Lalith Satkunam

RATIoNAle ANd deSIGN oF A MulTICeNTRe, douBle-BlINd, pRoSpeCTIve, RANdoMIzed, euRopeAN ANd CANAdIAN STudy: evAluATING pATIeNT ouTCoMeS ANd CoSTS oF MANAGING AdulTS WITH poST-STRoke FoCAl SpASTICITy

OBJECTIVE This report describes the design of a study aiming to provide evidence for the extended use of botulinum toxin A in focal post-stroke upper and lower limb spasticity and to evaluate the impact of incorporating botulinum toxin treatment into the rehabilitation of patients with spasticity. DESIGN International, prospective, randomized, double-blind, placebo-controlled study with an open-label extension. METHODS Approximately 300 adults with a stroke occurring ≥ 3 months before screening, presenting with symptoms and signs of an upper motor neuron syndrome and focal spasticity-related functional impairment, were randomized to botulinum toxin (BOTOX®, Allergan Inc.) + standard care or placebo + standard care. Study medication was administered at baseline and again at Week 12 if required, with follow-up to 52 weeks. The primary endpoint was the number of patients who achieved their investigator-rated principal active functional goal (as measured by Goal Attainment Scaling), at 10 weeks after the second injection (Weeks 22-34) or at the 24-week visit if no second injection was administered. Secondary endpoints included changes from baseline in level of goal achievement, health-related quality of life and resource utilization. CONCLUSION Botulinum toxin A Economic Spasticity Trial (BEST) will provide information regarding clinical and cost-effectiveness of botulinum toxin + standard care vs standard care alone in patients with upper and/or lower limb post-stroke spasticity typically seen in clinical practice. TRIAL REGISTRATION ClinicalTrials.gov number NCT-00549783.

Compression of the ulnar nerve at the elbow by an intraneural ganglion.

A rare cause of ulnar nerve compression at the elbow is presented in this report. A 42 year old right-handed mechanic developed subacute, progressive numbness, tingling and weakness in his right hand. Electrophysiologic studies demonstrated a severe conduction block affecting the ulnar nerve in the retrotrochlear groove but without any sign of major axonal loss. His hand functions were carefully studied prior to surgery. While fine motor tasks were not affected, the hand strength was markedly diminished. At surgery, a 1-cm diameter intraneural ganglion at the site of the conduction block was found and excised. The patient made a dramatic recovery within 6 weeks post-surgery. The conduction block completely resolved and the hand functions also returned to normal. This and other reported cases point to the importance of early diagnosis and intervention.

The impact of ulnar nerve compression at the elbow on the hand function of heavy manual workers.

The objectives of this article were to study the impact of the hand function disability due to ulnar neuropathy at the elbow (UNE) on workers engaged in occupations requiring heavy hand use. Four patients (42.5 ± 7 years old), all engaged in heavy-duty jobs, with severe conduction block but without severe axonal loss were recruited. The severity of ulnar nerve compression was quantified based on electrophysiologic studies, Jebsen-Taylor Hand Function Test, Jamar dynamometer, and Semmes-Weinstein Monofilaments Test. UNE resulted in a reduction in hand strength without any significant impact on fine motor dexterity. The 4 laborers whose work required strong hand grip found this debilitating. Severe UNE affects the hand function of heavy manual workers by impeding their grip and pinch strengths. However, UNE does not affect tasks requiring fine hand dexterity.

Multifaceted Support for a New Medical School in Nepal Devoted to Rural Health by a Canadian Faculty of Medicine and Dentistry

Nepal and Alberta are literally a world apart. Yet they share a common problem of restricted access to health services in remote and rural areas. In Nepal, urban-rural disparities were one of the main issues in the recent civil war, which ended in 2006. In response to the need for improved health equity in Nepal a dedicated group of Nepali physicians began planning the Patan Academy of Health Sciences (PAHS), a new health sciences university dedicated to the education of rural health providers in the early 2000s. Beginning with a medical school the Patan Academy of Health Sciences uses international help to plan, deliver and assess its curriculum. PAHS developed an International Advisory Board (IAB) attracting international help using a model of broad, intentional recruitment and then on individuals’ natural attraction to a clear mission of peace-making through health equity. Such a model provides for flexible recruitment of globally diverse experts, though it risks a lack of coordination. Until recently, the PAHS IAB has not enjoyed significant or formal support from any single international institution. However, an increasing number of the international consultants recruited by PAHS to its International Advisory Board are from the University of Alberta in Edmonton, Alberta, Canada (UAlberta). The number of UAlberta Faculty of Medicine and Dentistry members involved in the project has risen to fifteen, providing a critical mass for a coordinated effort to leverage institutional support for this partnership. This paper describes the organic growth of the UAlberta group supporting PAHS, and the ways in which it supports a sister institution in a developing nation.

A Delphi-based Consensus Statement on the Management of Anticoagulated Patients with Botulinum Toxin for Limb Spasticity

OBJECTIVE To create a consensus statement on the considerations for treatment of anticoagulated patients with botulinum toxin A (BoNTA) intramuscular injections for limb spasticity. DESIGN We used the Delphi method. SETTING A multiquestion electronic survey. PARTICIPANTS Canadian physicians (N=39) who use BoNTA injections for spasticity management in their practice. INTERVENTIONS After the survey was sent, there were e-mail discussions to facilitate an understanding of the issues underlying the responses. Consensus for each question was reached when agreement level was ≥75%. MAIN OUTCOME MEASURES Not applicable. RESULTS When injecting BoNTA in anticoagulated patients: (1) BoNTA injections should not be withheld regardless of muscles injected; (2) a 25G or smaller size needle should be used when injecting into the deep leg compartment muscles; (3) international normalized ratio (INR) level should be ≤3.5 when injecting the deep leg compartment muscles; (4) if there are clinical concerns such as history of a fluctuating INR, recent bleeding, excessive or new bruising, then an INR value on the day of injection with point-of-care testing or within the preceding 2-3 days should be taken into consideration when injecting deep compartment muscles; (5) the concern regarding bleeding when using direct oral anticoagulants (DOACs) should be the same as with warfarin (when INR is in the therapeutic range); (6) the dose and scheduling of DOACs should not be altered for the purpose of minimizing the risk of bleeding prior to BoNTA injections. CONCLUSIONS These consensus statements provide a framework for physicians to consider when injecting BoNTA for spasticity in anticoagulated patients. These consensus statements are not strict guidelines or decision-making steps, but rather an effort to generate common understanding in the absence of evidence in the literature.

TOWER: Design of an Open-Label Incobotulinumtoxina Dose-Titration Study (≤800 U) In Lower- and Upper-Limb Spasticity

Disclosures: K. Alekseyev, No Disclosures: I Have Nothing To Disclose. Objective: To assess the incidence of intracranial injuries identified by head CT for patients who fell during acute inpatient rehabilitation. Design: Retrospective chart review Setting: Acute inpatient rehabilitation unit of an inner city hospital Participants: 118 patients (mean age 63) undergoing acute inpatient rehabilitation. Interventions: Retrospective chart review of head CT scans that were ordered as part of work-up for patients who fell during their stay on an inpatient rehabilitation unit over a twelve month period. Charts were reviewed for the following: a) physical examination findings at time of fall b) evidence of intracranial injury as a consequence of the fall (eg. hemorrhage) c) evidence of a prolonged hospitalization as a result of the fall associated intracranial pathology. Main Outcome Measures: Results of head CT scans. Results or Clinical Course: 30 head CT scans (25%) were obtained as part of workup in post-fall patients. Each patient analyzed had between one and three head CT scans performed as a result of a fall. Only 1 positive finding of all 30 head CT scans performed resulted positive for acute head injuries. The total cost of the head CT scans indicating negative findings for acute head injuries over the one-year period was

Poster 77 Candidate and Interviewer Perceptions of a Novel Multistation Interview Format for Admission to a Physical Medicine and Rehabilitation Residency Training Program

49,445 (each CT scan cost:

Treatment for spasticity in amyotrophic lateral sclerosis/motor neuron disease

1705). Conclusions: There is a low diagnostic yield and high cost for head CT as part of post-fall evaluation in patients not exhibiting acute neurological changes. Physiatrists should use caution when ordering these imaging studies and limit their use to occasions when clinically indicated.

Safety and efficacy of incobotulinumtoxinA doses up to 800 U in limb spasticity: The TOWER study

Disclosures: F. Emamhosseini, none. Objective: To develop a novel quality improvement model and standardize the hand-off system in our institution. Design: Pre-post intervention survey and retrospective chart review. Setting: Acute inpatient rehabilitation hospital. Participants: Twelve physical medicine and rehabilitation residents. Interventions: A novel quality improvement model, the “LIFE Cycle” (L-Learn and highlight the basic tasks associated with patient handoffs; I-Identify opportunities for miscommunication through focus groups and root cause analysis; F-Formulate and implement a standardized hand-off template; E-Evaluate and monitor the initiative), was used to standardize our hand-off system. A color-coding system (RED, critical laboratory values and/or acutely ill patients; YELLOW, routine laboratory values and/or workups; GREEN, general medical check) was used to prioritize patients to be seen during the weekend call for a period of 4 months. Main Outcome Measures: (1) Preand postintervention resident satisfaction and efficiency survey, (2) retrospective chart review of number of patient-related rapid responses, code blue, transfers to acute care, and average length of stay. Results: Statistically significant improvement was noted in (1) residents overnight having a clear idea of what they need to accomplish (P .005, Stuart Maxwell test), (2) issues no longer arising that are directly attributable to an inadequate sign-out (P .05, Stuart Maxwell test), (3) decrease in rapid response rates (P .05, Fisher exact test). There was slight improvement in the residents’ perception of the new hand-off system as being efficient and complete (P .06, Stuart Maxwell test). Overall, there was no statistically significant difference in number of acute care transfers. However, in 1 unit, there was a statistically significant decrease in acute care transfers (P .05, Pearson 2 test). There was no significant change in the number of code blue and length of stay. Conclusions: Use of the “LIFE Cycle” improved the hand-off system in our institution. Future steps include the development of a color-coded electronic hand-off system by using this model to maintain continuity of care across transitions, reduce communication errors and preserve patient safety. Poster 77 Candidate and Interviewer Perceptions of a Novel Multistation Interview Format for Admission to a Physical Medicine and Rehabilitation Residency Training Program. Hernish Acharya (University of Alberta, Edmonton, AB, Canada); Nigel Ashworth, MB ChB, MSc, FRCPC, Curtis Hlushak, Lalith Satkunam.