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Poster 352 Transient Global Amnesia from Intrathecal Baclofen- A Case Report
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main outcome measure without explicit adjustment for potential confounding factors such as gender and formulation differences. Results or Clinical Course: The network of RCTs and treatment arms formed a linear series of “steps” which facilitated the meaningful comparison of all botulinum toxin type A treatments of interest. The results for MAS change from baseline for all treatments were: Placebo (mean -0.45, SE 0.08), abobotulinumtoxinA (mean -2.14, SE 0.75), incobotulinumtoxinA (mean -1.3, SE 1.15), and onabotulinumtoxinA (mean -1.10, SE 0.08) where a negative number indicates symptom improvement. There was reasonable agreement between the number of unconstrained data points, residual deviance and pair-wise results, suggesting a coherent network. Conclusions: AbobotulinumtoxinA and onabotulinumtoxinA were significantly more effective compared to placebo in treating upper limb spasticity. There was no significant efficacy difference between abobotulinumtoxinA and onabotulinumtoxinA. Due to the low number of patients for the incobotulinumtoxinA intervention, this analysis cannot assess the efficacy of incobotulinumtoxinA with reasonable certainty. Poster 352 Transient Global Amnesia from Intrathecal BaclofenA Case Report. David Rosenblum (Gaylord Hospital, Wallingford, CT, United States); Paul Desan, MD. Disclosures: D. Rosenblum, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 67-year-old woman with multiple sclerosis effectively treated for severe spasticity with the intrathecal baclofen pump (ITB) developed recurrent antegrade amnesia and was diagnosed wtih transient global amnesia (TGA). Neurologic and medical work up was negative for other etiologies, and there was no evidence of seizures. Her dose of intrathecal baclofen was carefully titrated down from 530 micrograms per day to 96 micrograms per day with resolution of TGA. She was then titrated up to 130 micrograms per day of ITB with good control of spasticity, and continued resolution of TGA. This is the first reported case of ITB associated TGA that was effectively managed with titration of dosing of ITB. The incidence, pathophysiology, differential diagnosis, and treatment options for TGA in patients with ITB are presented. Program Description: Spasticity Management. Setting: Outpatient Hospital setting. Results or Clinical Course: There was complete resolution of TGA in a patient with ITB with dosing adjustment. Discussion: TGA is a rare, temporary (less than 24 hour duration) episode of anterograde amnesia with no clouding of consciousness, no cognitive impairment, and no seizures. Intrathecal baclofen (ITB) is approved for the treatment of spasticity of both cerebral and spinal origin. ITB associated TGA is rare, and the incidence of TGA is 3-30/100,000. Baclofen, as a GABA-B receptor agonist, has been shown to induce antegrade amnesia in rodents, but it is very rare in humans. One previously reported case utilized nitroglycerin based on its role for nitric oxide metabolism and modulation of the release of GABA. However, this may adversely affect blood pressure, especially in patients with low systolic blood pressure at baseline. This report demonstrates the effective
PRESENTATIONS
management of TGA with titration of ITB dose, with resolution of TGA and effective control of spasticity. Presentation will include an overview of ITB, TGA, pathophysiology, and treatment approach. Patients with ITB who develop anterograde amnesia should be evaluated for TGA, and an effective treatment approach is outlined. Conclusions: Adjustment of ITB dosing was successful in eliminating TGA, while maintaining control of spasticity. Poster 353 Tolerability of the Powered Ekoskeleton Ekso TM in an Outpatient Rehabilitation Setting in Spinal Cord Injury. Erin Prastine, PT (Gaylord Hospital, Wallingford, CT, United States); Erika Ozdemirer, PT; David Rosenblum. Disclosures: E. Prastine, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: The aim of this study was to report patient experience using EKSO TM, and determine user tolerability and performance using Ekso TM in an outpatient setting in persons with spinal cord injury. Design: A retrospective study of Ekso TM users in an outpatient setting. Setting: Hospital based Participants: Spinal cord injury, motor complete or incomplete, who have participated in at least 10 skilled treatment sessions. Interventions: Retrospective data review of 11 patients with spinal cord injury participating in program that completed 10 training sessions Main Outcome Measures: Number of people in the program, age ranges, male vs female, diagnosis, complete vs incomplete, traumatic vs. non-traumatic, duration since injury, reasons for exclusion from treatment, and payer source. Average number of steps per session & total number of steps, walk time, progression to advanced modes, progression to use of crutches , amount of assistance required, safety of use, adverse effects, and self-reported comments at end of 10 sessions. Results or Clinical Course: There were 10 men and 1 woman of age range 19 to 76; 9 motor complete, 2 motor incomplete; 9 paraplegic, 2 tetraplegics; 9 traumatic and 2 non-traumatic. Average duration since injury was 90 months. 6 were excluded by screening due to lack of range of motion or leg length discrepency. 9 clients did not reach 10 visits due to lack of transportation, decreased motivation, return to work, or improved ability to ambulate. The payer sources were 7 commercial, 2 state/federal, two scholarship/ no out of pocket payment. At 10 visits, average number of steps was 590, and total number of steps was 6,488, up time average was 344 minutes, time spent walking averaged 267 minutes. Ten progressed to advance modes of walking. Six advanced to crutches; those not advancing were limited by decreased hand function, decreased balance, and personal preference. Balance and gait quality improved in all subjects. All were able to utilize the device and ambulate on the first visit. Sessions were well tolerated; no one dropped out of the program due to any adverse effects. Adverse effects included orthostasis, pain, spasticity. Improvements included less pain and spasms, more energy. Conclusions: Robotic assisted ambulation with Ekso TM is safe, well tolerated and can be utilized as a progressive gait training tool in spinal cord injury
main outcome measure without explicit adjustment for potential confounding factors such as gender and formulation differences. Results or Clinical Course: The network of RCTs and treatment arms formed a linear series of “steps” which facilitated the meaningful comparison of all botulinum toxin type A treatments of interest. The results for MAS change from baseline for all treatments were: Placebo (mean -0.45, SE 0.08), abobotulinumtoxinA (mean -2.14, SE 0.75), incobotulinumtoxinA (mean -1.3, SE 1.15), and onabotulinumtoxinA (mean -1.10, SE 0.08) where a negative number indicates symptom improvement. There was reasonable agreement between the number of unconstrained data points, residual deviance and pair-wise results, suggesting a coherent network. Conclusions: AbobotulinumtoxinA and onabotulinumtoxinA were significantly more effective compared to placebo in treating upper limb spasticity. There was no significant efficacy difference between abobotulinumtoxinA and onabotulinumtoxinA. Due to the low number of patients for the incobotulinumtoxinA intervention, this analysis cannot assess the efficacy of incobotulinumtoxinA with reasonable certainty. Poster 352 Transient Global Amnesia from Intrathecal BaclofenA Case Report. David Rosenblum (Gaylord Hospital, Wallingford, CT, United States); Paul Desan, MD. Disclosures: D. Rosenblum, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 67-year-old woman with multiple sclerosis effectively treated for severe spasticity with the intrathecal baclofen pump (ITB) developed recurrent antegrade amnesia and was diagnosed wtih transient global amnesia (TGA). Neurologic and medical work up was negative for other etiologies, and there was no evidence of seizures. Her dose of intrathecal baclofen was carefully titrated down from 530 micrograms per day to 96 micrograms per day with resolution of TGA. She was then titrated up to 130 micrograms per day of ITB with good control of spasticity, and continued resolution of TGA. This is the first reported case of ITB associated TGA that was effectively managed with titration of dosing of ITB. The incidence, pathophysiology, differential diagnosis, and treatment options for TGA in patients with ITB are presented. Program Description: Spasticity Management. Setting: Outpatient Hospital setting. Results or Clinical Course: There was complete resolution of TGA in a patient with ITB with dosing adjustment. Discussion: TGA is a rare, temporary (less than 24 hour duration) episode of anterograde amnesia with no clouding of consciousness, no cognitive impairment, and no seizures. Intrathecal baclofen (ITB) is approved for the treatment of spasticity of both cerebral and spinal origin. ITB associated TGA is rare, and the incidence of TGA is 3-30/100,000. Baclofen, as a GABA-B receptor agonist, has been shown to induce antegrade amnesia in rodents, but it is very rare in humans. One previously reported case utilized nitroglycerin based on its role for nitric oxide metabolism and modulation of the release of GABA. However, this may adversely affect blood pressure, especially in patients with low systolic blood pressure at baseline. This report demonstrates the effective
PRESENTATIONS
management of TGA with titration of ITB dose, with resolution of TGA and effective control of spasticity. Presentation will include an overview of ITB, TGA, pathophysiology, and treatment approach. Patients with ITB who develop anterograde amnesia should be evaluated for TGA, and an effective treatment approach is outlined. Conclusions: Adjustment of ITB dosing was successful in eliminating TGA, while maintaining control of spasticity. Poster 353 Tolerability of the Powered Ekoskeleton Ekso TM in an Outpatient Rehabilitation Setting in Spinal Cord Injury. Erin Prastine, PT (Gaylord Hospital, Wallingford, CT, United States); Erika Ozdemirer, PT; David Rosenblum. Disclosures: E. Prastine, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: The aim of this study was to report patient experience using EKSO TM, and determine user tolerability and performance using Ekso TM in an outpatient setting in persons with spinal cord injury. Design: A retrospective study of Ekso TM users in an outpatient setting. Setting: Hospital based Participants: Spinal cord injury, motor complete or incomplete, who have participated in at least 10 skilled treatment sessions. Interventions: Retrospective data review of 11 patients with spinal cord injury participating in program that completed 10 training sessions Main Outcome Measures: Number of people in the program, age ranges, male vs female, diagnosis, complete vs incomplete, traumatic vs. non-traumatic, duration since injury, reasons for exclusion from treatment, and payer source. Average number of steps per session & total number of steps, walk time, progression to advanced modes, progression to use of crutches , amount of assistance required, safety of use, adverse effects, and self-reported comments at end of 10 sessions. Results or Clinical Course: There were 10 men and 1 woman of age range 19 to 76; 9 motor complete, 2 motor incomplete; 9 paraplegic, 2 tetraplegics; 9 traumatic and 2 non-traumatic. Average duration since injury was 90 months. 6 were excluded by screening due to lack of range of motion or leg length discrepency. 9 clients did not reach 10 visits due to lack of transportation, decreased motivation, return to work, or improved ability to ambulate. The payer sources were 7 commercial, 2 state/federal, two scholarship/ no out of pocket payment. At 10 visits, average number of steps was 590, and total number of steps was 6,488, up time average was 344 minutes, time spent walking averaged 267 minutes. Ten progressed to advance modes of walking. Six advanced to crutches; those not advancing were limited by decreased hand function, decreased balance, and personal preference. Balance and gait quality improved in all subjects. All were able to utilize the device and ambulate on the first visit. Sessions were well tolerated; no one dropped out of the program due to any adverse effects. Adverse effects included orthostasis, pain, spasticity. Improvements included less pain and spasms, more energy. Conclusions: Robotic assisted ambulation with Ekso TM is safe, well tolerated and can be utilized as a progressive gait training tool in spinal cord injury