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652 - From Symptoms to Solutions: The Physiatrist's Approach to Multifactorial Upper Extremity Weakness

Friday, February 28, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

NR

Natalia Ryabenkova, n/a

Medical Student
NYITCOM
Brooklyn, New York, United States

Co-Author(s)

CK

Chi Lam Kwok, DO

Resident Physician
Nassau University Medical Center
East Meadow, New York, United States
FB

Forrest Butensky, DO

Resident Physician
Nassau University Medical Center
East Meadow, New York, United States
AI

Adam Isaacson, MD

Program Director. Department of Physical Medicine and Rehabilitation
Nassau University Medical Center
East Meadow, New York, United States

Case Diagnosis: Multifactorial Upper Extremity Weakness

Case Description: A 52-year-old male presented to physiatry clinic for evaluation of diffuse left upper extremity (LUE) weakness, muscle atrophy, and left shoulder subluxation. His symptoms began with left index finger weakness in September 2023, progressing to complete LUE weakness and loss of wrist and hand function. Physical exam revealed LUE strength no greater than 1/5, intact sensation and reflexes, and positive Hoffman’s sign. Left shoulder X-ray showed inferior humeral head subluxation. Cervical spine MRI revealed multilevel foraminal narrowing, while brachial plexus MRI was unremarkable. EMG was inconclusive due to poor tolerance, though spontaneous activity in the left deltoid suggested active denervation. The patient was referred to orthopedics and neurology and continued OT for LUE strengthening.

Discussions: This case presents a diagnostic challenge with severe LUE weakness and multiple potential etiologies, including brachial plexopathy, cervical radiculopathy, and intracranial pathology. OT focused on addressing functional impairments through range of motion, strengthening, and shoulder stabilization. Splinting included a cock-up wrist splint for daytime use and a custom resting hand splint for nighttime support, to maintain hand positioning and prevent contractures. Given the positive Hoffman’s sign, a brain MRI was ordered to rule out stroke, while cervical MRI findings indicated foraminal narrowing as a contributing factor. Collaboration with orthopedics and neurology was essential for exploring surgical or medical interventions.

Conclusions: This case illustrates the critical role of PM&R in addressing limb weakness with functional loss through a multidisciplinary approach. For this patient, PM&R initiated targeted OT interventions, prescribed functional braces to improve limb positioning, and ordered advanced imaging, including MRI of the brain, to rule out stroke due to the positive Hoffman’s sign. By coordinating with orthopedics and neurology, physiatry ensures that all potential causes are investigated and rehabilitation strategies are optimized to enhance the patient's functional recovery and quality of life.