Michael O’Dell

Traumatic Brain Injury

Patients with traumatic brain injury (TBI) pose an enormous clinical, emotional, and intellectual challenge to rehabilitation professionals. For public policymakers, the cost of care for approximately 6 million survivors of TBI is measured in the billions of dollars. In addition to the motor, sensory, and language deficits commonly seen in nontraumatic etiologies, the patient with TBI often experiences cognitive and/or behavioral manifestations that alter his or her ability to benefit from the rehabilitation process, and requires innovative treatment strategies on the part of the rehabilitation team. Beyond the core disciplines (physiatry, physical/occupational therapy, and speech/language pathology), neuropsychology services are added to provide cognitive and behavioral assessment, treatment, and guidance to the remainder of the treatment team.

The diagnostic accuracy of the Montreal Cognitive Assessment in inpatient stroke rehabilitation

ABSTRACT The Montreal Cognitive Assessment (MoCA) is a commonly used screening measure for cognitive impairment; however, the diagnostic accuracy and optimal cutoff points in inpatients with mild stroke severity is unknown. We examined the diagnostic accuracy of the MoCA in an acute inpatient stroke rehabilitation unit (N = 95). The criterion neuropsychological assessment was the 30-minute National Institute of Neurological Disorders and Stroke-Canadian Stroke Network battery, modified to include the Symbol-Digit Modalities Test and Trail Making Test A & B. The MoCA had moderately strong diagnostic accuracy in receiver operating curve analyses, with areas under the curve ranging from .80 to .89 depending on the threshold for defining cognitive impairment. Sensitivity ranged from .72 to .87, and was generally greater than specificity, which ranged from .60 to .81. The optimal cutoff on the MoCA for detecting mild or greater cognitive impairment was <25/30. The optimal cutoff using more conservative definitions of cognitive impairment ranged from <23–24/30. Exploratory analyses of MoCA subgroups (“normal,” “mildly impaired,” and “functionally impaired”) differed in the frequency and magnitude of impairment on the criterion neuropsychological assessment. These findings inform the clinical use of the MoCA in individuals with mild stroke in an inpatient rehabilitation setting.

Is the Routine Use of a Functional Electrical Stimulation Cycle for Lower Limb Movement Standard of Care for Acute Spinal Cord Injury Rehabilitation

You lead the rehabilitation team at a large, rural freestanding rehabilitation hospital with a small but growing and respected spinal cord injury (SCI) rehabilitation programdinpatient and outpatient. You are caring for a 25-year-old man, 3 weeks after a T10 American Spinal Injury Association Impairment Scale (AIS) B injury due to a motor vehicle accident. He is medically stable and participating well in his program. The man’s parents happen to have substantial resources. After doing research online, they approach you concerning the absence of a functional electrical stimulation (FES) cycle treatment for their son. They express their shock at this oversight as “everybody is convinced this technology is considered standard of care” for acute SCI and promise to take this up with the CEO of the rehabilitation hospital. After being told that the hospital’s budget will not support purchase of the device, the parents offer to buy one “if you feel that having one will benefit my son.” Would you accept the kind offer of this couple, taking the position that the FES is an essential component of care in acute SCI, or would you attempt to dissuade the couple from spending a great deal of their own money for an unnecessary treatment? Arguing in favor of accepting the gift and implementing FES is Argyrios Stampas, MD, and arguing against is Henry York, MD.

Detection of Botulinum Toxin Muscle Effect in Humans Using Magnetic Resonance Imaging: A Qualitative Case Series

Although important for dosing and dilution, there are few data describing botulinum toxin (BT) movement in human muscle.

Dose-Dependent Effects of AbobotulinumtoxinA (Dysport) on Spasticity and Active Movements in Adults With Upper Limb Spasticity: Secondary Analysis of a Phase 3 Study

AbobotulinumtoxinA has beneficial effects on spasticity and active movements in hemiparetic adults with upper limb spasticity (ULS). However, evidence‐based information on optimal dosing for clinical use is limited.

Poster 288 Efficacy and Safety of Repeated AbobotulinumtoxinA Injections in Adults with Lower Limb Spasticity

medical/neurological workup, a diagnosis of Cefepime Induced Encephalopathy was made. Cefepime dose was reduced to 1gm q24 hours. Within 2-3 days patient’s symptoms subsided and she returned to her neurologic baseline. Discussion: Cefepime is broad spectrum fourth generation cephalosporin introduced in 1990s. It covers broad spectrum of G+ and Gaerobic species. Major rare side effects that often are underdiagnosed are non-convulsive status epilepticus and encephalopathy. Most common signs of neurotoxicity are confusion, agitation, myoclonic jerks, epileptic seizures and coma. They may appear five days after therapy initiation. Cefepime inhibits GABA binding to GABAa receptors. EEG shows distinct wave and voltage activity. Symptoms disappear within 48-72 hours from Cefepime discontinuation. Conclusions: It is important to be aware of potential neurotoxic adverse effects by newly developed medications. This case was complicated by the onset of unexpected neurological findings. After significantly reducing Cefepime dosage, patient completely returned to her baseline. Level of Evidence: Level V

Should This Patient With Global Aphasia After a Left Cerebral Stroke Be Admitted to Your Hospital-Based Inpatient Rehabilitation Unit?

You are the medical director of a very busy, 20-bed, general inpatient rehabilitation unit (IRU) at a community hospital. About 40% of admissions to the unit are persons with moderate and severe stroke from the geographic region, and your census runs very nearly 100% capacity, usually with a waiting list. The neurology service asks you to assess a 60-year-old man with a long history of hypertension and diabetes mellitus who is now 6 days post a large left middle cerebral artery (MCA) ischemic stroke. He presented with sudden onset of weakness of the right side and difficulty speaking. He lives in a single-story, accessible home with his wife, who is supportive but must continue working to maintain their health insurance. Therapy assessment on the acute neurology floor, where he receives a total of no more than 60 min/d therapy, indicates he transfers withmaximum assistance of one person with a dense right hemiparesis. He has not yet taken steps. There has been a slight improvement in active movement of the lower limb over the past 2 days but still no more than trace. He is on a pureed diet with thickened liquids after a modified barium swallow indicated laryngeal penetration and aspiration risk. The assessment by a speech language pathologist (SLP) indicates a global aphasia with limited abilities in either comprehension or expression. All therapists note an inconsistent performance during treatment sessions. The IRU has only 2 beds available over the next 5 days, and 6 patients with diagnoses ranging from mild stroke to multiple trauma are waiting for a rehabilitation bed. Given the degree of aphasia and weakness reported 2 weeks’ poststroke and the current demand for beds, should this man be a priority to come to your IRU? Arguing in favor of an IRU admission is Leroy R. Lindsay, MD, and against is Kirk Lercher, MD.

Poster 292 Improvement of Spasticity Following AbobotulinumtoxinA (Dysport®) Injections in Shoulder Muscles in Hemiparetic Patients with Upper Limb Spasticity–Sub-Analysis of a Prospective, Long-Term, Open-Label Study with Single and Repeated Injection Cycles

Participants: A total of 134 patients (abobotulinumtoxinA, n1⁄489; placebo, n1⁄445) were randomized and 129 (abobotulinumtoxinA, n1⁄484; placebo, n1⁄445) completed the W4 primary endpoint evaluation. Interventions: CD patients were randomized (2:1) to abobotulinumtoxinA or placebo. Toxin-naı̈ve abobotulinumtoxinA patients received 500 units/2 mL in 2 affected neck muscles. AbobotulinumtoxinA CD subjects who had previously received botulinum treatment (non-naı̈ve) received 250-500 units/2 mL (2.5:1 abobotulinumtoxinA: previous onabotulinumtoxinA [Botox ] dose) into muscles injected during prior treatments. Main Outcome Measures: The primary endpoint was change from baseline to Week 4 (W4) in Toronto Western Spasmodic Torticollis Rating Oasis, The Online Abstract Submission System Scale (TWSTRS) total score. Safety was assessed over the 12-week study period. Results: Versus placebo, abobotulinumtoxinA patients experienced significantly greater changes from baseline in TWSTRS score at W4 (-2.5 versus -10.8, P<.001; based upon the modified intent-to-treat population). Adverse events (AEs) occurred in 41% and 22% of abobotulinumtoxinA and placebo patients, respectively. Dysphagia was reported in 9% of treated patients. Other AEs in treated patients were muscle weakness, neck pain, and headache, none of which were reported with placebo. Conclusions: Data from this study indicate a 2 mL dilution of abobotulinumtoxinA was significantly more effective than placebo in CD patients. No unexpected AEs were observed relative to previous studies that used the 1 mL dilution volume in this patient population. Level of Evidence: Level II