Ganesh Bavikatte

Cost-efficiency of specialist hyperacute in-patient rehabilitation services for medically unstable patients with complex rehabilitation needs: a prospective cohort analysis

Objectives To evaluate functional outcomes, care needs and cost-efficiency of hyperacute (HA) rehabilitation for a cohort of in-patients with complex neurological disability and unstable medical/surgical conditions. Design A multicentre cohort analysis of prospectively collected clinical data from the UK Rehabilitation Outcomes Collaborative (UKROC) national clinical database, 2012–2015. Setting Two HA specialist rehabilitation services in England, providing different service models for HA rehabilitation. Participants All patients admitted to each of the units with an admission rehabilitation complexity M score of ≥3 (N=190; mean age 46 (SD16) years; males:females 63:37%). Diagnoses were acquired brain injury (n=166; 87%), spinal cord injury (n=9; 5%), peripheral neurological conditions (n=9; 5%) and other (n=6; 3%). Intervention Specialist in-patient multidisciplinary rehabilitation combined with management and stabilisation of intercurrent medical and surgical problems. Outcome measures Rehabilitation complexity and medical acuity: Rehabilitation Complexity Scale—version 13. Dependency and care costs: Northwick Park Dependency Scale/Care Needs Assessment (NPDS/NPCNA). Functional independence: UK Functional Assessment Measure (UK FIM+FAM). Primary outcomes: (1) reduction in dependency and (2) cost-efficiency, measured as the time taken to offset rehabilitation costs by savings in NPCNA-estimated costs of on-going care in the community. Results The mean length of stay was 103 (SD66) days. Some differences were observed between the two units, which were in keeping with the different service models. However, both units showed a significant reduction in dependency and acuity between admission and discharge on all measures (Wilcoxon: p<0.001). For the 180 (95%) patients with complete NPCNA data, the mean episode cost was £77 119 (bootstrapped 95% CI £70 614 to £83 894) and the mean reduction in ‘weekly care costs’ was £462/week (95% CI 349 to 582). The mean time to offset the cost of rehabilitation was 27.6 months (95% CI 13.2 to 43.8). Conclusions Despite its relatively high initial cost, specialist HA rehabilitation can be highly cost-efficient, producing substantial savings in on-going care costs, and relieving pressure in the acute care services.

Symptomatology following traumatic brain injury in a multidisciplinary clinic: experiences from a tertiary centre

Abstract Background: Physical, cognitive and emotional sequelae in patients with traumatic brain injury (TBI) have been identified; some as late as two years post-injury. To aid in the specialist management of such patients, a multidisciplinary neurotrauma clinic was initiated at a tertiary centre. Aim: This study sought to describe the clinical features of patients who attended the clinic. Methods: Patient data was collected under several categories: basic demographics, mechanism and severity of injury, initial CT findings and management, hospital stay and discharge details, symptoms in clinic and actions performed by clinic staff (medication changes, referrals to other services, etc.). Results:Three hundred and five patients met the inclusion criteria. Mean age was 47.5 and most patients were male (72.1%). Commonest mechanism of injury was falls (53.1%). 17.4% of injuries were classed as mild, 68.2% moderate and 14.1% severe. Commonest injury locations were frontal (21.6%) and temporal (16.1%) with contusions (37.4%) and subdural hematomas (27.9%) the commonest type of injury on initial CT scan. The most frequent physical complaints were headache (47.9%) and memory problems (42.0%). 7.9% complained of new seizures since TBI. 41.6% were referred to further services: most frequently psychology (19.3%) and neuropsychiatry (18.4%). Of 184 known to be employed before their injury, 48.4% of these returned to work before their last appointment. 28.5% were unable to continue driving. Conclusion: Our study provides an insight into the reality of long term sequelae of TBI, especially those at the more severe end of the spectrum, who are likely to present to tertiary or specialist services. Information gathered in this study about characteristics of the TBI population and their outcomes allows for better targeting of suitable patients for referral to a multidisciplinary clinic and improved resource planning.

Poster 66: The Adult Spasticity International Registry (ASPIRE) Study: Treatment Utilization Patterns in Patients Treated for Both Upper and Lower Limb Spasticity

hemiparetic subjects who received abobotulinumtoxinA (Dysport , aboBoNT-A) in both UL and LL simultaneously. Design: Phase-III, open-label (OL) study (NCT01251367). Setting: 52 centres;11 countries worldwide. Participants: Eligible subjects previously completed double-blind (DB) placebo-controlled study (NCT01249404). Interventions: DB: aboBoNT-A 1000U or 1500U in LL for one treatment cycle (TC). OL: repeated injections (up to 4 TC) performed over max18 months. Subjects received aboBoNT-A 1500U in LL for TC1/TC2; from TC3 subjects could receive up to 500U in UL, providing total aboBoNTA dose did not exceed 1500U. Main Outcome Measures: Ten-meter comfortable barefoot walking speed. Results: Of 352 subjects, 63 received co-injection in LL+UL at both TC3/TC4, and 64 received injection in LL only. Mean (SD) aboBoNT-A doses in LL at TC3 and TC4 were 1380U (210) and 1360U (220), respectively, in subjects injected in LL only, and 1000U (50) and 1000U (50), respectively, for subjects injected in LL+UL. At baseline, tenmeter comfortable barefoot walking speed (mean [SD]) was similar in subjects injected in LL+UL (0.42 [0.20]) and LL only (0.42 [0.20]). At TC3 Wk4, both subgroups had improvements from baseline (mean change [SD]: LL+UL: 0.063 [0.131]; LL only: 0.078 [0.114]), which further improved to TC4 Wk4 ( LL+UL: 0.086 [0.166]; LL only: 0.086 [0.123]). Conclusions: In subjects with spastic paresis requiring concurrent treatment of UL and LL, it was possible to split 1500U total dose of aboBoNT-A between both extremities while still improving walking speed similarly to that observed in subjects injected in lower extremities only. This provides important information for the treatment of LL and UL simultaneously with aboBoNT-A in adult patients with hemiparesis. Level of Evidence: Level I

Poster 281 The Adult Spasticity International Registry (ASPIRE Study): Baseline Demographics and Clinical Characteristics of Patients Treated for Spasticity

Disclosures: Joel Castellanos: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 32-year-old right-handed woman with metastatic malignant mixed Mullerian tumor (MMMT) presented with left upper extremity numbness, tingling, and pain along her posterior forearm, thumb, and second digit. She developed mild symptoms during pregnancy 7 months prior, and severe symptoms three months before presentation after receiving carboplatin and paclitaxel chemotherapy for MMMT. Four years earlier, she also experienced a milder form of these symptoms; electromyography (EMG) found no abnormalities and the symptoms resolved spontaneously. Of note, her history is significant for numerous left shoulder subluxations requiring reduction. Setting: Outpatient cancer rehabilitation clinic. Results: Physical examination revealed decreased strength in left elbow extension (4-/5) and wrist extension (4/5), absent left triceps reflex, and diminished pinprick sensation over the posterior forearm with increased sensitivity to light touch over the distal radial nerve distribution. Computerized tomography of her neck and chest did not reveal neural foraminal narrowing or metastatic disease to explain her symptoms. On EMG testing, radial sensory nerve conduction studies (NCS) were not recordable, and radial motor studies at the forearm showed decreased amplitude compared to the right side (1.7mV vs 3.7mV) with comparable distal latencies. Median and ulnar motor and sensory NCS were normal. Needle electromyography revealed positive waves, fibrillations, and chronic changes in the extensor carpi radialis brevis, brachioradialis, and extensor indicis, but not the triceps, suggesting an incomplete chronic axonal neuropathy proximal to the brachioradialis. Deltoid, biceps brachii, pronator teres, and first dorsal interosseus (hand) had no abnormal EMG findings. Discussion: Repetitive shoulder subluxation likely created tension on the radial nerve at the spiral groove of the humerus, causing a stretch injury. Ligamentous laxity in pregnancy caused symptoms to recur, and chemotherapy worsened the injury to the point of axonotmesis. Conclusions: Pregnancy may exacerbate neuropathies associated with ligamentous laxity, and chemotherapy can worsen pre-existing neuropathies. Level of Evidence: Level V