1303 - “Injecting Progress in Acute Inpatient Rehabilitation (AIR)”: A Case Report on How to Prioritize Rehabilitation and Chemotherapy

Case Diagnosis: Successful inpatient onabotulinumtoxinA injections in a patient with spasticity after mechanical fall leading to traumatic subdural and subarachnoid bleeds on top of pre-existing glioblastoma multiforme.

Case Description: 69-year-old male with history of hypertension and left posterior frontal glioblastoma multiforme presented to AIR due to traumatic left subarachnoid hemorrhage and left temporoparietal subdural hemorrhage after a fall two weeks prior. Admission exam notable for right sided hemiparesis, tone of 3-4 of the right upper and lower extremities, dysarthria, and dysphagia. His tone caused significant pain that interfered with therapy. He was initially started on oral medications, but this failed to improve his tone and caused side effects. Given this, and the need to expedite his therapy gains so that his cancer treatment could resume, 600 units of onabotulinumtoxinA was administered on the right side. Within the next week, his tone reduced and the patient was able to make steady progress in therapy.

Discussions: Spasticity is a complication seen in traumatic brain injury that can limit functional gains in therapy. Oral medications were trialed but side effects interfered with therapy. Although inpatient oncobotulinumtoxinA is not typically covered by insurance and it takes time to see its effects, in this unique case it was determined that the therapeutic benefit outweighed the aforementioned concerns, ultimately expediting his rehab and the resumption of chemotherapy. Due to time constraints and difficulty contacting the patient's primary oncologist, this decision was made between the rehabilitation team and the family.

Conclusions: This case serves as an example of how inpatient toxin can improve tone in patients with spasticity refractory to therapy and oral medications. In the future, palliative care should be involved early in discussions surrounding rehabilitation versus chemotherapy, as many oncology teams are hesitant in discussing prognosis which is an important factor in determining rehabilitation course and goals.