Abstract 22

A5 hospital stay, need for intercurrent transfer back to the acute hospital, final discharge destination, and survival status. All data were recorded concurrently in a computerized stroke rehabilitation data bank by rehabilitation team members unaware of the study hypothesis. Statistical analyses were as follows: the Student t test for linear data, Mann-Whitney U test for ordinal data, the chi-square test for categorical data. Variances are provided as mean ⫾ SEM. Results: Outcomes for the 2 groups, PEG versus controls, respectively, were as follows: change in FIM scores from admission to discharge (17.3⫾1.3 vs 20.5⫾1.2, P⫽.07); length of rehabilitation hospital stay (45.4⫾1.8d vs 44.1⫾1.5d, P⫽.57); need for intercurrent transfer back to the acute hospital (51/182 vs 22/182, P⫽.0001); final discharge destination home/institutional care (92/74 vs 97/80, P⫽.91); and survival status dead/alive (16/166 vs 5/177, P⫽.01). Conclusions: Patients who require PEG placement are at increased risk for medical complications and death. Those who survive, however, show similar functional recovery and rate of home discharge as case-matched controls. Key Words: Dysphagia; Gastrostomy; Rehabilitation; Stroke. Abstract 21 Treadmill With Partial Body-Weight Support Versus Conventional Gait Training After Stroke. Laura Lennihan, MD (Helen Hayes Hospital, W. Haverstraw, NY); Mary E. Wootten, MS; Mary Wainwright, RPT; Laura Tenteromano, RN; Don McMahon; Jill Cotier, PTA, e-mail: [email protected]. Disclosure: None. Objective: To test the hypothesis that stroke patients treated with treadmill training and partial body-weight support walk faster 90 days after stroke than patients treated with conventional gait training. Design: Block randomized, 2 treatment arm trial. Outcome measurement was performed blind to treatment group. Setting: Inpatient rehabilitation hospital. Participants: 83 patients randomized to the treadmill (n⫽42) or conventional (n⫽41) treatments within 30 days of stroke. Patients were stratified by initial walking speed (0, ⬎0, ⬍.25, ⱖ.25m/s) and stroke location (cortical, subcortical). Eligible patients had first stroke, hemiparesis, required at least contact guard to walk, and were not ataxic. Interventions: Subjects received 12 once-daily 30-minute treatments over a 3-week period and received equal study treatment time in addition to their normal therapy. Treadmill subjects started treatment with average unweighting of 30% body weight and treadmill speed set at 1.1 miles/h. Conventional treatment included standing, walking, sit to stand, standing with activity, and walking with activity. Main Outcome Measure: The primary outcome was velocity 90 days after stroke. Secondary outcomes included 6-minute walk distance, FIM™ instrument mobility subscale score, National Institutes of Health Stroke Scale score, Fugl-Meyer Assessment leg motor score, and Tinetti score. Results: All demographic, medical, and other risk factors showed no difference except for mean age (treadmill group, 69.4⫾10.6y vs conventional group, 62.0⫾12.9y). 90-day walking speed did not differ significantly (treadmill group, .71⫾.50m/s vs conventional group, .83⫾.50m/s), nor was there a difference in change in walking speed between initial measurement and 90 days. There was no significant difference in the 6-minute walk distance at 90 days or in any of the other secondary outcomes. Conclusions: Both treatment groups made improvements in walking velocity and clinical measures during rehabilitation, but treadmill training with partial body-weight support conferred no additional benefit compared with conventional training. Age may be a contributing factor to the results. Key Words: Gait; Rehabilitation; Stroke. Abstract 22 Acute Neuroradiograhic Predictors of Rehabiliation Costs. Ross D. Zafonte, DO (University of Pittsburgh, Pittsburgh, PA); Joseph Ricker, PhD; Robin Hanks, PhD; Kertia Black, MD, e-mail: [email protected]. Disclosure: None. Objective: To examine acute neuroradiographic and injury predictors of rehabilitation costs in a large traumatic brain injury (TBI) population. Design: Multiple regression– based within-group design. Setting: Urban university-based neurotrauma center and rehabilitation hospital. Participants: 293 persons presenting to a level 1 trauma center with a primary diagnosis of moderate or severe TBI who required inpatient rehabilitation. Interventions: Not applicable. Main Outcome Measures: Multiple variables derived from demographics, injury characteristics, ratings of various computed tomography (CT) scan indicators of neuropathology, and charges for rehabilitation services. Results: Several key variables that are predictive of rehabilitation outcome (including age, cause of injury, admission Glasgow Coma Scale [GCS] score) and several CT-derived neuroradiographic variables were entered into a multiple regression model to predict the total dollar charges for all rehabilitation services. The variables that emerged as statistically significant were (in order of amount of variance accounted for in the predictive model: presence of subarachnoid hemorrhage (SAH) (F change⫽17.89; P⬍.0001), admission GCS total score (F change⫽13.59; P⬍.0001), presence of frontal lobe contusion (F change⫽8.26; P⬍.004), presence of left parietal contusion (F change⫽7.15; P⬍.008), presence of right epidural hemorrhage (F change⫽4.51; P⫽.035), and

presence of a punctate hemorrhage (F change⫽4.89; P⫽.028). Conclusions: Charges for TBI rehabilitation are an important consideration. The ability to predict the relative cost of rehabilitation can facilitate planning and may be helpful in more accurately determining the allocation of resources. The presence of SAH was an important predictor of charges and may reflect a risk factor for secondary brain injury not captured by other measures. Key Words: Brain injuries; Neuroimaging; Prediction; Rehabilitation economics. Abstract 23 Selective Serotonin Reuptake Inhibitors in Acute Ischemic Stroke Patients During Inpatient Rehabilitation. Ellen M. Whyte, MD (University of Pittsburgh School of Medicine, Pittsburgh, PA); Terry Puet, MD; Benoit H. Mulsant, MD; Mary Amanda Dew, PhD; Charles F. Reynolds III, MD; Ross D. Zafonte, DO, e-mail: [email protected]. Disclosure: None. Objective: To examine the safety of selective serotonin reuptake inhibitor (SSRI) antidepressants after stroke and their effect on rehabilitation. Design: Chart review study. Setting: Community-based rehabilitation hospital. Participants: 147 ischemic stroke survivors admitted between August 1, 2001 and May 31, 2002. Interventions: Not applicable. Main Outcome Measures: Evidence of SSRI-related adverse events and FIM™ instrument score. Results: 85 patients received an SSRI for depressive symptoms. ⫹SSRI and ⫺SSRI patients did not differ in age, gender, length of stay (LOS) in the acute care hospital (9.5⫾7.6d vs 8.2⫾5.9d, P⫽.065), or change FIM score (22.1⫾13.2 vs 20.5⫾16.2, P⫽0.5). ⫹SSRI patients had longer LOS in rehabilitation (20.1⫾9.1d vs 13.7⫾8.0d, P⬍.0001), lower FIM score at admission (55.6⫾20.7 vs 73.8⫾20.2, P⬍.0001), and lower FIM efficiency (1.2⫾1.0 vs 1.8⫾1.5, P⫽.01). 16 ⫹SSRI (18.8%) and 6 ⫺SSRI (9.7%) patients experienced 1 or more bleeding episodes, most commonly: gastrointestinal bleed (including occult bleeding), bleeding from a recently inserted gastrostomy tube or pacemaker, nose bleeds, hematuria, or easy bruising. Only 1 ⫹SSRI and 1 ⫺SSRI patient with bleeding required acute medical care. No hemorrhagic transformations of ischemic strokes were noted. Altered mental status occurred in 2 ⫹SSRI and 6 ⫺SSRI patients. Worsening neurologic symptoms occurred only in 4 ⫺SSRI patients. All patients with abnormal bleeding received ⱖ1 anticoagulant or antiplatelet agents (n⫽21) or had recently undergone a surgical procedure (renal stent placement, n⫽1). Conclusions: Bleeding complications were more common in ⫹SSRI patients despite equivalent anticoagulant and antiplatelet treatment, emphasizing the importance of monitoring for bleeding complications during SSRI treatment. ⫹SSRI patients experienced a similar improvement in FIM score, but had lower FIM efficiency, possibly reflecting the underlying effect of depressive symptoms. Key Words: Depression; Rehabilitation; Selective serotonin reuptake inhibitors; Stroke. Abstract 24 Occupational Categories and Return to Work After Traumatic Brain Injury. Merle R. Orr, MD (Virginia Commonwealth University, Richmond, VA); William C. Walker, MD; Jenny H. Marwitz, MA; Jeffrey Kreutzer, PhD, e-mail: [email protected]. Disclosure: None. Objectives: To further evaluate determinants of return to work (RTW) after traumatic brain injury (TBI) by examining the relationship between preinjury occupational category and RTW outcome. Design: Prospective collaborative cohort study. Setting: To be eligible for this study, patients had to have been hospitalized with a diagnosis of TBI and have received both acute neurotrauma services and inpatient rehabilitation services at any of the 17 Traumatic Brain Injury Model Systems centers. Participants: Consecutive sample of 1173 patients with TBI who consented to participate, were employed prior to injury, and had completed 1-year follow-up assessment. Intervention: Included an inpatient interdisciplinary brain injury rehabilitation program. Main Outcome Measure: Competitive employment 1 year after rehabilitation. Results: Participants (N⫽1173) were categorized into 1 of 3 groups, depending on preinjury occupational title: high decision making (n⫽170), service related (n⫽622), or manual labor (n⫽381). Chi-square analysis showed an association between these categories and RTW at 1 year (P⬍.005). The chance of successful RTW was greatest for high decision making (58.8%), less for service related (42.8%), and lowest for manual labor (32.5%). Of those with successful RTW, the majority did so within the same occupational category grouping. Preinjury manual labor jobs were most likely to shift to a different category postinjury (39.1%), whereas service-related jobs were least likely to shift (25.5%). Conclusions: Prior research has shown that preinjury employment status (employed vs unemployed) greatly influences the odds of successful RTW after TBI. The current study convincingly demonstrates that the type of occupation also influences RTW outcome, with the best prospect for RTW being among persons with high decision-making jobs. Occupational category should be examined in the future development of predictive models for RTW after TBI. Key Words: Brain injuries; Employment; Occupational groups; Rehabilitation.

Arch Phys Med Rehabil Vol 84, September 2003