Disclosures: Elizabeth A. Aguila, MD: Nothing to disclose

Case Description: 72-year-old male with 4 months of unintentional 20-pound weight loss, diffuse weakness and dysphagia. He was admitted with pneumonia and twice underwent esophageal dilatation with no improvement of his dysphagia. His acute care stay was complicated by recurrent aspiration pneumonia and hypoxic respiratory failure. A gastrostomy tube and tracheostomy were performed and he was unable to be weaned from positive pressure ventilator support. He was admitted to a ventilator acute inpatient rehabilitation (IPR) unit with a presumptive diagnosis of critical illness neuromyopathy. Upon admission to IPR he had upper motor neuron findings, multiple areas of muscle fasciculations and hand intrinsic muscle atrophy, which differed from the prior Neurology examinations. Magnetic resonance imaging of the brain and cervical spine were negative for acute process. Electrodiagnostic study (EDX) was completed while in IPR, supportive of the diagnosis of motor neuron disease.

Setting: Inpatient Rehabilitation

Patient: 72-year-old male

Assessment/Results: Patient was diagnosed with critical illness neuromyopathy but due to symptom-specific additional history, physical exam findings and the progressive difficulty weaning off the ventilator this diagnosis was not supported. The additional evaluation performed during IPR admission was presumptive for bulbar-onset ALS, which significantly changed the patient’s prognosis and home discharge. A multi-disciplinary family meeting was held to coordinate a plan for discharge home on full-time positive pressure ventilator support and intermittent gastrostomy tube enteral feedings. The patient and his family were trained, and patient was discharged home successfully.

Discussion: Traditionally in IPR, patients come with a presumptive diagnosis. Subsequently, the multidisciplinary treatment plan is formulated focusing on neurologic and musculoskeletal recovery. In this case, the unique perspective and experience of the rehabilitation team helped to quickly determine the appropriate work-up and diagnosis. After a new diagnosis was established, the focus shifted from functional improvement to patient-centered care and a medically complex home discharge.

Conclusion: Bulbar onset ALS

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/the-role-of-inpatient-rehabilitation-for-the-diagnosis-and-management-of-amyotrophic-lateral-sclerosis-als-case-report/