Dominic Marchese

Poster 205 Treatment Characteristics of Post-Stroke Adults Diagnosed with Spasticity Among Commercially and Medicare Insured Populations

toxin, Dysport, spasticity, and clinical trial. The review was first conducted in 2013 and was updated up to February 2016. Setting: All studies included in this review were conducted in specialist centers. Participants: Subjects with ALLS, irrespective of etiology. Interventions: Not applicable. Main Outcome Measures: Study methodology, patient, and treatment-level data were extracted from the full-text publications under predefined headings (efficacy, safety, dosing). Results: A total of 6 primary publications evaluating abobotulinumtoxinA in a total of 468 patients with ALLS due to stroke, TBI, or multiple sclerosis met inclusion criteria. A range of outcome measures were used including: muscle tone (assessed using the Modified Ashworth Scale), range of movement (passive and active), walking parameters, pain, and activities of daily living. Total abobotulinumtoxinA doses ranged between 500U and 2000U, depending on the lower limb muscles injected. All studies showed significant reductions in muscle tone. When assessed, abobotulinumtoxinA was consistently associated with significant effects on pain. Effects on walking parameters were less consistent but generally favored abobotulinumtoxinA injections. AbobotulinumtoxinA was generally welltolerated across the studies. Treatment-related adverse events included but were not limited to fatigue, local pain at injection site, hypertonia, weakness of the noninjected muscle, abnormal gait, and urinary tract infection. Conclusions: Based on the evidence from 6 randomized clinical studies reviewed, it can be concluded that abobotulinumtoxinA injections consistently reduce tone and can be effective in the management of ALLS. However, there was a relative lack of large trials of abobotulinumtoxinA in this indication. Ongoing studies in this area will add to this evidence base. Level of Evidence: Level I

Poster 296 AbobotulinumtoxinA Injection Patterns in Patients with Cervical Dystonia from the ANCHOR-CD Registry Study

fear of being “fat” and gaining weight for the last 9 months resulting in self starvation. She also self discontinued her post surgery recommended vitamins 1 year ago. She weighed 350 lbs prior to gastric by pass surgery 3 years ago and at the time of admission patient weighed 110 lbs. She was admitted initially at Tertiary care hospital for generalized weakness and malnutrition; she was recommended for an inpatient eating disorder clinic. However, the patient was not eligible for the clinic due to her physical/functional deficit as their patients are required to be independent. Upon rehab admission, she complained of ankle pain with weight bearing and right elbow soreness with any lifting activity. She also complained of numbness in her feet and hands with intermittent burning pain radiating from feet to thighs. There were also a non-pruriginous, non-tender erythematous punctate macular skin changes on upper extremities, areas of diffuse ecchymosis lower extremities, and minor gum bleeding with teeth brushing. Setting: Rehabilitation Hospital. Results: BMI was 19.1 on admission. Xray of elbow negative for fracture. Laboratory testing showed low vitamin D (27 ng/mL), hypokalemia, low albumin, hypomagnesia, vitamin C, zinc, MMA, B1, and B12 were pending. Treatment for scurvy and other vitamin deficiencies was initiated with oral and IV magnesium, oral potassium chloride, vitamin D, zinc, folate, thiamine, B12, multivitamin with minerals, and vitamin C. After 1 week, rash resolved, gum bleeding improved, and joint pain improved. After improved oral intake and supplements, patient improved with traditional physical and occupational therapy. There was emphasis on education regarding food for functional gain in contrast to solely weight gain. She achieved modified-independence level for bed mobility, transfers, CGA for ambulation and stairs, supervision-modified independence for ADLs. Her BMI on discharge was 20. Discussion: The patient was not responding to traditional physical and occupational therapy due to generalized weakness and pain. After gastric bypass surgery, patients are prone to deficiencies with fat soluble vitamins, calcium, iron, vitamin B12, and folate. In cases with increased vomiting, thiamine may be deficient. Poor nutrition intake can lead to vitamin C deficiency also known as Scurvy. Vitamin C is integral in the formation of collagen and deficiency due to poor intake can lead to malaise, fatigue, gum bleeding, poor wound healing, joint pain, and capillary fragility. The recommended daily allowance of Vitamin C is 60 mg. Usual cases of anorexia nervosa do not have the physical and neurological deficits this patient exhibited secondary to decreased vitamin absorption combined with poor nutrition intake. After improved oral intake and vitamin supplementation, the patient was more responsive to therapies and achieved her functional goals. Conclusions: Generalized weakness and joint pain after gastric bypass surgery should include evaluation of all vitamins and not just fat soluble vitamins especially when the patient has history of psychiatric diagnoses and an eating disorder. Level of Evidence: Level V

Poster 479 Economic Burden of Pediatric Spasticity in Cerebral Palsy: A Review of the Literature

Disclosures: Nicole Clarke: Ipsen provided research funding to Pharmerit Ispen Biopharmacueticals Objective: To evaluate the health related quality of life (HRQoL) associated with spasticity in cerebral palsy patients (CP). Design: Comprehensive literature review from 2005-2015 in PubMed & Embase. Setting: Various. Participants: Pediatric and/or young adult patients (up to age 24) and their caregivers. Interventions: Various. Main Outcome Measures: Patient reported outcomes. Results: At least 22 studies reviewed used various validated instruments to capture HrQoL, including the SF-36 and SF-6D, Child Health Questionnaire, Pediatric Outcomes Data Collection Instrument, Questionnaire on Pain Caused by Spasticity, and the Pediatric Evaluation and Disability, among others. Consistently reported domains impacting CP patients with spasticity included physical functioning, bodily pain, mental health, and social functioning. Health state utility values from the SF-6D (range 0.741 to 0.797) were lower than the population norm of 0.82 for young adults aged 20-29 years. Pain was the domain that maximally impacted HrQoL in spastic CP patients and was the highest reported symptom followed by tightness due to spasticity. Those with lower limb spasticity experienced high scores and impact on disability domains. Caregivers were more likely to over-report pain, and provide lower HrQoL compared to those reported by CP patients. Gait speed was reported as important for the caregiver, though correlated less with self-perceived HrQoL for children. Interventions to reduce spasticity such as botulinum toxin type A injections, intrathecal baclofen therapy, or selective dorsal rhizotomy improved HrQoL. A reduction in parental stress levels and caregiver burden was reported for treatments that reduce spasticity with both patient and parents likely to request these treatments. Conclusions: Studies suggest treatments to reduce spasticity improve overall HrQoL, measured by various instruments, and improve selfreported pain scores. Future areas of research should include humanistic value of new treatments based on type of CP and severity. Level of Evidence: Level II

ANCHOR-CD (AbobotulinumtoxinA Neurotoxin: Clinical and Health Economics Outcomes Registry in Cervical Dystonia): An Economic Evaluation of the Reimbursement Cost of Dysport® Treatment for Non-Naive Patients

Setting: Outpatient Physical Medicine and Rehabilitation Clinic Results or Clinical Course: EMG testing was consistent with denervation of both the trapezius and rhomboids on the right side. Normal paraspinal and serratus anterior electrodiagnostics ruled out other potential causes of lateral scapular winging such as C5-6 radiculopathy and upper trunk plexopathy. The electrodiagnostic studies indicated peripheral damage to both the dorsal scapular and spinal accessory nerves. Discussion: Lateral scapular winging is a rare condition that can result in severe pain and functional limitations. Lateral scapular winging is most commonly attributed to iatrogenic damage to the spinal accessory nerve. A search of the literature did not reveal any cases of lateral scapular winging secondary to peripheral nerve injury involving both the trapezius (spinal accessory nerve) and rhomboids (dorsal scapular nerve). The patient’s physical examination, mechanism of injury, and electrodiagnostic findings highlight the close anatomic relationship between these 2 nerves and their potential for damage in cases of penetrating neck trauma. Conclusions: In cases of neck trauma with persistent shoulder pain, scapular winging due to peripheral nerve damage must be considered. The possibility of multiple peripheral nerve lesions should be carefully assessed when selecting muscles to sample on EMG for lateral scapular winging.

ANCHOR-CD (AbobotulinumtoxinA Neurotoxin: Clinical and Health Economics Outcomes Registry in Cervical Dystonia): A Multicenter, Observational Study of Dysport® (AbobotulinumtoxinA) in Cervical Dystonia: Baseline Data and Cycle One Efficacy Data

Poster 29 ANCHOR-CD (AbobotulinumtoxinA Neurotoxin: Clinical and Health Economics Outcomes Registry in Cervical Dystonia): A Multicenter, Observational Study of Dysport (AbobotulinumtoxinA) in Cervical Dystonia: Baseline Data and Cycle One Efficacy Data. Elena L. Polukhin, MD (University of Minnesota, Minneapolis, MN, United States); Patricia Jozefczyk, MD; Daniel Truong, MD; Alberto J. Espay, MD, MSc; Chandra Abbott, PhD; Cynthia Comella, MD; Dominic Marchese, RPh; Richard Trosch, MD.