Poster 469: Incidence of Headaches in Combat Injured United States Service Members and Veterans Deployed to Iraq and Afghanistan with Traumatic Brain Injury (TBI)

Abstracts / PM R 9 (2017) S131-S290 Objective: To ascertain if early MRI level of injury accurately determines the clinically-assessed neurologic level of injury (NLI) in patients who have sustained acute blunt spinal cord trauma. Design: Prospective observational study. Setting: Level I trauma center. Participants: Patients enrolled into TRACK-SCI trial between 20152017 who had both early MRI (within 24 hours of admission) and clinical assessment of NLI (clinical NLI) within 48 hours of admission, 6 months and 12 months after injury. Interventions: N/A. Main Outcome Measures: Three MRI measures of NLI were defined: 1) cranial margin of spinal cord (SC) T2-hyperintensity, 2) caudal margin of SC T2-hyperintensity, and 3) epicenter of injury as determined by the axial level for which the BASIC score was obtained. Level designation was based on the vertebral level. Clinical NLIs were obtained consistent with ASIA guidelines. Results: Spearman rank correlation analyses showed significant correlation between all 3 early MRI measures of NLI and clinical NLI within 48 hours of admission, and 6-months post-injury (Spearman rhos > 0.56, Ps < .05). Bland Altman agreement analyses showed that when MRI NLI and edema boundaries were compared to clinical NLI, the epicenter level used for BASIC scoring showed less overall bias and was in closer agreement with clinical NLI, particularly at Day 1 and 6 months (mean vertebral level difference between measurements < 1.0). MRI measures of NLI did not correlate with clinical NLI at 12 months (Spearman rhos < 0.66, Ps > .05). Conclusions: Our prospective data validate prior retrospective data showing correlation between MRI NLI and clinical NLI. Use of the BASIC scoring system to determine the epicenter of injury shows closest agreement with clinical NLI. Present data are the first to demonstrate that early MRI measures of NLI do not correlate with long term (12 month) clinical NLI. Further investigation of conventional MRI measures for predicting long term clinical NLI are warranted. Level of Evidence: Level II

CATEGORY: PAIN & SPINE MEDICINE

Poster 467: Improved Functional Capacity but Stagnant Real-Life Physical Activity After both Injection and Surgical Decompression for Lumbar Spinal Stenosis Patricia Z. Zheng, MD (Stanford Univ, Santa Clara, California, United States), Galym Imanbayev, Bachelor of Arts, MD Candidate, Amir Muaremi, PhD, Justin Norden, MPhil, Aman Sinha, MPhil, Christy C. Tomkins-Lane, PhD, Matthew Smuck, MD Disclosures: Patricia Zheng: I Have No Relevant Financial Relationships To Disclose Objective: We compared free-living physical activity in patients who underwent either injection or surgical decompression for lumbar spinal stenosis (LSS). Design: This was a retrospective analysis of results from two separate studies looking at outcomes after injection or surgical decompression for LSS. Setting: 3 tertiary medical institution in North America. Participants: At least 40 years of age, had received a diagnosis of LSS, and were scheduled for epidural steroid injection (ESI) or surgical treatment of LSS through a shared-decision process with the treating physician. Interventions: ESI or surgical decompression for LSS. Main Outcome Measures: Reported (ODI, SSSQ, SF-36) function, objective function (self-paced walk test (SPWT), and 7 days of free-living physical activity as measured using Actigraph accelerometers were measured at baseline and 1 week after ESI and 6 months after surgery.

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Results: Participants included 17 who underwent injections (average 70.1
6.7 years old, 47% women) and 28 who underwent surgeries (average 70.1
8.9 years old, 60.7% women). All subjective measures (ODI, SSSQ, and SF-36) improved significantly after injections and surgeries, as did objective functional measures including maximum ambulated distance (SPWT). However, objectively measured real-life physical activity did not change after either injections or surgeries. Patients were just as sedentary after surgeries as they were after injections (82.7
5.4% vs 88.6
5.8%, P¼.09). Conclusions: Our studies were the first to track real-life physical activity in people with LSS post-intervention. We found that after both injections and surgeries, participants failed to demonstrate increased physical activity as measured by continuous activity monitoring. This lack of improvement in free-living physical activity contrasts measured improvements in self-reported function and objective ability to move. Given that we previously showed that a focused multidisciplinary lifestyle modification program can increase free-living physical activity levels and quality of life in patients with LSS; our findings here suggest a role for focused post-intervention rehabilitation to increase activity after interventions in the LSS population. Level of Evidence: Level II

CATEGORY: NEUROLOGICAL REHABILITATION

Poster 469: Incidence of Headaches in Combat Injured United States Service Members and Veterans Deployed to Iraq and Afghanistan with Traumatic Brain Injury (TBI) Stephanie A. Jones, DO (Stanford University PM&R Program, Mountain View, CA, United States), Molly A. Timmerman, DO, Olga Katsnelson, RN Disclosures: Stephanie Jones: I Have No Relevant Financial Relationships To Disclose Objective: Post-traumatic headaches (PTHs) are significant complication of traumatic brain injury, a condition that our military population is at higher risk of given their combat experience and an evergrowing clinical concern as more of our active duty soldiers return home from war. Our study sought to identify those at higher risk of developing PTHs so that clinically we can offer treatment earlier and facilitate assimilation into post-war life. Design: Retrospective chart review. Setting: Retrospective chart review. Participants: United States veterans or active duty service members with combat deployments to either Iraq (Operation Iraqi Freedom [OIF]) or Afghanistan (Operation Enduring Freedom [OEF]), who screened positive for history of head injury and were seen in TBI specialty clinic at Palo Alto Veterans Hospital from 2013-2017. Interventions: Not applicable. Main Outcome Measures: Self report of headaches in the moderate to very severe range on neurobehavioral symptom index (NSI). Results: A total of 829 patients were identified who had physician diagnosed, combat related head injury of any severity (mild, moderate, and severe). Of those patients 613 (75%) reported headaches to be a clinically significant problem in the moderate to very severe range on NSI. Of patients with combat related head injury, 799 sustained mild severity head injury, 25 sustained moderate severity head injury, and 5 sustained severe head injury. Incidence of headaches in patients who sustained mild TBI was 596/799 (75%), moderate TBI 15/25 (60%), and severe TBI was 2/5 (40%). Conclusions: The incidence of PTHs, though consequential for all severities of TBI, was highest among patients with mild TBI. Clinicians should be vigilant about screening patients with all grades of

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Abstracts / PM R 9 (2017) S131-S290

TBI, especially those with seemingly mild TBI, for PTHs in order to offer treatment sooner and prevent adverse effects on veterans’ daily lives. Level of Evidence: Level IV

CATEGORY: NEUROLOGICAL REHABILITATION

Poster 470: Safety and Tolerability of Transcranial Direct Current Stimulation to Stroke Patients e A Phase I Current Escalation Study Wuwei Feng, MD MS (Medical University of South Carolina, Charleston, SC, United States), Pratik Y. Chhatbar, MD PhD, Steven A. Kautz, PhD, Mark George, MD Disclosures: Wuwei Feng: I Have No Relevant Financial Relationships To Disclose Objective: A prior meta-analysis revealed that higher doses of transcranial direct current stimulation (tDCS) have a better poststroke upper-extremity motor recovery. While this finding suggests that currents greater than the typically used 2 mA may be more efficacious, the safety and tolerability of higher currents have not been assessed in stroke patients. We aim to assess the safety and tolerability of single session of up to 4 mA in stroke patients. Design: We adapted a traditional 3 + 3 study design with a current escalation schedule of 1>2>2.5>3>3.5>4 mA for this tDCS safety and tolerability study. Setting: Stroke rehabilitation center Participants: First-ever ischemic stroke patients with unilateral motor impairment with Fugl-Meyer upper extremity scale score <¼ 56/66. Interventions: We administered one 30-min session of bihemispheric montage tDCS and simultaneous customary occupational therapy to patients with first-ever ischemic stroke. Main Outcome Measures: We assessed safety with pre-defined stopping rules (second degree skin burn, clinical seizure; ADC abnormality or discontinuation from the study) and investigated tolerability through a questionnaire. Results: 18 patients completed the study. The current was escalated to 4 mA without meeting the pre-defined stopping rules or causing any major safety concern. 50% of patients experienced transient skin redness without injury. No rise in temperature (range 26-35 C) was noted and skin barrier function remained intact (i.e. body resistance >1KM). Conclusions: Our phase I safety study supports that single session of bihemispheric tDCS with current up to 4 mA is safe and tolerable in stroke patients. A phase II study to further test the safety and preliminary efficacy with multi-session tDCS at 4 mA (as compared with lower current and sham stimulation) is a logical next step. ClinicalTrials.gov Identifier: NCT02763826. Level of Evidence: Level I

CATEGORY: NEUROLOGICAL REHABILITATION

Poster 471: SIAXI: Efficacy and Safety of IncobotulinumtoxinA for the Treatment of Sialorrhea in Parkinson’s Disease (PD), Stroke, and Other Neurological Conditions: Results of a Phase III, Placebo-Controlled, Randomized, Double-Blind Study Andrew Blitzer, MD (Columbia University, New York, NY, United States), Andrzej Friedman, MD, Olaf Michel, MD, Birgit Flatau-Baque´, MD, Ja´nos Csiko´s, MD, Wolfgang Jost, MD Disclosures: Andrew Blitzer: Research Grants - Merz

Objective: To examine the safety and efficacy of incobotulinumtoxinA in the treatment of sialorrhea due to PD and other etiologies. Design: Prospective, randomized, double-blind, placebo-controlled, parallel-group study. Setting: 33 European sites. Participants: Adults with chronic, troublesome sialorrhea due to Parkinson’s disease (PD), stroke, and other etiologies. Interventions: 75U or 100U incobotulinumtoxinA, or placebo. For the higher/lower dose groups, 15U/20U of incobotulinumtoxinA were injected into each submandibular gland, and 22.5U/30U into each parotid gland. Main Outcome Measures: Co-primary outcomes: Unstimulated Salivary Flow Rate (uSFR) at week 4 vs baseline and Global Impression of Change Scale (GICS) at week 4. Secondary outcomes: Drooling Severity and Frequency Scale (DSFS); modified Radboud Oral Motor Inventory in Parkinson’s Disease (mROMP) drooling. Safety was monitored throughout. Results: 184 subjects received treatment (75U, n¼74; 100U, n¼74; placebo, n¼36). Sialorrhea etiologies: PD (70.6%), atypical Parkinson syndromes (8.7%), stroke (17.9%), traumatic brain injury (2.7%). The 100U group showed -0.13 g/min (SE 0.026, 95% CI) LS-mean uSFR reduction and +1.25 points (SE 0.144, 95% CI) LS-mean improvement on GICS at week 4 compared with baseline. Both coprimary outcomes were significantly greater in the 100U dose group vs placebo at week 4 (P<.005). The 75U dose was numerically more effective than placebo at week 4 but did not reach statistical significance. Improvements in uSFR and GICS at weeks 8 and 12 were observed in both incobotulinumtoxinA groups, with improvement in the uSFR maintained at week 16. DSFS and mROMP drooling assessments supported the effectiveness of both doses. The safety and tolerability profile was favorable; no new or unexpected safety signals were identified. Conclusions: Doses of 75U and 100U incobotulinumtoxinA are effective up to 16 weeks for treatment of sialorrhea in PD and other neurological conditions; greater improvement was observed for the 100U treatment without meaningful added risks for adverse effects. Level of Evidence: Level I

CATEGORY: QUALITY IMPROVEMENT

Poster 472: Improving Breadth, Depth, and Outcomes of Medical Rehabilitation after Level One Trauma Care Daniela A. Iliescu, Medical Student (Creighton University School of Medicine, Omaha, Nebraska, United States), Karl J. Sandin, MD, MPH Disclosures: Daniela Iliescu: I Have No Relevant Financial Relationships To Disclose Objective: To define interventions associated with better access to and better outcomes of medical rehabilitation after trauma. Design: Before and after non-experimental trial with 12-month follow-up. Setting: Academic Trauma Center and Associated Rehabilitation Unit. Participants: 56 Trauma patients admitted over 2-year period to rehabilitation. Interventions: 1. Twice weekly participation by consultation/liaison physiatrist in trauma pass-on teaching rounds. 2. Participation by physiatrist and rehabilitation admissions coordinator, in weekly trauma discharge planning conference. 3. Monthly presentation by physiatrist at formal trauma quality improvement committee. 4. Continued training of admissions coordinator in trauma rehabilitation by physiatrist. 5. Week-daily availability of physiatrist for formal acute care consultation. Main Outcome Measures: Number of patients admitted from level one trauma to inpatient acute medical rehabilitation; rehabilitation impairment group codes of those admitted patients; mean Functional