S202 PRESENTATIONS

Results or Clinical Course: After 8 days of CIR, her sensationand strength were unchanged, but her endurance improved totolerate standing 10 minutes and ambulating 80 feet without rest ata modified-independent level of function using a rolling walker.She was discharged home and briefly achieved remission after 6cycles of dose-adjusted etoposide, prednisone, vincristine, cyclo-phosphamide, and doxorubicine (EPOCH) chemotherapy 4months after discharge. Her cancer relapsed, but she remainedfunctionally independent.Discussion: ATL is a rare cancer always associated with HumanT-Lymphotropic Virus Type I. in the United States, the incidence ofATL is 0.05/100,000 people. Fatigue is a common cancer symptomand side-effect of chemotherapy that correlates with decreasedfunction. By comparing physical fitness before, during, and afterchemotherapy, researchers found that lymphoma patients had, overthe course of chemotherapy, increasing reports of fatigue andsignificant declines in quadriceps force, handgrip force, andmaximum oxygen uptake. This case illustrates how CIR canpreserve function in ATL patients prior to undergoing treatment.Conclusions: Providers should be aware that ATL is a raredisease with insidious onset and a poor prognosis. CIR has beengenerally shown to be beneficial, but this is the first description ofa patient with ATL receiving durable functional benefits prior toundergoing chemotherapy.

Poster 59Acupuncture Treatment for Scar Release AfterTraumatic Burn to the Lower Extremity: A CaseReport.Kashif Saeed, MD (Rush University Medical Center,Chicago, IL, United States); Craig Best, DO;Colleen M. Sullivan, MD; Stathis Poulakidas, MD;Gerard L. Dysico, MD.

Disclosures: K. Saeed, No Disclosures: I Have No RelevantFinancial Relationships to Disclose.Case Description: A 56-year-old man status post motor vehicleaccident (MVA) with third degree burns (total body surface area of5%) to the right posterior lateral thigh and lower leg who under-went grafting with skin grafts taken from the anterior upper thigh.Post-surgical scar was approximately 15 cm in length. Patient wasnoted to have an area of increased scar thickness at the lateral lowerleg just inferior to the fibular head. Additionally, his examinationwas significant for altered biomechanics with resulting compensa-tory overuse throughout the kinetic chain superior to the right leg.After minimal relief with oral medications, the patient agreed toa localized acupuncture treatment to the right leg.Setting: Outpatient musculoskeletal clinic.Results or Clinical Course: Initial acupuncture treatmentconsisted of a myofascial scar release to the right proximal lateral legwith 10 needles surrounding the length of the scar within his graftsite. Electric stimulation was applied to the superior and inferiorends as well as at the greatest area of immobile scar tissue (6 leads intotal) at 150 Hz for 20 minutes. After the treatment, patient wasinstructed to start passive dorsiflexion range of motion exerciseprogram with gastrocnemius stretching. On follow up, patient wasnoted to have improvement in sensation to light touch in theperoneal nerve distribution in the leg and foot. The scar at thesurgical graft site showed an improved central puckering along thefibular head and neck.

Discussion: The acupuncture protocol utilized in this case wastaught at the Helms Medical Institute. The use of non-pharma-ceutical methods such as acupuncture for scar release should beconsidered as an alternative to using steroid injections.Conclusions: In addition to the western treatment modalitiesand methods, acupuncture is a viable method for scar releasetreatment.

Poster 60Baclofen-Induced Depression in a Multiple SclerosisPatient: A Case Report.Ty D. Lai, MD (Sinai Hospital, Baltimore, MD, UnitedStates); Sarah A. Eby, MD.

Disclosures: T. D. Lai, No Disclosures: I Have No RelevantFinancial Relationships to Disclose.Case Description: A 45-year-old woman with a history ofmultiple sclerosis (MS) presented with a 4-day history of worseninglower extremity weakness and spasticity. MRI of the brain showedextensive plaques, but no new lesions were identified. Upontransfer to inpatient rehabilitation, initial motor examination wasnormal in the upper limbs and 3/5 in the key muscles of the rightlower limb and 4/5 in the left lower limb. She had significant rightquadriceps spasticity with Modified Ashworth Scale (MAS) grade 3and hyperreflexia throughout the right lower extremity. Initialpsychiatric evaluation was normal. She required assistance withmobility and activities of daily living.Setting: Tertiary medical center inpatient rehabilitation unit.Results or Clinical Course: The patient was initiated on oralbaclofen 10 mg twice daily and up-titrated to 50 mg per day overthe course of 1 week. She had significant improvement in rightquadriceps spasticity to MAS grade 2. She was able to ambulatewith rolling walker. She initially tolerated baclofen well. However,she developed increasing depression with suicidal ideations. Shealso had severe headaches. Baclofen was suspected and she wasweaned off. She returned back to her normal baseline mental statusand her headaches resolved. She was discharged home withsupervision from her family.Discussion: Oral baclofen is widely used to treat spasticity relatedto MS and other neurological conditions. Baclofen is well known tocause psychiatric withdrawal symptoms such as hallucinations andconfusion. However, although more rare, baclofen can also causeadverse psychiatric side effects such as major depression as seen inour case.Conclusions: Providers should be aware, not only of thepsychiatric withdrawal symptoms of baclofen, but also of lesscommon psychiatric side effects such as depression and halluci-nations.

Poster 61An Evaluation of the Content of DischargeSummaries for Patients Admitted to an InpatientRehabilitation Facility (IRF).Kirill Alekseyev, EMBA (Kingsbrook Jewish MedicalCenter, Brooklyn, NY, United States); Ashish Khanna, MD;Adrian Cristian, MD, MHCM; Marc K. Ross, MD.

Disclosures: K. Alekseyev, No Disclosures: I Have No RelevantFinancial Relationships to Disclose.

PM&R Vol. 6, Iss. 9S, 2014 S203

Objective: To evaluate barriers to discharge during dischargesummary of patients being admitted to an inpatient rehabilitationfacility (IRF).Design: Retrospective review.Setting: IRF in an inner city hospital.Participants: 87 individuals referred for admission to IRF fromin-hospital as well as from outside hospitals.Interventions: A discharge summary questionnaire was designedbased on the Joint Commission Transitions of Care HandoverProcess (JCTCHP) recommendations. The questionnaire wasimplemented as a part of admission record review prior to admis-sion to the IRF.MainOutcomeMeasures: Discharge SummaryQuestionnaire.Results or Clinical Course: Sixteen criteria for a qualitydischarge to IRF were identified and placed on the questionnaire.Their percentages are as follows: 1. ‘Name of Transferring AttendingPhysician’ with 89.3% (75/84) of discharge packets, 2. ‘Reason forHospitalization and Diagnosis’ was present with 92.9% (78/84), 3.‘Hospital Course Clearly Described’ was present with 72.3% (60/83), 4.‘Procedures Performed’ present with 70.4% (50/71), 5.‘Accurate and Up-to-date Medication List, Including Instructionsfor Discontinuation of Medications’ was present with 75.6% (65/86), 6.’Telephone or In-Person Conversation with TransferringPhysician’ occurred with 23.2% (19/82), 7.’Names of Key Consul-tants’ was present with 44.3% (35/79, 8.’Labs and Imaging ReportsProvided’ was present with 81.3% (65/80), 9.’Test Results’ waspresent with 36.4% (20/55), 10.’Anti-coagulation Instructions’ waspresent with 27.0% (10/37), 11.’Weight Bearing Status TherapyInstructions’ was present with 50.0% (24/48), 12.’Seizure Treat-ment, Prophylaxis Instructions’ was present with 15.4% (2/13),13.’Antibiotic Instructions provided’ was present with 50.0% (14/28), 14.’ Wound Care Instructions’ was present with 21.9% (7/32),15.’ Diet Instructions’ was present with 93.7% (74/79), 16.’Instructions for Further Treatment’ was present with 72.0% (59/82). The total patient population included 44.8% (39/87) of patientfrom in-hospital discharges (82.1% (32/39) from medicine and17.9% (7/39) from surgery) and 55.2% (48/87) from outsidehospitals discharges.Conclusions: Poor or incomplete discharge information hasa very real impact on the safety of patients in an IRF. To maximizepatient safety at transitions in care, it is important for physiatrists toobtain accurate information from the transferring service andinstitution.

Poster 62The Ethical Considerations of Treating a PediatricPatient Who Is Unaware of Her Diagnosis DespiteHaving the Capacity to Assent: A Case Report.Michael J. Ingraham, MD (Georgetown/NationalRehabilitation Hospital, Washington, DC, United States);Justin Burton, MD.

Disclosures: M. J. Ingraham, No Disclosures: I Have No RelevantFinancial Relationships to Disclose.Case Description: A 14-year-old female patient was admitted toour inpatient pediatric rehabilitation unit after an orthopedicprocedure. She had a medical history notable for viral encepha-lopathy from perinatally acquired human immunodeficiency virus(HIV) with resultant spastic dystonic quadriparesis. Prior to

admission, the team was informed that the patient was unaware ofher HIV diagnosis. Cognitively, the patient had mild impairmentsbut was enrolled in a public high school at the 9th grade level. Shewas on an experimental protocol of antiviral drugs, for which hermother consented on her behalf without the patient’s knowledge.Our team was expected to continue to provide this experimentalmedication during her inpatient rehabilitation stay and we wereinstructed to tell her “that medications are for her legs” if the patientasked a team member.Setting: Inpatient Pediatric Rehabilitation Unit.Results or Clinical Course: Several team conferences were heldto discuss the ethical dilemma of withholding treatment informa-tion from a patient with the capacity to understand her diagnosis.We worked with the patient’s adopted mother to determine whythe patient had not yet been informed and when she planned to tellthe patient her full diagnosis. A plan was put in place to involve thepatient’s biologic mother in the discussion of her diagnosis whichwas to happen as soon as all family members could be present.Discussion: This case exhibits several issues regarding patientrights and community safety. First, having to lie in order todistribute the medication implies the patient has the capacity tounderstand her diagnosis, despite family concern she is notemotionally ready for such news. Additionally, providing a poten-tially harmful experimental medication to a patient who has thecapacity to make her own decisions violates her right to autonomy.Lastly, withholding the HIV diagnosis from the patient has potentialcommunity health concerns as this patient has a resistant case ofHIV that she could potential transmit unknowingly to any sexualpartners if proper barrier protection is not used.Conclusions: It is important to involve the entire medical teamwhen addressing ethical dilemmas in patient care.

Poster 63Hereditary Motor and Sensory Neuropathy Presentingas a Crush Injury with Ulnar Neuropathy: A CaseReport.Michael J. Ingraham, MD (Georgetown/NationalRehabilitation Hospital, Washington, DC, United States).

Disclosures: M. J. Ingraham, No Disclosures: I Have No RelevantFinancial Relationships to Disclose.Case Description: Patient was an athletic 24-year active dutymale who had a metal door slam onto his wrists 1 year ago whileserving in Afghanistan. Thereafter, patient noted progressiveweakness and wasting in his hands, but did not report thesesymptoms to his superior as he was afraid it would remove himfrom active duty. Patient finally presented when he was no longerable to salute properly. Given his history of crush injury to hisbilateral wrists, his primary care physician provided a referral forelectrodiagnostic studies to assess for ulnar neuropathy.Setting: Outpatient Physical Medicine and Rehabilitation Clinic ata Tertiary Care CenterResults or Clinical Course: Nerve Conduction Studies revealedseverely decreased conduction velocities between 12-20 meters/second in bilateral ulnar nerves. However, bilateral median nerveswere also noted to be markedly slowed. Further history andphysical revealed a family history of ankle sprains and foot defor-mity, and lower extremity conductions were equally slowed.Discussion: Given the above findings, concern for hereditarymotor and sensory neuropathy (HMSN) was high. Genetic testing