Treatment programs including botulinum toxin, treatment goals, and goal achievment for poststroke spasticity: Does time matter?

Treatment programs including botulinum toxin, treatment goals, and goal achievment for poststroke spasticity: Does time matter?

Abstracts / Toxicon 123 (2016) S2eS90 therapeutic effect of IM BoNT or of other therapies. Further studies are needed to confirm this hypothesis. Keyw...

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Abstracts / Toxicon 123 (2016) S2eS90

therapeutic effect of IM BoNT or of other therapies. Further studies are needed to confirm this hypothesis. Keywords: Cervical dystonia; Pain; Sensory trick; Subcutaneous botulinum neurotoxin; Trigger point 81. AESTHETIC BONT INJECTIONS OF THE FACE: OPTIONS AND OUTCOMES Ellen C. Gendler. NYU Langone Medical Center, 1035 Fifth Avenue, New York, NY 10028, USA. E-mail address:[email protected]

A brief discussion of anatomic considerations in the aging face, followed by a road map to addressing various cosmetic concerns in this population using botulinum toxin. Appropriate treatment plans will be outlined and outcomes, both good and bad, will be presented. 82. BONT INJECTIONS FOR HYPERHIDROSIS: TECHNICAL PEARLS Dee Anna Glaser. Departments of Dermatology, Internal Medicine, and Otolaryngology, Saint Louis University School of Medicine, 1755 S. Grand Boulevard, ABI 4th Floor, St. Louis, MO 63104, USA. E-mail address:[email protected] Hyperhidrosis (HH) is characterized by excessive sweating greater than that required for normal physiologic temperature regulation and can be a primary or secondary disorder. Regardless of the etiology, therapy with botulinum toxins is a valuable therapy with high efficacy rates and excellent tolerability. Like most procedures, technique is crucial to obtaining optimal outcomes while minimizing adverse events. Areas commonly treated in patients with primary focal HH include the axilla, palms, face and scalp, and inframammary and groin regions. Secondary HH therapy can be more diverse, but the presentation will include pearls for gustatory HH, and amputation stump HH. Special considerations need to be addressed when treating the various areas, including neurotoxin type, dose, concentration, injection spacing, underlying anatomy, and pain control. Starch iodine testing can be extremely useful to delineate the area of treatment, and general principles will be reviewed. 83. HAND DYSTONIA: MUSCLE SELECTION FOR BONT Jennifer G. Goldman. Department of Neurological Sciences, Section of Parkinson Disease and Movement Disorders, Rush University Medical Center, 1725 W. Harrison Street, Suite 755, Chicago, IL 60612, USA. E-mail address:[email protected] rush.edu

This session will focus on muscle selection for botulinum toxin injections for hand dystonias. Hand dystonias are primarily focal dystonias that are task-specific and produce abnormal, involuntary postures and muscle contractions during selective motor activities. Examples of hand dystonias include writer’s cramp, which is considered the most common type, as well as other dystonias affecting a wide range of occupations (musicians and golfers, among others). Chemodenervation with botulinum toxin injection has been a commonly used treatment strategy for focal hand dystonia, including writer’s cramp. Many of the studies of botulinum toxin for writer’s cramp have been open-label series, but several randomized, blinded, placebocontrolled trials have also been performed. Symptomatic benefit for the dystonia can occur with botulinum toxin injections, though there are potential side effects such as weakness that should be minimized. When injecting with botulinum toxin for hand dystonias, one must carefully evaluate and select the muscles affected. Muscle selection is often based on a combination of patient history of symptoms and patterns of tightness, clinical observation of dystonic postures and/or tremor during writing/ activity and examination, and sometimes EMG findings or ultrasound localization of muscle overactivity. This session will discuss principles of muscle selection for botulinum toxin injections, relevant upper extremity anatomy, and a variety of complementary techniques such as EMG identification, ultrasound, or electrical stimulation, as well as cases of hand dystonia and botulinum

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toxin treatment. 84. IS FUNCTIONAL IMPROVEMENT THE SAME IN STROKE PATIENTS TREATED WITH BOTULINUM TOXIN IN UPPER LIMB ONLY VS A TYPICAL POSTSTROKE INPATIENT POPULATION IN A NEUROREHABILITATION SERVICE? ~o Castro, Isabel Amorim, Carolina Melissa Gorayeb*, Daniela Pinto, Joa ~o, Maria Pais Carvalho, Andre  Ladeira, Andre  Yee, Jorge Jacinto. Falca ~o de Alcoita ~o, Serviço de Reabilitaça ~o de Centro de Medicina de Reabilitaça Adultos 3, Alcabideche, Portugal ~o, Rua * Corresponding author: Centro de Medicina de Reabilitaç~ ao de Alcoita ~oeAlcoita ~o, 2649-506 Alcabideche, Portugal. E-mail address:melisaConde Bara [email protected]

Introduction and objectives: To evaluate if stroke patients treated with botulinum toxin (BoNTA) in the upper limb only during an inpatient rehabilitation program (IRP) had the same functional outcome as the total typical stroke population in our service. Methods: Stroke patients (n¼41) treated in an IRP were allocated to the botulinum-toxin-in-upper-limb study group (UL-BoNTA) in any of their inpatient interventions between 2011 and 2016. The control group (CG) consisted of 114 stroke patients in their first IRP who were treated in 2014. Data were collected in a specific form, at admission and discharge. Stroke was classified by etiology, localization, and impairment. Functionality was assessed with the functional independence measure (FIM). The correlations between these characteristics were investigated. Results: Patients’ characteristics regarding age (64 years in both groups), gender (44% and 49% of the CG and UL-BoNTA groups, respectively, were males), etiology (73% and 78% of the CG and UL-BoNTA groups, respectively, were ischemic), and length of stay (median, 69 days for both groups) were homogeneous in both groups. The most affected hemisphere in the CG was the right (47%) and in the UL-BONTA group was the left (54%; P¼0.20). The CG patients were in an earlier phase (median stroke to admission time of 59 vs 107 days for CG and ULBONTA groups, respectively). Among the 114 patients in the CG, 1 had UL, 8 had lower limb, and 13 had upper + lower limb BoNTA injections according to current practice. The mean FIM score at admission and at discharge for CG and UL-BONTA groups were similar (66 and 73; 84 and 91, respectively; P¼0.59). The mean total FIM improvement was 18 for both (P<0.05). Conclusions: In our group, expert selection for UL-BoNTA injection in post-acute and chronic stroke patients allowed them to have functional improvement as good as the typical general poststroke population of the department, including those patients treated earlier poststroke. Keywords: Botulinum toxins; Muscle spasticity; Rehabilitation; Stroke 85. POSTSTROKE UPPER LIMB SPASTICITY TREATMENT INCLUDING BOTULINUM TOXIN IN AN INPATIENT POST-ACUTE REHABILITATION PROGRAM: HOW ARE WE DOING IT? ~o Castro, Isabel Amorim, Carolina Melissa Gorayeb*, Daniela Pinto, Joa ~o, Maria Pais Carvalho, Andre  Ladeira, Andre  Yee, Jorge Jacinto. Falca ~o de Alcoita ~o, Serviço de Reabilitaça ~o de Centro de Medicina de Reabilitaça Adultos 3, Alcabideche, Portugal ~o, Rua * Corresponding author: Centro de Medicina de Reabilitaç~ ao de Alcoita ~o 2649-506, Alcabideche, Portugal. E-mail address:melisaConde Bar~ ao e Alcoita [email protected]

Objectives: To describe the patterns of upper limb botulinum toxin injections (UL-BoNTA) during an inpatient rehabilitation program. Methods: Prospectively collected data from 41 stroke inpatients treated from 2011 to 2016. Objectives were classified based on Goal Attainment Scaling e Evaluation of Outcomes for Upper Limb Spasticity. Injected muscles and BoNTA doses are described. Results: Mean age was 64.2 years, and 51% were females. The most frequent etiology was ischemic (78%). Impairment was left hemiparesis in 42% and right hemiparesis in 51%. Mean stroke to admission interval was 107 days. Mean functional independence measure (FIM) score at admission was 72 and 91 at discharge. Of 41 patients, 24 had goals properly

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Abstracts / Toxicon 123 (2016) S2eS90

described, 20 of which had UL-BoNTA for goals related to Impairment/ Symptoms (15 pain/discomfort, 4 involuntary movements, 1 range of motion) and 4 to Activities/Function (2 mobility, 1 passive function, 1 active function). The most frequently injected muscles were in the shoulder and arm: biceps brachii/brachialis anterior/brachioradialis (34/ 41), subscapularis (22/41), pectoralis major (20/41), followed by forearm flexors (flexor carpi radialis 17/41, flexor carpi ulnaris 16/41, and flexor digitorum superficialis 14/41). The dose proportion between BoNTA preparations (abobotulinumtoxinA/incobotulinumtoxinA/onabotulinumtoxinA) were: subscapularis 1/ 0.38/0.26; pectoralis major 1/0.44/0.27; biceps brachii 1/0.43/0.30; flexor carpi radialis 1/0.39/0.28; flexor carpi ulnaris 1/0.41/0.26; flexor digitorum superficialis 1/0.31/0.31, and flexor pollicis longus 1/0.46/0.37. Conclusions: We found that, in our practice, the most frequent UL goals in poststroke spasticity were related to pain/discomfort and impairment. This is not too surprising, taking into consideration that these are postacute care inpatients, so their real life is focused on and partly limited by the hospital environment and their therapeutic activities. Keywords: Botulinum toxin; Muscle spasticity; Rehabilitation; Stroke 86. TREATMENT PROGRAMS INCLUDING BOTULINUM TOXIN, TREATMENT GOALS, AND GOAL ACHIEVEMENT FOR POSTSTROKE SPASTICITY: DOES TIME MATTER? Melissa Gorayeb*, Daniela Pinto, Jorge Jacinto. ~o de Alcoita ~o, Serviço de Reabilitaça ~o de Centro de Medicina de Reabilitaça Adultos 3, Alcabideche, Portugal ~o de Alcoita ~o, Rua * Corresponding author: Centro de Medicina de Reabilitaça ~oeAlcoita ~o, 2649-506 Alcabideche, Portugal. E-mail address:melisaConde Bara [email protected]

Introduction and objectives: To compare the goals and outcomes for poststroke spasticity (PSS) patients treated with botulinum toxin (BoNTA) at different stages of the disease. Methods: Data were collected prospectively and retrieved from clinical files of outpatients treated in 2014, including all BoNTA treatment sessions (2001 to 2016). We investigated: time from stroke to first BoNTA treatment, limbs treated (upper limb, UL; upper + lower limb, UL + LL; lower limb, LL), adjunctive treatments, primary goals and their achievement. BoNTA treatments were divided into 3 groups based on time elapsed between onset of stroke and each BoNTA treatment session: < 1year, from 1 to 4 years and  4 years. Results: There were 117 patients (1057 BoNTA sessions). Mean age at stroke was 54 years (standard deviation [SD], 12.37). Median time from stroke to first BoNTA treatment was 0.9 years (range, 0.1 to 9.8). Forty-four percent of patients had left hemiparesis, and 55% had right hemiparesis. The mean number of sessions was 9 (SD, 6), and mean follow up was 4.2 years (SD, 3.35). AbobotulinumtoxinA was used in 69% of patients; the mean total dose was 1108 U (SD, 367). IncobotulinumtoxinA was used in 17%, with a mean total dose of 402 U (SD, 138). OnabotulinumtoxinA was used in 13%, with a mean total dose of 368 U (SD, 113). UL + LL were treated in 63% of patients, UL in 28%, and LL in 9%. Patients were more likely to have injections in UL only in the first year but LL only at 4 years after stroke (P<0.001). Of 1057 treatment cycles, 87% were associated with physiotherapy (PT), 31% with occupational therapy (OT), and 40% with orthosis (OT). Patients were more likely to have PT + OT for up to 4 years, but after the fourth year, most were treated with OT (P¼0.008). Primary goals were effect on impairment/symptoms in 59% and activities/function in 41%. Primary goal areas were influenced by time (P¼0.8). The achievement/ overachievement rate was 83% for <1year, 84% for 1 to 4 years, and 73% for  4 years (P¼0.03). Conclusions: Our sample consists of relatively young patients and started BoNTA relatively early but otherwise is typical of stroke patients. Up to 9.8 years, time since stroke seems to influence which limbs were treated (UL, LL, or UL+LL) in each BoNTA session, the adjunctive therapies, and goal achievement. Broad primary goal areas were not influenced by time between stroke and each BoNTA treatment. The high rate of goal achievement in our patients suggests adequate patient selection and interventions.

Keywords: Botulinum toxins; Goal; Muscle spasticity, Rehabilitation; Stroke 87. DURATION OF EFFECT OF ABOBOTULINUMTOXINA (DYSPORT) IN ADULT PATIENTS WITH LOWER LIMB SPASTICITY POST STROKE OR TRAUMATIC BRAIN INJURY Jean-Michel Gracies a, *, Allison Brashear b, Alberto Esquenazi c, Michael O'Dell d, Thierry Deltombe e, Senen Gonzalez f, Francois Boyer g, AnneSophie Grandoulier h, Claire Vilain h, Philippe Picaut h. a Hospital Albert Chenevier-Henri Mondor, Service de R e education Neurolocomotrice, Cr eteil, France; b Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA; c MossRehab & Albert Einstein, Elkins Park, PA, USA; d Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, NY, USA; e Service de M edecine Physique et de R eadaptation, Centre Hospitalier Universitaire Dinant Godinne/ Universit e Catholique de Louvain Namur, Yvoir, Belgium; f Royal Melbourne es de M edecine Hospital, Royal Park Campus, Victoria, Australia; g Unit ^pital S Physique et de R eadaptation, Ho ebastopol, CHU Reims, ChampagneArdenne, Reims, France; h Ipsen, Les Ulis, France  Paris-Est Cre teil, Service de * Corresponding author: EA 7377 BIOTN, Universite e ducation Neurolocomotrice, Ho ^ pitaux Universitaires Henri Mondor, Assistance Re ^pitaux de Paris, 51, av du Mare chal De Lattre De Tassigny, Cre teil Publique - Ho 94010, France. E-mail address:[email protected]

Introduction: Few studies have assessed the treatment interval during repeated injections of botulinum toxin. In a double-blind (DB), singletreatment study followed by a long-term open-label (OL) extension study, abobotulinumtoxinA (aboBoNT-A, Dysport) was efficacious and did not generate unexpected safety findings (Gracies 2016). This additional analysis reports the retreatment intervals for the lower limb in hemiparetic adults after repeated injections of aboBoNT-A. Methods: This was a phase 3, international, multicenter, double-blind (DB), single-treatment study of aboBoNT-A in the hemiparetic lower limb, followed by a long-term open-label (OL) extension study with a maximum of 4 additional treatment cycles over a maximum of 18 months. Retreatment was per investigator’s clinical judgment and possible at Weeks 12, 16, 20, and 24. Results: Among the subjects who received aboBoNT-A in the DB study and were treated in Cycle 1 of the OL extension study, 20% were reinjected at Week 16 or later (10% at Week 16, 5% at Week 20, 5% at Week 24 or later). For those who received a second cycle of treatment in the OL phase, 32% of subjects were reinjected at Week 16 or later (17% at Week 16, 9% at Week 20, 7% at Week 24). For those who received a third cycle of treatment in the OL phase, 15% of subjects were reinjected at Week 16 or later. Conclusions: These data demonstrate the long duration of effect of aboBoNT-A in the spastic lower limb with 15% to 32% of subjects reinjected at Week 16 or later across repeated cycles. A long duration of effect leading to a longer interval between injections may reduce the burden associated with frequency of injections for patients and their caregivers/families. This also highlights the need for a tailored approach to the treatment of the lower limb in hemiparesis. Keywords: AbobotulinumtoxinA; Dysport; Duration of action; Interval; Lower limb spasticity Reference Gracies JM, Esquenazi A, Brashear A, et al. Poster 288. Efficacy and Safety of Repeated AbobotulinumtoxinA Injections in Adults with Lower Limb Spasticity. PM R. 2016 Sep;8(9S):S254. http://dx.doi.org/10.1016/j.pmrj. 2016.07.461. Epub 2016 Sep 24. PubMed PMID: 27673046. 88. IMPROVEMENT OF ACTIVE MOVEMENT AND FUNCTION IN ADULTS WITH CHRONIC SPASTIC PARESIS FOLLOWING REPEATED TREATMENT WITH ABOBOTULINUMTOXINA (DYSPORT®) Jean-Michel Gracies a, Allison Brashear b, Alberto Esquenazi c, Robert Jech d, Marta Banach e, Peter McAllister f, Serdar Kocer g, Anne-Sophie Grandoulier h, Claire Vilain h, *, Philippe Picaut h. a EA 7377 BIOTN, Universit e Paris-Est, Hospital Albert Chenevier-Henri Mondor, Service de R e education Neurolocomotrice, Cr eteil, France;