-spiratory pressure, maximal expiratory pressure, and quality of voice. Anonsignificant improvement in coping was found in chronic painpatients after enrolling in singing classes. A pilot study was also done onchronic snorers, which suggested singing could reduce the time ofsnoring.Conclusions: More studies are needed to establish objective sta-tistically significant improvements for pulmonary function, qualityof life, stress reduction, and phonation with singing as an interven-tion.This tool could be a cost-effective, enjoyable adjunctive modal-ity for recreation or speech therapists.

Poster 328Acupuncture for Treating Chronic Distal Stump Painin an Above Knee Amputee Veteran: A Case Report.Kamala Shankar (VAPAHCS/Stanford, Livermore, CA,United States); Arlene Frobish, OTR, CHT, BCB; Jeffrey K.Teraoka, MD.

Disclosures: K. Shankar, No Disclosures.Case Description: A 69-year-old veteran with history of withchronic distal stump pain for 5 years. He has peripheral vasculardisease and in 2007 had a re-vascularization procedure, followed bybelow knee amputation. He was having constant pain in distalstump and he has tried physical therapy, prosthesis and narcoticmedications. He underwent at knee amputation in November 2009.

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The AKA revision was done in January 2010. His residual limb islong and is tender to palpation at the distal end. Acupuncture wasdone because he had ongoing pain in the residual distal stump.Program Description: He had tried other conservative modal-ities prior to acupuncture trial. Prior to initiation of acupuncturetreatments, patient reported pain at 8/10 on the Visual Analog PainScale (VAS). Biofeedback measures were done to assess heart rate(HR) variability, abdominal breathing, EMG muscle tension andskin conductance during rest, stressor and recovery. VAS was alsodocumented before and after treatment. Biofeedback measures weredone immediately before and after acupuncture treatment to assessfor objective improvement.Setting: Veterans administration outpatient PM&R clinic; acu-puncture has been utilized for pain control. In this case we haveused SP 9, GB 34, GB 33, ST 36 in the opposite limb, amputeelimb-GB 32, amputee distal stump points; side of amputation LI11,LI4 were also done.Results or Clinical Course: Patient demonstrated improve-ment after acupuncture. Improvement was seen in 1) HR variabilityrecovery after stressor, 2) skin conductance, 3) pain scores, and 4)decrease and regularity in respiratory rate with abdominal breath-ing, and 5) EMG muscle tension in quadriceps muscle showed 40%decrease in muscle tension was noted. Overall improvement inscores since beginning of acupuncture treatment is 50%.Discussion: In this case, there were significant improvements inall 5 measures. This case report shows potential for acupuncture fortreatment of chronic distal stump pain.Conclusions: Future studies with larger sample sizes are neededto find an objective tool to measure long-term effectiveness ofacupuncture for amputee stump pain.

Poster 329The Effect of Bilateral Above the Knee Amputationsin Becker Muscular Dystrophy: A Case Report.Keith Burchill, DC, MD (William Beaumont Hospital,Royal Oak, MI, United States); David Hass, ATP; RandiLong, MD.

Disclosures: K. Burchill, No Disclosures.Case Description: Patient is a 66-year-old man with Beckermuscular dystrophy (BMD) and bilateral above knee amputations(AKA). Patient required a left AKA for peripheral vascular disease(PVD) and femur fracture secondary to a fall. A right AKA had beenrequired several years earlier, also in the milieu of PVD. He lastwalked at the age of 47. Immediately prior to his second AKA, thepatient’s strength was such that he required 2 persons with maxi-mum assistance for transfers.Setting: Tertiary care hospital: inpatient rehabilitation.Results or Clinical Course: Therapies focused on bed mobility,transfers, sitting balance and the family was trained to performsliding board transfers. FIM scores improved from 39 at admissionto 47 at discharge. Most of the patient’s improvement was seen inwheelchair/locomotion (1 to 6) as well as eating (1 to 4). Ourmultidisciplinary team worked to identify barriers to his wheelchairuse. Prior to his second AKA his chair was 20” wide to accommodatehis hip abduction contractures. Bathroom access was hampered bywheelchair width. After the amputations, the spread of abductionwas reduced, allowing for scaling back to an 18” width. The loss ofhis lower limbs resulted in loss of counter balance. He would fallforward in his chair. His shoulders’ weakness and limited range

required him to bring his head forward while eating which furtheraltered his balance. Falling forward also occurred with mobility.These needs were met by moving the center of gravity rearward by6” with a 15-25 degree tilt while driving.Discussion: To the best of our knowledge there are no docu-mented cases of bilateral AKA in patients with BMD. As medicalmanagement of cardiac dysfunction improves, these men are livinglonger. New challenges in activities of daily living presented them-selves after the loss of his legs as a counter balance. Assistance withbed mobility was reduced due to not having to manage his weaklegs. He declined cosmetic prosthetic fitting.Conclusions: New considerations must be employed when pa-tients with severe myopathy undergo amputations of their limbs.Changes to wheelchair specifications may be needed. Mobility withprosthetic limbs is likely not possible due to severe weakness andcardiac demands.

Poster 330Rehabilitation of a Patient with Polymyositis-Dermatomyositis Complicated by Heart Failure: ACase Report.Kelly Baron, MD (Moss Rehab, Elkins Park, PA, UnitedStates); Heather R. Galgon, DO; Harry W. Schwartz, MD.

Disclosures: K. Baron, No Disclosures.Case Description: The patient is a 57-year-old man who wasadmitted to a tertiary care hospital with complaints of progressiveweakness in the upper and lower extremities. He was found to haveelevated creatinine phosphokinase (CPK) and a rash. MRI revealeddorsal paraspinal muscle signal abnormality compatible with myositis.Electromyography (EMG) results were consistent with inflammatorymyopathy. He was admitted for acute inpatient rehabilitation with adiagnosis of polymyositis-dermatomyositis (PM-DM). On hospital day9 he complained of shortness of breath requiring oxygen supplemen-tation. Clinical examination revealed crackles bilaterally, jugular ve-nous distension, and 3� pitting edema in bilateral lower extremities.Cardiology was consulted and further work-up was initiated. B-typenatriuretic peptide (BNP) was elevated at 1000 and the patient wasaggressively diuresed without significant improvement. Transthoracicechocardiogram revealed an ejection fraction (EF) of 45%, mild dia-stolic dysfunction, and volume overload. Unable to fully participate inacute rehabilitation, the patient was transferred to acute care for furtherwork-up and management of new onset heart failure.Setting: Acute inpatient rehabilitation hospital.Results or Clinical Course: The patient’s cardiopulmonarystatus was stabilized; however, he was unable to participate at therequired level for acute inpatient rehabilitation. Rheumatology con-cluded the patient had a poor prognosis given his cardiac involve-ment in the setting of PM-DM.Discussion: Although cardiac involvement in the setting ofPM-DM has been well described in the Cardiac literature, it has notbeen well documented in the Rehabilitation literature. Implicationsfor diagnosing and rehabilitating a patient with concomitant inflam-matory myopathy and heart failure will be discussed further.Conclusions: Serious cardiac complications are possible in thesetting of idiopathic inflammatory myopathies, including PM-DM.If present, cardiac conditions may adversely affect the course ofrehabilitation as well as provide insight to the patient’s long-termprognosis.

S302 PRESENTATIONS