Poster 238

E46

2005 ACADEMY ANNUAL ASSEMBLY ABSTRACTS

rehabilitation was 25.3⫾16.9 days (median, 20), while the mean time of hospital care was 52.3⫾29.4 days (median, 45). Upper and lower Motricity Index, TCT, FIM, and FIM motor, and age at admission were significantly linearly related to FAC at discharge, while side of hemorrhage, type of stroke (hemorrhagic or ischemic), hypertension, diabetes, dyslipidemia, and sex were not. Logistic regression analysis showed that the independent variables related to FAC were age, TCT and total FIM: the model correctly allocated 124 of 150 cases (83%). Considering an output value below .05 on logistic regression to be a risk factor of FAC⫽0, we found that 21 of 35 patients with FAC⫽0 had an output value below .05 and that only 3 patients with an output below .05 had FAC⬎0. Conclusions: We used FAC as a measure of outcome in walking because of its reliability and sensitivity in patients with stroke. Logistic regression showed that dichotomized FAC was explained by TCT, total FIM, and age, with an 83% correct allocation rate. Focusing on the group with FAC⫽0 (35 patients), output below .05 on logistic analysis was a risk factor with an odds ratio of 41.6 (95% CI, 12.5–139; sensitivity, 60%; specificity, 96.5%). These findings seem to be interesting for optimizing rehabilitation goals. Key Words: Cerebrovascular accident; Recovery of function; Rehabilitation. Poster 237 The Use of Botulinum Toxin Type A in the Treatment of Hemiplegic Shoulder Pain: A Preliminary Investigation. Keng H. Kong, MD (Tan Tock Seng Hospital, Singapore, Singapore); Karen Chua; Jong Neo, e-mail: [email protected]. Disclosure: None. Objective: To assess the efficacy of one-time injection of botulinum toxin type A (Dysport) in reducing shoulder spasticity and pain in subjects with shoulder pain after a stroke. Design: Randomized, double-blind, placebo-controlled study. Setting: Outpatient clinic of a rehabilitation department. Participants: 17 subjects with hemiplegic shoulder pain associated with shoulder adductor and elbow flexor spasticity, randomly assigned to Dysport (n⫽8) or placebo (n⫽9) groups. Intervention: Injection of Dysport or placebo into the pectoralis major (250U) and biceps brachii (250U). Main Outcome Measures: Visual analog scale (VAS) of shoulder pain (0-10), muscle tone of shoulder adductor and elbow flexor using the Modified Ashworth Scale (MAS) and passive range of shoulder abduction. These were assessed at baseline, 4 weeks, 8 weeks, and 12 weeks postinjection. Results: The mean baseline pain score was 7 and the mean shoulder adductor and elbow flexor MAS scores were 2.3 and 2.4, respectively. Subjects who received Dysport showed greater improvements in mean shoulder adductor and elbow flexor MAS scores of at least 1 grade at all follow-up visits than did subjects who received placebo. However, statistically significant improvements were noted only at week 4 for shoulder adductor tone (P⫽.003) and at week 4 (P⫽.01) and week 8 (P⫽.04) for elbow flexor tone. For shoulder pain and passive shoulder abduction range, all subjects showed postinjection improvements and no statistical difference could be demonstrated between the Dysport and placebo groups. Conclusions: Even though intramuscular injections of Dysport was effective in reducing shoulder adductor and elbow flexor spasticity, its effects on shoulder pain was not any better than placebo. Key Words: Botulinum toxin type A; Shoulder pain; Muscle spasticity. Poster 238 Perceptions of the Rehabilitation Environment: Staff and Patients. Dale C. Strasser, MD (Emory University, Atlanta VA, Atlanta, GA); Judith A. Falconer, PhD; Jay M. Uomoto, PhD; Alan B. Stevens, PhD; Susan E. Bowen, PhD; Jeph S. Herrin, PhD, e-mail: [email protected]. Disclosure: None. Objective: To characterize the differences of perception of the rehabilitation environment between patients and staff. Design: Prospective, observational. Setting: 10 Veterans Administration inpatient rehabilitation units. Participants: 312 staff (13% occupational therapists, 18% physical therapists, 7% social workers/case managers, 5% speech therapists, 27% registered nurses, 7% physicians, 4% activity therapists, 4% kinesiotherapists) and 298 patients (mean age ⫾ SD, 67⫾12.4y; 94% men). Interventions: Not applicable. Main Outcome Measures: Surveys of the social climate of the rehabilitation environment. The survey consisted of 7 scales with a total of 80 true-false questions. These scales assess the social climate or “personality” of a rehabilitation environment and such measures have been shown to correlate with stroke rehabilitation outcomes. Three of the scales (patient-centered, interdisciplinary consistency, rehabilitation milieu) were developed by project staff, while the other 4 (involvement, spontaneity, program clarity, unit order and organization) were adapted from work by Moos. Results: Even after accounting for clustering by unit, staff rated the social climate of the rehabilitation unit higher than patients on 4 scales (P⬍.01): involvement, patient-centered, interdisciplinary consistency, and unit spontaneity. Patients rated the environment higher on unit order and organization (P⬍.01). No differences were found on program clarity (P⫽.09) and rehabilitation milieu (P⫽.41). Conclusions: Staff perceive the rehabilitation environment as more consistent and patient focused and with less structure than patients. These differences may provide insights into how the patients’ experience of rehabilitation differs from staff expectations. Such differences may offer clues how to make rehabilitation more congruent with patients’ expectations. Key Word: Rehabilitation.

Poster 239 Resource Utilization, Productivity, and Caregiver Burden Impact in a Trial of Repeated Doses of Botulinum Toxin Type A for the Treatment of Focal Upper-Limb Poststroke Spasticity: A Multicenter Open-Label Study. Elie P. Elovic, MD (Kessler Medical Rehabilitation Research and Education Corp; New Jersey Medical School, West Orange and Newark, NJ); Richard L. Barron, MS; Jingyu Liu, PhD; Catherine C. Turkel, PharmD, MBA, e-mail: [email protected]. Disclosure: Elovic, Research grant from Allergan Inc., Consultant for Allergan Inc., Allergan Inc. Speakers Bureau; Pfizer, Pharmacia, Cephalon other; Proctor and Gamble, NeuroControl other; Barron, Allergan Inc. employee; Liu, Allergan Inc. employee; Turkel, Allergan Inc. employee. Objective: To measure the functional utility of repeated treatments of botulinum toxin type A (BTX-A) on burden of illness using the Spasticity Impact Questionnaire (SIQ). Design: Multicenter,

Arch Phys Med Rehabil Vol 86, September 2005

open-label, repeated dose study. Setting: 35 North American stroke research centers. Participants: 279 patients with poststroke, upper-limb spasticity. Intervention: Patients received up to 5 treatment cycles with BTX-A over 54 weeks. The SIQ was administered at baseline, week 6, 12, 24, 30, 36, and 48 posttreatment. Main Outcome Measures: Analysis of resource utilization, productivity, and caregiver burden using data from the SIQ. Results: 279 patients were enrolled and treated; 81% completed the year-long study. Mean age ⫾ SD was 58.2⫾13.24 year, 53.8% of patients were men, and most patients were white (82.1%). The average time since stroke was 4.98 years, with the average time since onset of spasticity being 4.43 years. There were consistent statistically significant reductions in days per month (average, 1–1.5d) that friends or family members had to take off work to care for patients. There were also consistently significant reductions in hours a week (mean range, 4.9 – 8.8h/wk) of assistance required of friends and family members after treatment with BTX-A. There were significant reductions in the number of days a month (1.5–3) that arm function interfered with usual activities. The largest percentage of patients reported improvements (vs no change or worsening) in accomplishing more work, in requiring less adaptation and changes to perform work, and in working less carefully or accurately. Conclusions: Results from this large, open-label study suggest that BTX-A may improve resource utilization, productivity, and caregiver burden. Key Words: Botulinum toxin type A; Quality of life; Rehabilitation; Muscle spasticity. Poster 240 Towards Identifying Clinical and Kinematic Predictors of Learned Nonuse. Michelle J. Johnson, PhD (Medical College of Wisconsin, Milwaukee, WI); Kimberly Wisneski; Adam Hermsen; Roger Smith, PhD; Terry Walton, OTR; John McGuire; et al, e-mail: [email protected]. Disclosure: None. Objective: To identify clinical and kinematic predictors of learned nonuse (LNU) behavior that can be used as a measure for carryover after robotic therapy. Design: Cross-sectional, controlled study. Setting: Human motion analysis lab. Participants: 6 stroke subjects with hemiparesis and 2 able-bodied subjects. Intervention: Kinematic data collection using motion analysis as subjects completed unilateral and bilateral functional reach to a bell. Main Outcome Measures: Clinical scales such as Fugl-Meyer Assessment, the Functional Hand Evaluation (FHE), FIM instrument, and the actual amount of use and kinematic measures of movement time, total displacement, peak velocity, and movement smoothness. Results: LNU was found in all stroke subjects (P⫽.003), indicating a significant difference in forced and spontaneous use of the impaired arm. Nonsignificant trends were seen in the kinematic and clinical data, possibly due to small sample size. Movement time, peak velocity, total displacement, and movement smoothness accounted for less than 17% of the variability in LNU actual amount of use scores. Typically, impairment and disability scales accounted for less that 36% of the variance seen in these LNU scores. Although no significant predictors were identified, the FHE scale was the most promising predictor because it accounted for about 60% of the variance seen. Conclusions: Objectively quantifying LNU may require metrics that measure proximal and distal sensory and motor impairment. We speculate that in order to impact LNU, effective robot training may need to incorporate tasks that would train motor, sensory, and functional skills. Key Words: Functional reaching; Rehabilitation. Poster 241 The Effect of Inpatient Rehabilitation Unit Closure on Patient Stay and Readmission Characteristics of Stroke Patients. John DeWitt, MS; Mabel E. Caban, MD (UTMB, Houston, TX); Elizabeth Protas, PhD, e-mail: [email protected]. Disclosure: None. Objective: To determine if the closure of the inpatient rehabilitation unit at the University of Texas Medical Branch hospitals (UTMB) and length of stay (LOS) and number of readmissions are related. Design: Retrospective, case-control study. Setting: Hospital. Participants: 1317 hospital admissions from 741 unique patients admitted to UTMB during 2002 and 2003 with stroke indications. Interventions: Not applicable. Main Outcome Measures: LOS in days and number of readmissions. Results: Mean LOS for the initial admission was longer before (12.89⫾22.60d) than after (9.64⫾10.37d) closure of the unit (P⬍.01). For subsequent admissions, mean LOS did not differ before and after the unit closure (open, 11.82⫾25.23d; closed, 7.85⫾20.03d). The closure status of the unit and LOS were not independent (␹26 test⫽23.17, P⬍.001); after closure more patients stayed for only 1 day and less patients stayed for longer than 13 days than expected. Rehab unit status and the incidence of a patient being readmitted once were not related (unit open, 36.3%; unit closed, 32.9%). It appears that fall-related cause of readmission increased after closure of the unit. Conclusions: After closure of the inpatient rehabilitation unit at UTMB, initial LOS for stroke patients appears to decrease, and LOS trends were affected. It is possible that patients are forced to seek rehabilitation elsewhere or are transferred to skilled nursing facilities without a chance to rehabilitate. Key Words: Length of stay; Patient readmission; Rehabilitation; Stroke.

Poster 242 Safety and Efficacy of Repeated Botulinum Toxin Type A Treatments for Focal Upper-Limb Poststroke Spasticity: Results of a 12-Month Multicenter, Open-Label Trial. Elie P. Elovic, MD (Kessler Medical Rehabilitation Research and Education Corp, New Jersey Medical School, West Orange and Newark, NJ); Allison Brashear, MD; Darryl Kaelin, MD; Robin McIntosh; Jingyu Liu, PhD; Catherine C. Turkel, PharmD, MBA, e-mail: [email protected]. Disclosure: Elovic, Research from Allergan Inc., Consultant for Allergan Inc., Allergan Inc. Speakers Bureau, Consultant for Pfizer, Pharmacia, Cephalon, Proctor and Gamble, NeuroControl; Brashear, Research grant from Allergan Inc., Consultant for Allergan Inc., Allergan Inc. Speakers Bureau, Other, Consultant for Merz Pharmaceuticals, Research grant from Elan Corp.; Kaelin, Research grant from Allergan Inc., Consultant for Allergan Inc., Speakers Bureau Allergan Inc., Speakers Bureau Cephalon, Speakers Bureau Pfizer, Speakers Bureau Aventis; McIntosh, Allergan Inc. employee; Liu, Allergan Inc. employee; Turkel, Allergan Inc. employee. Objective: To evaluate the long-term safety and efficacy of repeated doses of botulinum toxin type A (BTX-A) for the treatment of focal upper-limb poststroke spasticity. Design: Multicenter, open-label study. Setting: 35 North American study centers. Participants: 279 patients with