Stella Lee

Patient registry of outcomes in spasticity care.

ObjectiveThis study aimed to provide clinical injection data and real-world patient-reported and clinical outcomes for the chemodenervation and neurolytic treatment of muscle overactivity including spasticity in patients with traumatic brain injury and stroke. DesignThis study used a prospective multicenter observational design. The participants were 487 patients with stroke or traumatic brain injury. The interventions used were onabotulinumtoxin A or phenol. Nine subjects received both onabotulinumtoxin A and phenol. The main outcome measures were satisfaction and goal attainment, pain, and Ashworth Scale scores. ResultsThe most commonly treated pattern of dysfunction in the upper limb was the flexed wrist, with the flexor carpi radialis as the most frequently treated muscle. The mean total dose for the upper limb muscle was 57.7 ± 34.1 U, and phenol volume was 3.9 ± 0.7 ml. The most commonly treated pattern of dysfunction in the lower limb was the equinovarus/equinus foot, with the medial/lateral gastrocnemius as the most frequently treated muscles. The mean total dose for the lower limb muscle was 93.8 ± 63.5 U, and phenol volume was 4.1 ± 1.3 ml. There was a significant improvement in Ashworth Scale and pain scores. Generally, the patients reported that they were satisfied with their treatment and made progress toward their goals. No significant treatment-related adverse effects were reported. ConclusionsBased on 487 patients with stroke and traumatic brain injury who were selected by their physician and clinical presentation for treatment using chemodenervation and neurolysis, this report of injection data reflecting actual clinical practice may serve as a further clinical guide in the management of patients with muscle overactivity, including spasticity.

A Randomized Comparative Study of Manually Assisted Versus Robotic-Assisted Body Weight Supported Treadmill Training in Persons With a Traumatic Brain Injury

(1) To compare the effects of robotic‐assisted treadmill training (RATT) and manually assisted treadmill training (MATT) in participants with traumatic brain injury (TBI) and (2) to determine the potential impact on the symmetry of temporal walking parameters, 6‐minute walk test, and the mobility domain of the Stroke Impact Scale, version 3.0 (SIS).

A Comparison of Locomotor Therapy Interventions: Partial-Body Weight−Supported Treadmill, Lokomat, and G-EO Training in People With Traumatic Brain Injury

Literature in the application of gait training techniques in persons with traumatic brain injury (TBI) is limited. Current techniques require multiple staff and are physically demanding. The use of a robotic locomotor training may provide improved training capacity for this population.

A Randomized Comparison of Locomotor Therapy Interventions: Partial Body Weight Supported Treadmill, Lokomat® and G-Eo® Training in Traumatic Brain Injury

Disclosures: Alberto Esquenazi: Research Grants Allergan, Research Grants Ipsen Objective: To examine the impact on gait velocity and spatiotemporal symmetry using three different modes of locomotor therapy: an end effector robot (G-EO ); a robotic exoskeleton (Lokomat ) and manual assisted partial-body weight supported treadmill training (PBWSTT) in patients with traumatic brain injury (TBI). Design: Randomized, prospective, pilot study. Setting: Tertiary rehabilitation hospital. Participants: 22 TBI participants able to walk with or without assistance at velocities between 0.2 and 0.6 m/s. Interventions: 45 minutes of selected training for a total of 18 sessions. Main Outcome Measures: Overground walking self-selected velocity (SSV); maximal velocity (MV) and spatiotemporal symmetry. Results: Mean age was similar for the three groups. 50% of the participants were men. Right hemiparesis was more common in the G-EO and PBWSTT groups; paretic side was evenly distributed in the Lokomat group. Post training elicited a statistically significant median increase in SSV compared to pre-training, (G-EO, P 1⁄4.028; Lokomat, P 1⁄4.035 and PBWSTT, P 1⁄4.018) and MV excluding the G-EO group (G-EO, P 1⁄4 .150; Lokomat, P 1⁄4 .036 and PBWSTT, P 1⁄4.027). No pre-post significant differences in SSV or MV swing time, stance time and step length symmetry ratios. Mean rank in the change of SSV and MV were not statistically significantly different between groups, P 1⁄4 .744, .658. Mean rank in the change of SSV and MV swing time, stance time and step length symmetry ratios were not statistically significantly different between groups (SSV: P 1⁄4.552; 0.139 and 0.574; MV: P 1⁄4.492; 0.483 and 0.131). Conclusions: Locomotor therapy in the TBI population using G-EO, Lokomat or PBWSTT produced equivalent increases in SSV and MV without significant changes in symmetry. A larger study may further define changes in gait symmetry and group differences. Level of Evidence: Level II

Poster 14: Randomized Supplemental Therapeutic Conventional or Robotic Upper Limb Exercise in Acute Stroke Rehabilitation

Disclosures: Alberto Esquenazi: I Have No Relevant Financial Relationships To Disclose Objective: To maximize improvements on function and activity level in the recovery of the upper limb, we implemented a pilot study to determine the feasibility and impact of supplemental upper limb exercises in an acute stroke population. Design: Blinded, randomized pilot study. Setting: Tertiary rehabilitation hospital, inpatient stroke unit. Participants: Stroke patients with unilateral hemiparesis with minimum Fugl-Meyer Assessment (FMA) score of 8/66 or Modified Ashworth Score of <3 receiving usual minimum of 3 hours of daily therapy. Interventions: Patients were randomized to conventional or robotic additional upper extremity exercise groups. Main Outcome Measures: This study collects the number of completed sessions; withdrawals; serious/adverse events and functional parameters data: FMA, Functional Independence Measure (FIM) and FIM efficiency. Results: Data on 15 acute post stroke patients of <2 months. Mean age was 66 years. More than half of the participants were male (64%) and most participants presented left-sided paresis (79%). Embolic and ischemic strokes were similarly represented (36%) and 29% of hemorrhagic stroke. One patient withdrew for personal reasons prior to his first session. All 14 participants (8 robotic, 6 conventional) continued their training sessions until discharge. Of a total of 80 training sessions, 15 were incomplete. Adverse events ranged from upper limb pain; fatigue; gastrointestinal symptoms interfering with training and falls that occurred unrelated to their study participation. Conclusions: This ongoing study depicts an acute stroke population that received additional upper extremity exercises. Based on the available data thus far, it is feasible to provide a supplemental functional exercise program to acute post stroke patients in an Inpatient Rehabilitation Facility (IRF) without serious adverse effects. We expect to complete and present data analysis on all 40 subjects including functional outcomes. Level of Evidence: Level II

Patient Registry of Spasticity Care World: Data Analysis Based on Physician Experience

Objective The aim of the study was to report physician experience–based “real-world” treatment patterns with botulinum toxin type A in patients with stroke and traumatic brain injury. Design A prospective, multicenter, international observational registry design was used. Results Six hundred twenty-seven participants with stroke and 132 participants with traumatic brain injury were assessed and treated by 17 more experienced physicians and 12 less experienced physicians. Due to the limited usage of abobotulinumtoxinA Dysport and incobotulinumtoxinA Xeomin, data were reported on onabotulinumtoxinA BOTOX only. Based on physician experience, onabotulinumtoxinA doses were statistically different with larger mean doses injected by more experienced physicians in the upper limb (59.9 [39.0], P = 0.001) and in the lower limb (101.8 [69.2], P < 0.001). Treated deformities significantly differed for both upper limb and lower limb (P < 0.001). More experienced physicians showed a larger mean change in Ashworth Scale scores from baseline for the equinovarus/equinus foot and stiff knee (P = 0.001 and 0.03). Less experienced physicians showed a larger mean change in Ashworth Scale scores from baseline for the adducted thigh (P = 0.05). Less experienced physicians had statistically significant larger change in hand pain scores for clenched fist deformity treatment at follow-up compared with more experienced physicians (P = 0.01). Physician experience demonstrated a significant difference on patients reported satisfaction toward their secondary goal with higher scores for more experienced physician (P = 0.04). Conclusions This international registry provides clinical nuances of treatment based on physician clinical experience in a robust sample size.

Poster 289 Patient Registry of Spasticity Care World Data Analysis Based on Physician Experience

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

Poster 488 Upper Limb Treatment With OnabotulinumtoxinA in Patients With Stroke, Traumatic Brain Injury, and Adult Cerebral Palsy: A 6-Year Retrospective Review

functional ambulation category II-IV. Interventions: Divided into 3 groups by random allocation: group I, overground gait training; group II, treadmill without bodyweight support; and group III, treadmill training with body-weight support. Each group underwent 20 sessions (20 min/d, 5 d/wk for 4 weeks) of additional gait training by respective means over conventional rehabilitation program. Main Outcome Measures: Overground walking distance, speed and endurance. Data were analyzed at completion of training and at 3 months follow-up by using paired t-test for improvement within the groups and analysis of variance for comparison between the groups. Results: The clinical profile (n 45); M:F, 36:9; age range, 22-65 years; duration of symptoms, 4-59 months (mean, 16.51 months). Intragroup analysis suggests statistically significant improvement (P .05) for all outcome variables in 3 groups, both at the end of training and follow-up, except for overground walking endurance in subjects of group I. Intergroup assessment suggests a trend for better outcome for subjects trained in group II/III, but it is was statistically not significant. Conclusions: Treadmill training with or without body-weight support offers subtle additional advantage over conventional physical therapy approaches in improving gait in chronic ambulatory stroke survivors and is worth a trial.

Poster 252 Patient Registry of Outcomes in Spasticity Care

block after being evaluated by 2 independent pain physicians. The patient experienced an excellent result immediately on the procedure table. We will discuss 3 other case scenarios. We will review the medical literature to identify the pain generators after a spinal wedge fracture and evaluate the validity of the entire medical literature about vertebroplasty as a tool for pain management. Discussion: We believe that there has never been mention in the medical literature of thoracic medial branch block compared with the thoracic vertebroplasty for pain management. However, we will provide information about the pain generators in the spinal wedge fracture, and we will explain why we believe that possibly medial branch block would play a tremendous role for pain management in this group of patients.