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Poster 281 The Adult Spasticity International Registry (ASPIRE Study): Baseline Demographics and Clinical Characteristics of Patients Treated for Spasticity
Abstracts / PM R 8 (2016) S151-S332 Poster 279 Radial Neuropathy Exacerbated by Ligamentous Laxity in Pregnancy and by Chemotherapy: A Case Report Joel Castellanos, MD (University of Michigan, Ypsilanti, Michigan, United States), Sean R. Smith, MD Disclosures: Joel Castellanos: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 32-year-old right-handed woman with metastatic malignant mixed Mullerian tumor (MMMT) presented with left upper extremity numbness, tingling, and pain along her posterior forearm, thumb, and second digit. She developed mild symptoms during pregnancy 7 months prior, and severe symptoms three months before presentation after receiving carboplatin and paclitaxel chemotherapy for MMMT. Four years earlier, she also experienced a milder form of these symptoms; electromyography (EMG) found no abnormalities and the symptoms resolved spontaneously. Of note, her history is significant for numerous left shoulder subluxations requiring reduction. Setting: Outpatient cancer rehabilitation clinic. Results: Physical examination revealed decreased strength in left elbow extension (4-/5) and wrist extension (4/5), absent left triceps reflex, and diminished pinprick sensation over the posterior forearm with increased sensitivity to light touch over the distal radial nerve distribution. Computerized tomography of her neck and chest did not reveal neural foraminal narrowing or metastatic disease to explain her symptoms. On EMG testing, radial sensory nerve conduction studies (NCS) were not recordable, and radial motor studies at the forearm showed decreased amplitude compared to the right side (1.7mV vs 3.7mV) with comparable distal latencies. Median and ulnar motor and sensory NCS were normal. Needle electromyography revealed positive waves, fibrillations, and chronic changes in the extensor carpi radialis brevis, brachioradialis, and extensor indicis, but not the triceps, suggesting an incomplete chronic axonal neuropathy proximal to the brachioradialis. Deltoid, biceps brachii, pronator teres, and first dorsal interosseus (hand) had no abnormal EMG findings. Discussion: Repetitive shoulder subluxation likely created tension on the radial nerve at the spiral groove of the humerus, causing a stretch injury. Ligamentous laxity in pregnancy caused symptoms to recur, and chemotherapy worsened the injury to the point of axonotmesis. Conclusions: Pregnancy may exacerbate neuropathies associated with ligamentous laxity, and chemotherapy can worsen pre-existing neuropathies. Level of Evidence: Level V Poster 280 ALS Masked by Breast Cancer History and Low Back Pain: A Case Report Patrick Dolan, MD (SUNY Downstate Medical Center, Brooklyn, NY, United States), Bhavi Patel, DO, Marcel G. Bayol, MD Disclosures: Patrick Dolan: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 56-year-old African American woman with a past medical history of hypertension and ductal carcinoma in situ of the breast (treated by resection and radiation) was evaluated for worsening leg and arm weakness. She had leg weakness requiring the use of a cane. She later developed arm weakness resulting in decreased grip with her cane and almost daily falls. She also noted low back pain and occasional urinary incontinence. There was concern for metastases or a paraneoplastic syndrome from her breast cancer history but CT and MRI of the head revealed no new changes. CT of the spine revealed L3-S1 disk herniations (L3/4, L4/5, L5/S1) so she was given two epidural steroid injections for possible lumbar radiculopathy. Her symptoms continued to worsen with new vocal
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hoarseness accompanied by shortness of breath. On initial exam, she was found to have 4/5 muscle strength with 3+ hyperreflexia throughout, upgoing plantar reflex bilaterally and a positive jaw jerk reflex. She was able to transfer independently and exhibited a very slow and narrow, unsteady gait. Otherwise, the rest of her examination was within normal limits. Workup including antibodies, inflammatory markers, and infectious etiologies were all negative except for a CK of 777. MRI of spine corroborated previous CT findings. After no imaging or laboratory abnormalities pointed to any diagnosis, EMG was performed leading to Amyotrophic Lateral Sclerosis (ALS) diagnosis. Patient was subsequently transferred to acute inpatient rehab then referred to outpatient movement disorder specialist for further care. Setting: Inpatient Acute Rehabilitation Facility. Results: EMG demonstrated reduced amplitude, prolonged latencies, or decreased conduction velocity in right median and ulnar motor nerves, right medial sensory nerve, right peroneal motor and sensory nerves, and right sural sensory nerve. Discussion: This case demonstrates the importance of physical exam and significance of inpatient electrodiagnostic studies in helping to establish or confirm a diagnosis. Conclusions: Based on our physical examination revealing UMN/LMN signs with LMN findings corroborated by EMG and absence of other more likely diagnoses this patient demonstrates ALS. Level of Evidence: Level V Poster 281 The Adult Spasticity International Registry (ASPIRE Study): Baseline Demographics and Clinical Characteristics of Patients Treated for Spasticity Gerard E. Francisco, MD (University of Texas and TIRR Memorial, Houston, TX, United States), Daniel Bandari, Ganesh Bavikatte, Wolfgang H. Jost, MD, PhD, Aubrey Manack Adams, PhD, Joan Largent, Alberto Esquenazi, MD Disclosures: Gerard Francisco: Research Grants - Allergan, Research Grants - Merz, Research Grants - Mallinckrodt, Research Grants - Ipsen, Research Grants - Nexstim, Research Grants - Micro transponder Objective: To describe baseline demographics and clinical characteristics in patients treated with onabotulinumtoxinA for spasticity. Design: Multicenter, prospective, observational registry study (NCT01930786). Setting: Select clinical sites in North America, Europe, and Asia. Participants: Patients with spasticity of multiple etiologies, including those naı¨ve to and previously treated with onabotulinumtoxinA. Interventions: OnabotulinumtoxinA treatments administered per routine care. Main Outcome Measures: Primary objectives were to assess onabotulinumtoxinA treatment utilization, patient/physician treatment satisfaction, and botulinum toxin treatment incidence for other indications among adult spasticity patients treated with onabotulinumtoxinA. Baseline demographics and clinical characteristics as of September 10, 2015 are summarized (enrollment completed September 11, 2015). Results: A total of 727 patients were enrolled in ASPIRE and treated by 63 healthcare providers (69.4% PM&R’s) across France, Germany, Italy, Spain, Taiwan, UK, and USA (n¼54 sites). More patients (n¼602/ 715, 84.2%) had lower limb spasticity (most common: equinovarus foot [35.2%] and extended knee [16.1%]), than upper limb spasticity (n¼513/716, 71.2%; most common: flexed elbow [22.4%] and clenched fist [21.5%]). At baseline, 36.8% (n¼268) of patients were botulinum toxin naı¨ve for spasticity treatment. Patients with spasticity due to stroke (58.1%), multiple sclerosis (15.7%), other etiologies (10.1%), cerebral palsy (9.8%), traumatic brain injury (5.9%), and spinal cord injury (5.4%), were on average 53.7 years old, majority were Caucasian (77.4%), and gender was nearly evenly distributed (52.1% female). Patients were mainly on disability (44.2%) and had a caregiver (57.9%;
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most common: spouse/live-in partner [53.3%]). Demographics were generally comparable across countries, except Taiwan. Conclusions: Global epidemiological data for spasticity is lacking. ASPIRE represents the largest existing international database prospectively evaluating demographics and clinical characteristics of spasticity across multiple etiologies. Further baseline analyses will describe onabotulinumtoxinA utilization patterns, treatment satisfaction, individual/caregiver burden, and characterize the healthcare providers treating spasticity. Level of Evidence: Level II Poster 282 Functional Gains after Diagnosis of Central Pontine Myelinolysis due to Hypophosphatemia in a Leukemia Patient on an Acute Inpatient Rehabilitation Unit: A Case Report Ekta Gupta, MD (University of Texas, M.D. Anderson Cancer Center, Houston, Texas, United States), Jack B. Fu, MD Disclosures: Ekta Gupta: I Have No Relevant Financial Relationships To Disclose Case/Program Description: This is a 20-year-old female with relapsed T-cell acute lymphoblastic leukemia (ALL) who presented with bacteremia and septic shock. MRI brain on admission showed no acute abnormalities. She had a prolonged intensive care unit (ICU) course on multiple vasopressors; had multi-organ failure including acute renal failure requiring dialysis; poor enteral feeding tolerance requiring total parenteral nutrition; and left leg ischemia requiring below-theknee amputation. She was hypoalbuminemic, hypophosphatemic, and mildly hyponatremic, with subsequent slow correction in levels and no rapid fluctuations noted. She was transferred to inpatient rehabilitation on day 64, requiring maximum to total assistance with transfers and dressing and minimum assistance with bathing. She was noted to have right hemiparesis and hypertonicity in her lower extremity with clonus and hyper-reflexia. MRI lumbar spine showed no acute abnormality. MRI brain was consistent with central pontine myelinolysis (CPM). The patient had no quadriparesis, dysphagia, cognitive deficits, or other signs of classic CPM. She was evaluated by Neurology and Endocrinology, with conclusion that her atypical presentation of CPM was most likely due to hypophosphatemia. The patient continued therapy, with significant improvement in right-sided strength and no notable cognitive impairments. Setting: Tertiary Care. Results: The patient was discharged home on day 77 at minimal assistance with toileting and transfers, and modified independent with wheelchair mobility. Discussion: This is the first reported case of CPM with an atypical presentation of right hemiparesis, hypertonicity, and no cognitive deficits that was due to hypophosphatemia diagnosed on an acute inpatient rehabilitation unit. Her diagnosis and presentation was relevant to her rehabilitation team for assessing her potential for functional gains. Conclusions: CPM should be considered as an etiology of hemiparesis and hypertonicity in a hypophosphatemic patient with good potential for functional recovery. Level of Evidence: Level V Poster 283 Improvement in Compensation for Chronic Post-Stroke Homonymous Hemianopsia following Initiation of an SSRI: A Case Report Benjamin A. Abramoff, MD (Emory University Affiliated Hospital, Decatur, Georgia, United States), Samir Belagaje, MD, Samuel Milton Disclosures: Benjamin Abramoff: I Have No Relevant Financial Relationships To Disclose
Case/Program Description: A 22-year-old woman with a one-year history of left sided homonymous hemianopsia (HH) secondary to a stroke presented to acute inpatient rehabilitation following a motor vehicle collision (MVC). One year prior to her rehabilitation admission, the patient presented with an acute visual field (VF) deficit and was found to have a right posterior cerebral artery stroke. Over the following year, the patient continued to have stable HH both subjectively and on multiple VF examinations, leading to an impaired quality of life. The patient subsequently presented to acute inpatient rehabilitation after being a restrained passenger in an MVC in which she suffered a mild traumatic brain injury, pelvic and vertebral column fractures. During her hospitalization for her MVC, the patient was started on a selective serotonin reuptake inhibitor (SSRI) due to several months of clinical depression. Setting: Acute Inpatient Rehabilitation Hospital. Results: Following initiation of the SSRI, the patient reported subjective improvement in her VFs. VF testing revealed improved compensatory strategies for her VF deficits. The patient also experienced improvement in her quality of life in relation to her improved vision. Discussion: Spontaneous recovery of VF deficits one year following a stroke is very unlikely. Previous studies have demonstrated beneficial effects of SSRIs in stroke patients with cognitive impairment, motor impairment, dependency, disability, depression and anxiety. This has been attributed to direct effects through neurogenesis, neuron migration, neuroprotection, adrenergic effects, and indirectly through effects on depression and anxiety. We postulate that this patient had improvement in her visual compensation secondary to an improvement in her depression. To our knowledge, this is the first case that has shown improvement of visual compensation in stroke patients following the initiation of an SSRI. Conclusions: This case report suggests the potential for a novel utilization of SSRIs to improve compensation for HH following stroke. Level of Evidence: Level V Poster 284 The Effect Playing Electronic Musical Instruments has on the Functional Improvement of the Hemiplegic Upper Limbs and Its Psychological Effect Fumihito Kasai, MD, PhD (Showa University School of Meicine, Kotoku, Tokyo, Japan), Yoshitaka Wada, MD, Shinichi Wada, MD, MPH Disclosures: Fumihito Kasai: I Have No Relevant Financial Relationships To Disclose Objective: To evaluate the effect playing electronic musical instruments has on functional improvement of the hemiplegic upper limbs and the psychological effect in patients living at home. Design: Experimental clinical study. Setting: Outpatient visits at the university hospital. Participants: Twelve cases of stroke hemiplegia patients (56 6.4 year old) living at home. Interventions: Electronic musical instruments with performance support functions, electric guitars and electric drums, were lent to the patients to practice playing the instrument at home using their hemiplegic upper limbs. Patients were tasked to engage in a minimum of 30 minutes practice every day. Instructions on playing the musical instrument were provided by a music therapist at the outpatient visit once every week, along with ensemble practices with other patients, for 14 weeks. A concert to which the families of the patients were invited was held at the end. The concert was planned and prepared by the patients as part of a group activity, for which we provided advice as necessary. Main Outcome Measures: Fugl-Meyer Assessment for the Upper Extremity (FMA-UE, 66 points maximum), Goldberg’s General Health Questionnaire (GHQ), Rosenberg’s Self-Esteem Scale (SES), Collaborative Activities Assessment Scale (CAAS), and individual questionnaires.
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hoarseness accompanied by shortness of breath. On initial exam, she was found to have 4/5 muscle strength with 3+ hyperreflexia throughout, upgoing plantar reflex bilaterally and a positive jaw jerk reflex. She was able to transfer independently and exhibited a very slow and narrow, unsteady gait. Otherwise, the rest of her examination was within normal limits. Workup including antibodies, inflammatory markers, and infectious etiologies were all negative except for a CK of 777. MRI of spine corroborated previous CT findings. After no imaging or laboratory abnormalities pointed to any diagnosis, EMG was performed leading to Amyotrophic Lateral Sclerosis (ALS) diagnosis. Patient was subsequently transferred to acute inpatient rehab then referred to outpatient movement disorder specialist for further care. Setting: Inpatient Acute Rehabilitation Facility. Results: EMG demonstrated reduced amplitude, prolonged latencies, or decreased conduction velocity in right median and ulnar motor nerves, right medial sensory nerve, right peroneal motor and sensory nerves, and right sural sensory nerve. Discussion: This case demonstrates the importance of physical exam and significance of inpatient electrodiagnostic studies in helping to establish or confirm a diagnosis. Conclusions: Based on our physical examination revealing UMN/LMN signs with LMN findings corroborated by EMG and absence of other more likely diagnoses this patient demonstrates ALS. Level of Evidence: Level V Poster 281 The Adult Spasticity International Registry (ASPIRE Study): Baseline Demographics and Clinical Characteristics of Patients Treated for Spasticity Gerard E. Francisco, MD (University of Texas and TIRR Memorial, Houston, TX, United States), Daniel Bandari, Ganesh Bavikatte, Wolfgang H. Jost, MD, PhD, Aubrey Manack Adams, PhD, Joan Largent, Alberto Esquenazi, MD Disclosures: Gerard Francisco: Research Grants - Allergan, Research Grants - Merz, Research Grants - Mallinckrodt, Research Grants - Ipsen, Research Grants - Nexstim, Research Grants - Micro transponder Objective: To describe baseline demographics and clinical characteristics in patients treated with onabotulinumtoxinA for spasticity. Design: Multicenter, prospective, observational registry study (NCT01930786). Setting: Select clinical sites in North America, Europe, and Asia. Participants: Patients with spasticity of multiple etiologies, including those naı¨ve to and previously treated with onabotulinumtoxinA. Interventions: OnabotulinumtoxinA treatments administered per routine care. Main Outcome Measures: Primary objectives were to assess onabotulinumtoxinA treatment utilization, patient/physician treatment satisfaction, and botulinum toxin treatment incidence for other indications among adult spasticity patients treated with onabotulinumtoxinA. Baseline demographics and clinical characteristics as of September 10, 2015 are summarized (enrollment completed September 11, 2015). Results: A total of 727 patients were enrolled in ASPIRE and treated by 63 healthcare providers (69.4% PM&R’s) across France, Germany, Italy, Spain, Taiwan, UK, and USA (n¼54 sites). More patients (n¼602/ 715, 84.2%) had lower limb spasticity (most common: equinovarus foot [35.2%] and extended knee [16.1%]), than upper limb spasticity (n¼513/716, 71.2%; most common: flexed elbow [22.4%] and clenched fist [21.5%]). At baseline, 36.8% (n¼268) of patients were botulinum toxin naı¨ve for spasticity treatment. Patients with spasticity due to stroke (58.1%), multiple sclerosis (15.7%), other etiologies (10.1%), cerebral palsy (9.8%), traumatic brain injury (5.9%), and spinal cord injury (5.4%), were on average 53.7 years old, majority were Caucasian (77.4%), and gender was nearly evenly distributed (52.1% female). Patients were mainly on disability (44.2%) and had a caregiver (57.9%;
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most common: spouse/live-in partner [53.3%]). Demographics were generally comparable across countries, except Taiwan. Conclusions: Global epidemiological data for spasticity is lacking. ASPIRE represents the largest existing international database prospectively evaluating demographics and clinical characteristics of spasticity across multiple etiologies. Further baseline analyses will describe onabotulinumtoxinA utilization patterns, treatment satisfaction, individual/caregiver burden, and characterize the healthcare providers treating spasticity. Level of Evidence: Level II Poster 282 Functional Gains after Diagnosis of Central Pontine Myelinolysis due to Hypophosphatemia in a Leukemia Patient on an Acute Inpatient Rehabilitation Unit: A Case Report Ekta Gupta, MD (University of Texas, M.D. Anderson Cancer Center, Houston, Texas, United States), Jack B. Fu, MD Disclosures: Ekta Gupta: I Have No Relevant Financial Relationships To Disclose Case/Program Description: This is a 20-year-old female with relapsed T-cell acute lymphoblastic leukemia (ALL) who presented with bacteremia and septic shock. MRI brain on admission showed no acute abnormalities. She had a prolonged intensive care unit (ICU) course on multiple vasopressors; had multi-organ failure including acute renal failure requiring dialysis; poor enteral feeding tolerance requiring total parenteral nutrition; and left leg ischemia requiring below-theknee amputation. She was hypoalbuminemic, hypophosphatemic, and mildly hyponatremic, with subsequent slow correction in levels and no rapid fluctuations noted. She was transferred to inpatient rehabilitation on day 64, requiring maximum to total assistance with transfers and dressing and minimum assistance with bathing. She was noted to have right hemiparesis and hypertonicity in her lower extremity with clonus and hyper-reflexia. MRI lumbar spine showed no acute abnormality. MRI brain was consistent with central pontine myelinolysis (CPM). The patient had no quadriparesis, dysphagia, cognitive deficits, or other signs of classic CPM. She was evaluated by Neurology and Endocrinology, with conclusion that her atypical presentation of CPM was most likely due to hypophosphatemia. The patient continued therapy, with significant improvement in right-sided strength and no notable cognitive impairments. Setting: Tertiary Care. Results: The patient was discharged home on day 77 at minimal assistance with toileting and transfers, and modified independent with wheelchair mobility. Discussion: This is the first reported case of CPM with an atypical presentation of right hemiparesis, hypertonicity, and no cognitive deficits that was due to hypophosphatemia diagnosed on an acute inpatient rehabilitation unit. Her diagnosis and presentation was relevant to her rehabilitation team for assessing her potential for functional gains. Conclusions: CPM should be considered as an etiology of hemiparesis and hypertonicity in a hypophosphatemic patient with good potential for functional recovery. Level of Evidence: Level V Poster 283 Improvement in Compensation for Chronic Post-Stroke Homonymous Hemianopsia following Initiation of an SSRI: A Case Report Benjamin A. Abramoff, MD (Emory University Affiliated Hospital, Decatur, Georgia, United States), Samir Belagaje, MD, Samuel Milton Disclosures: Benjamin Abramoff: I Have No Relevant Financial Relationships To Disclose
Case/Program Description: A 22-year-old woman with a one-year history of left sided homonymous hemianopsia (HH) secondary to a stroke presented to acute inpatient rehabilitation following a motor vehicle collision (MVC). One year prior to her rehabilitation admission, the patient presented with an acute visual field (VF) deficit and was found to have a right posterior cerebral artery stroke. Over the following year, the patient continued to have stable HH both subjectively and on multiple VF examinations, leading to an impaired quality of life. The patient subsequently presented to acute inpatient rehabilitation after being a restrained passenger in an MVC in which she suffered a mild traumatic brain injury, pelvic and vertebral column fractures. During her hospitalization for her MVC, the patient was started on a selective serotonin reuptake inhibitor (SSRI) due to several months of clinical depression. Setting: Acute Inpatient Rehabilitation Hospital. Results: Following initiation of the SSRI, the patient reported subjective improvement in her VFs. VF testing revealed improved compensatory strategies for her VF deficits. The patient also experienced improvement in her quality of life in relation to her improved vision. Discussion: Spontaneous recovery of VF deficits one year following a stroke is very unlikely. Previous studies have demonstrated beneficial effects of SSRIs in stroke patients with cognitive impairment, motor impairment, dependency, disability, depression and anxiety. This has been attributed to direct effects through neurogenesis, neuron migration, neuroprotection, adrenergic effects, and indirectly through effects on depression and anxiety. We postulate that this patient had improvement in her visual compensation secondary to an improvement in her depression. To our knowledge, this is the first case that has shown improvement of visual compensation in stroke patients following the initiation of an SSRI. Conclusions: This case report suggests the potential for a novel utilization of SSRIs to improve compensation for HH following stroke. Level of Evidence: Level V Poster 284 The Effect Playing Electronic Musical Instruments has on the Functional Improvement of the Hemiplegic Upper Limbs and Its Psychological Effect Fumihito Kasai, MD, PhD (Showa University School of Meicine, Kotoku, Tokyo, Japan), Yoshitaka Wada, MD, Shinichi Wada, MD, MPH Disclosures: Fumihito Kasai: I Have No Relevant Financial Relationships To Disclose Objective: To evaluate the effect playing electronic musical instruments has on functional improvement of the hemiplegic upper limbs and the psychological effect in patients living at home. Design: Experimental clinical study. Setting: Outpatient visits at the university hospital. Participants: Twelve cases of stroke hemiplegia patients (56 6.4 year old) living at home. Interventions: Electronic musical instruments with performance support functions, electric guitars and electric drums, were lent to the patients to practice playing the instrument at home using their hemiplegic upper limbs. Patients were tasked to engage in a minimum of 30 minutes practice every day. Instructions on playing the musical instrument were provided by a music therapist at the outpatient visit once every week, along with ensemble practices with other patients, for 14 weeks. A concert to which the families of the patients were invited was held at the end. The concert was planned and prepared by the patients as part of a group activity, for which we provided advice as necessary. Main Outcome Measures: Fugl-Meyer Assessment for the Upper Extremity (FMA-UE, 66 points maximum), Goldberg’s General Health Questionnaire (GHQ), Rosenberg’s Self-Esteem Scale (SES), Collaborative Activities Assessment Scale (CAAS), and individual questionnaires.