Hematoma Presenting as Lower Extremity Pain: A Case Series

Case Diagnosis: 67-year-old woman with right adductor pain and 57-year-old woman with right knee pain, both found to have hematomas Case Description or Program Description: Patient A is a 67-year-old female with breast cancer who presented to hospital with vomiting, was diagnosed with COVID, and developed encephalopathy. During inpatient rehabilitation (IPR), she developed right adductor muscle pain. Patient B is a 57-year-old female with history of multiple aneurysms, who presented to hospital with COVID complicated by gastrointestinal bleed. She required intubation due to altered mental status. During IPR, she developed severe right knee pain. Setting(s): Inpatient rehabilitation hospital Assessment/Results: Patient A had increase in right thigh circumference with negative bilateral lower extremity Dopplers. Her hemoglobin was 5.4. CT right lower extremity without contrast revealed a large hematoma in left mid thigh. Surgery recommended wrapping with ACE bandage. Patient B was found unresponsive with pulse and significant hypotension. Her hemoglobin dropped to 6.1. CT abdomen and pelvis revealed large retroperitoneal bleed of right iliopsoas and iliacus. She underwent interventional radiology guided embolization of lumbar artery. Discussion (relevance): Patient A had pancytopenia due to cancer. Her hemoglobin was 8.5 prior to the discovery of the hematoma. Her underlying comorbidities played a role in her rapid presentation of hematoma. Patient B was found to be unresponsive at home prior to acute care hospital admission. Etiology was unclear. Her decreased mental status may have complicated the interpretation of musculoskeletal pain. She reported 10/10 knee pain but had a benign exam. Conclusion(s): Musculoskeletal complaints are common, especially in IPR setting. As physiatrists, we must keep anemia from hematomas, associated with high mortality, on the differential diagnosis for lower extremity musculoskeletal pain. Frequent lab monitoring and physical exams are essential in timely diagnosis and treatment of hematomas.

Functional Improvements of Patients Admitted to an Inpatient Rehabilitation Facility after Bilateral Lung Transplant Due to Severe COVID-19 Pulmonary Disease

Objective: To describe the inpatient rehabilitation (IPR) course of patients who underwent bilateral lung transplant due to severe COVID-19 pulmonary disease. Design(s): Retrospective chart review Setting: Free-standing, academic, urban inpatient rehabilitation hospital Participants: Seventeen patients aged 28-67 years old (mean 53.9 +/- 10.7) who developed COVID-19 respiratory failure and underwent bilateral lung transplant. Intervention(s): Patients participated in a comprehensive IPR program including physical, occupational, and speech therapy tailored to the unique functional needs of each individual. Main Outcome Measure(s): Primary outcome measures of functional improvements, include mobility and self-care GG scores, as defined as quality measures by the Centers for Medicare and Medicaid Services. Other functional measures included 6 minute walk test, Berg balance scale, and Mann Assessment of Swallowing Ability (MASA). Wilcoxon Signed Rank Sum Test was used to evaluate statistical significance between admission and discharge scores. Result(s): Fourteen patients completed inpatient rehabilitation. Self-care (GG0130) mean score improved from 20.9 to 36.1. Mobility (GG0170) mean score improved from 30.7 to 70.7. Mean 6-minute walk distance improved from 174.1 to 455.1 feet. Mean Berg balance scores improved from 18.6/56 to 36.3/56. MASA scores improved from 171.3 to 182.3. All scores changes were statistically significant with p value < 0.01. 76% of patients discharged home. Conclusion(s): This retrospective review demonstrates that this new and unique patient population can successfully participate in a comprehensive inpatient rehabilitation program and achieve functional improvements despite medical complications. Advances in medical technology have increased the number of people with severe respiratory failure who are eligible for lung transplant and inpatient rehabilitation facilities have adapted to the changing COVID-19 medical landscape. It is important for rehabilitation providers to recognize opportunities to treat new patient populations and to be able to adjust treatment protocols accordingly.

Baseline Levels of Inflammation in Association with Functional Recovery in COVID-19 Patients

Background and/or Objectives: Elevated levels of inflammatory laboratory markers have been shown to be associated with increased severity of acute COVID- 19 infection, and may have prognostic value in predicting mortality. However, the relationship between inflammatory markers and functional outcomes in inpatient rehabilitation has not yet been studied. Our study examines this relationship, with the goal of investigating if there is prognostic value of these labs for rehabilitation potential. Design(s): Retrospective cohort study Setting: Acute inpatient rehabilitation at Shirley Ryan AbilityLab, Chicago IL Participants: N=182 patients admitted to an inpatient rehabilitation facility (IRF) for functional impairment secondary to acute COVID-19 infection. Intervention(s): Not applicable Main Outcome Measure(s): The relationship between change in mobility, self-care, and cognition functional independence measures from admission to discharge, and selected laboratory values on admission: leukocyte count, platelet count, erythrocyte sedimentation rate (ESR), and c-reactive protein (CRP). Statistical analysis was performed using Spearman's rank correlation for lab values as continuous variables and two-sample t-tests for labs as categorical values (normal vs abnormal). Result(s): There were no statistically significant associations between change in functional outcomes and selected inflammatory laboratory values. However, the baseline laboratory values of ESR and CRP trended towards an association with change in self-care (p=0.09 and p=0.08, respectively), and baseline CRP trended towards an association with change in mobility (p=0.07). An abnormal platelet count trended towards less improvement in self-care scores in IRF from admission to discharge (p=0.08). Conclusion(s): Inflammatory laboratory markers do not show a clear association with functional improvement through inpatient rehabilitation for COVID-19-related debility. However, given the near significance of several lab values, a larger sample size may elucidate prognostic value of several of these markers, which would provide utility for expected rehabilitation needs after infection with acute COVID-19.