WCNR 2012 Oral Abstracts

Theme: Basic Science

Abstract Id: 373

Duration of Treadmill Training and Recovery of Locomotion in Spinal Cord Injured Mice

Fiore CB¹, Hickey L², Rank M², Callister RJ², Galea MP¹

¹Department of Physiotherapy, The University of Melbourne, Melbourne, VIC, Australia

²School of Biomedical Sciences and Pharmacy, and Hunter Medical Research Institute, The University of Newcastle, Callaghan, NSW, Australia

Background and Aim: Treadmill training has been shown to improve locomotion in animals with spinal cord injury (SCI). However, there is little evidence regarding the length of training required to optimize recovery. The aim of this study was to compare the effects of treadmill training for 3 or 6 weeks on the recovery of locomotion in SCI mice.

Method: Experiments were performed in adult male C57/B16 mice. After a left hemisection at T12, animals were randomized to trained (n = 6) or untrained groups (n = 7). Prior to surgery all animals were familiarized with running on a treadmill for 10 minutes, 2× per day, 5 days per week. The trained group recommenced the training one week after SCI and continued for 3 or 6 weeks. Kinematic gait analysis was performed at baseline, 1, 4 and 7 weeks after surgery using a high-speed camera to record step cycles of each animal. Spatiotemporal characteristics of locomotion and excursion of hindlimb joints were analyzed with the Peak Motus software.

Results: Prior to SCI, all animals showed a coordinated pattern of locomotion. Following injury, there had no movement of the left hindlimb and the animals dragged their foot. Untrained animals progressed to an uncoordinated locomotion that was maintained during the whole experiment. After 3 weeks of training, trained animals had an uncoordinated locomotor pattern and limited excursion of all hindlimb joints. After 6 weeks of training, there was recovery of hip and knee joints excursions similar to pre-injury values, but not at the ankle joint.

Conclusions: Six weeks of treadmill training were show to improve locomotor pattern in SCI mice in comparison to no training or training for 3 weeks. Differences in excursion were only observed at the hip and knee joints. A longer period of training might be necessary to improve excursions at all joints.

Abstract Id: 218

Aripiprazole Facilitates Functional Recovery After Experimental Traumatic Brain Injury

Phelps TI^1,2, McAloon RL^1,2, Yelleswarapu NK^1,2, Garcia AN^1,3, Shah MA^1,3, Cheng JP^1,2, Kline AE^1,4

¹Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, USA

²Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA

³Center for Neuroscience, University of Pittsburgh, Pittsburgh, USA

⁴Psychology, University of Pittsburgh, Pittsburgh, USA

Background and Aims: Antipsychotic drugs (APDs) are routinely administered after traumatic brain injury (TBI) to reduce agitation and aggression. However, APDs with dopamine₂ (D₂) receptor antagonist properties (e.g., haloperidol and risperidone) impede cognitive recovery after TBI. Therefore, evaluation of APDs with different mechanisms of action is warranted. Aripiprazole (ARIP) exhibits 5-HT_1A and D₂ receptor agonist activity, but not D₂ antagonism. Studies from our laboratory have shown that pharmacological agents with these properties enhance outcome after TBI. Thus, the aim of the study was to test the hypothesis that ARIP will enhance motor and cognitive performance after TBI.

Methods: Adult male rats were anesthetized and received either a cortical impact (2.8 mm depth) or sham injury and then received either ARIP (0.1, 0.5, or 1.0 mg/kg; i.p.) or saline VEHicle beginning 24 hours after injury and once daily for 19 days. Motor (beam-balance/walk) and cognitive (Morris water maze) performance was assessed on post-operative days 1-5 and 14-19, respectively.

Results: The Sham groups did not differ from one another and thus the data were pooled. No motor differences were revealed among the TBI+VEH and TBI+ARIP groups [p > 0.05]. No cognitive differences were revealed among the TBI+VEH and the TBI+ARIP (0.5 and 1.0 mg/kg) groups [p = 0.94 and p = 0.43]. In contrast, the TBI+ARIP (0.1 mg/kg) group performed better in the water maze vs. the TBI+VEH group [p = 0.0036] and did not differ from the SHAM controls [p > 0.05].

Conclusions: No deleterious effects on behavioural outcome were observed with ARIP after TBI. Furthermore, the lower dose of ARIP facilitated spatial learning. The findings support our hypothesis and suggest that 1) ARIP may be a safer alternative for alleviating behavioural disturbances in TBI patients and 2) may be effective in improving cognitive function. Future studies will explore specific mechanism(s) mediating the beneficial effects of ARIP on recovery after TBI.

Theme: Cerebral Palsy

Abstract Id: 103

Can Training Change the Brain?

Boyd RN^1,3, Badawy R², Abbott D², Sakzewski L^1,3, Gilmore R¹, MacDonnell R¹, Jackson G¹

¹Brain Research Institute, Melbourne Brian Centre, Florey Neurosciences

²Division of Occupational Therapy, The University of Queensland

³Queensland Cerebral Palsy and Rehabilitation Research Centre, The University of Queensland, Australia

Objective: To understand the neural mechanisms underlying response to Constraint Induced Movement Therapy (CIMT) compared with Bimanual Training (BIM).

Design: Single blind RCT.

Participants: 30 children with hemiplegia (15 pairs) matched for age (mean 10.2 yrs), gender (15 males) and side of hemiplegia (13 right) were randomly allocated.

Interventions: Each intervention was delivered in a “day camp” for 6 hours/day over 10 days (60 hours).

Main Outcome Measures: 27 children (15 CIMT, 12 BIM) completed structural MRI (including 18 PVL, 11 cortical/deep gray matter, 1 malformation and 1 other). fMRI studies (3T) were conducted for a motor/sensory task (active/passive wrist extension/rest block design). On TMS, bilateral motor threshold and constructed recruitment curves at 100-140% of MT were measured. Function on Melbourne Unilateral Upper Limb Function (MUUL) & Assisting Hand Assessment (AHA).

Results: For BIM group on TMS, there were no changes in cortical excitability in either side (impaired/unimpaired MD 0.14 /0.7 at 3 weeks, 0.61/0.16 at 6 months, NS). In the CIMT group, there were significant increases in excitability on the impaired motor cortex at the 120-140% intensities (impaired/unimpaired MD 0.06/0.29 at 3 weeks, 0.24/0.38 at 6 months). There were no changes in the unimpaired side that wore the glove. CIMT group made greater gains on unimanual capacity (MUUL) at 3 weeks and 6 months with MD 4.8 (1.0-8.5; p = 0.02). There was a corresponding greater increase in voxel count on fMRI active motor task for the ROI for the CIMT group (p < 0.05) post treatment.

Conclusion: Our results provide direct evidence of neural plasticity for the group who received CIMT (increased cortical excitability of the impaired motor cortex supported by neurovascular changes). This corresponded with greater improvements in unimanual capacity by the CIMT group. Upper limb rehabilitation should commence with CIMT followed by bimanual training to maximize neural plasticity.

Abstract Id: 85

Executive Functioning in Children with Congenital Hemiplegia

Bodimeade H^1,2, Whittingham K^1,2, Lloyd O³, Boyd R¹

¹Queensland Cerebral Palsy and Rehabilitation Research Centre, School of Medicine, The University of Queensland, QLD, Australia

²School of Psychology, The University of Queensland, QLD, Australia

³Queensland Paediatric Rehabilitation Service, Royal Children’s Hospital Brisbane, Herston, QLD, Australia

Background and Aims: Early brain injury, as in congenital hemiplegia (CH), can cause deficits in higher-order cognitive tasks known as executive functions. This can disrupt normal development by impeding the child’s ability to effectively interact with their environment and acquire new skills. The aim of this study was to investigate executive functioning in children with congenital hemiplegia.

Methods: A cross-sectional cohort of forty-six children with CH (25 male; mean age 11.08 [SD 2.38], range 8-16 years, including 24 right [R], 22 left [L] CH; GMFCS I = 35, II = 11) and twenty typically developing children (TDC; 9 male; mean age 10.8 [SD 2.29], range 8-16 years) were included. Four domains of executive function were assessed: attentional control; cognitive flexibility; goal setting; and information processing utilising neuropsychological assessments. Between-group differences (CH vs. TDC and R vs. L) on measures of EF were examined in a series of one-way analyses of covariance. An overall composite of EF measures was created by standardising and aggregating all measures, α = .93.

Results: Children with CH performed significantly poorer on measures of executive functioning compared to TDC (aggregate executive function:

F(1, 63) = 31.16, p < .001, η² = 0.33). There were no significant differences between children with left and right CH on all measures, with the exception of Inhibition/Switching total errors, where children with left CH made fewer errors than children with right CH, F(1, 39) = 4.14, p = 0.049, η² = 0.1.

Conclusions: Children with CH experience more executive dysfunction compared to TDC, irrespective of side of hemiplegia. Findings from this study support an early vulnerability model of early brain injury and are in line with recent literature documenting the detrimental effects of early brain injury on EF (e.g., Anderson, Spencer-Smith). This has profound implications for the planning of interventions and monitoring of child development.

Abstract Id: 104

The Relationship Between Brain Structure and Gait Patterns in Children with Congenital Hemiplegia

MacFarlane S¹, Taufika S¹, Guzzetta A³, Edwards P², Boyd R^1,2

¹Queensland Cerebral Palsy and Rehabilitation Research Centre, School of Medicine, The University of Queensland, QLD, Australia

²Queensland Cerebral Palsy Health Service Royal Children’s Hospital, Brisbane, QLD, Australia

³Department of Developmental Neuroscience, Instituto di Ricovero e Cura a Carattere Scientifico Stella Maris, Pisa, Italy

Objective: Relationship between the severity of brain lesions and gait patterns in children with congenital hemiplegia.

Study Participants: 23 children with congenital hemiplegia (10 males; mean age 8⁺⁹, range 5-13⁺¹¹ years; 13 right; GMFCS I = 10, II = 13; spastic 20, dystonia 3) and gait patterns (Winters, Gage and Hicks I = 5, II = 11, III = 2, IV = 5).

Methods: MRIs were classified according to location, extent, and presumed timing (Krageloh-Mann) by a child neurologist masked to the clinical presentation and gait pattern. The WGH gait pattern was classified by two raters from video.

Results: The predominant brain lesion was white matter (65.2%), followed by grey matter (26.1%) and unclassifiable lesions (8.7%). Grey matter lesions were 13 times more likely (p = 0.026) to be WGH type III or IV (Logistic regression). The odds of being GMFCS I were 12 times higher (p = 0.041) in children with bilateral damage. FMS scores were found to have a significant relationship with cerebellar involvement (p = 0.031). Results of logistic regression comparing gait patterns and brain structure classification (KM) were significant, Exp(B) = 13, p = 0.026, and comparing GMFCS and laterality of MRI score were significant, Exp(B) = 12, p = 0.041.

Conclusion: Brain lesion type can predict the severity of gait patterns in children with hemiplegia, which has profound implications for prognosis, planning of interventions (conservative and surgical), and monitoring of hip development.

Abstract Id: 105

The Relationship Between Brain Structure and Gait Patterns in Children with Diplegia

Taufika S¹, MacFarlane S¹, Edwards P², Guzzetta A³, Boyd R^1,2

¹Queensland Cerebral Palsy and Rehabilitation Research Centre, School of Medicine, The University of Queensland, QLD, Australia

²Queensland Cerebral Palsy Health Service Royal Children’s Hospital, Brisbane, QLD, Australia

³Department of Developmental Neuroscience, Istituto di Ricovero e Cura a Carattere Scientifico Stella Maris, Pisa, Italy

Objective: Relationship between brain structure, gait patterns and gross motor function in ambulant children with diplegia.

Study Participants: 30 children with diplegia, motor type (28 spastic, 2 dystonia); 22 male; mean age 6, range 5-13 years; GMFCS I = 6, II = 15, III = 9.

Method: Gait patterns were classified as True Equinus (TE = 14), Jump Knee (JK = 5), Apparent Equinus (AE = 3) or Crouch gait (CG = 8) by two raters. Brain lesions on MRI scans were classified as Cortical Malformations (2), PVL (20) or miscellaneous (8). Lesion severity by number of affected (i) anatomical lobes, (ii) slices, (iii) size, and distribution as a total lesion score (sum/24) and an asymmetry index (AI).

Results: All measures of brain lesion severity (no. of affected lobes, slices and total lesion score) were significantly different between gait pattern types (χ² (2) = 7.36, p = 0.025, Kruskal Wallis). The greatest difference in number of affected slices between gait pattern groups (F(2) = 9.18, p < 0.001, ANOVA) was between TE and CG groups (p = 0.002, Sidaks test). The classification of lesion type was not significantly different between gait pattern groups. No measures of brain structure and severity were related to GMFCS or FMS scores.

Conclusion: This is the first study to investigate the relationship between measures of brain structure and gait patterns in children with diplegia. We found a relationship between measures of brain lesion severity and different sagittal plane gait patterns in children with diplegia. Early MRI and brain lesion assessment could predict later gait patterns at school age, which would assist in treatment planning.

Gait Pattern (n)	GMFCS	FMS (score/18)	KM Class	No. of Lobes (Av)	No. of Slices (Av)	Total Lesion Score	Asymmetry Index (range)
TE (n = 14)	I = 4, II = 7, III = 3	5-18	I = 1, II = 8; III = 0; IV = 5	2.03	3.03	3.9	−0.05 to 0.43
AE (n = 3)	II = 2, III = 1	5-15	II = 2, IV = 1	2	2.3	2.3	−0.2 to 1
JG (n = 5)	II = 3, III = 2	5-14	II = 4, IV = 1	2.3	4.13	4.3	–.03 to 0
CG (n = 7)	I = 2, II = 3, III = 3	5-18	I = 1, II = 6, IV = 1	3.9	8.9	9	−0.27 to 0.47
Total		15 (5-18)		2.57 (±1.7)	4.32 (±3.4)	4.83 (±3.8)	0.2 (±0.24)

Key: TE = True Equinus; JG = Jump gait; AE = Apparent Equinus; CG = Crouch gait; KM = Krageloh Mann classification (I = Cortical malformations; II = PVL; III = Misc); FMS = Functional Mobility scale.

Abstract Id: 252

Cross-Cultural Validation of Pediatric Evaluation of Disability Inventory Using Rasch Analysis

Berg M¹, Kleiven J², Dolva AS², Krumlinde-Sundholm L³

¹Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway

²Lillehammer University College, Lillehammer, Norway

³Karolinska institutet, Stockholm, Sweden

Background and Aims: In order to meet children with a disability with realistic developmental expectations and fair challenges, valid knowledge of children’s functional development in their own culture is crucial. One of the most used instruments worldwide for the purpose of clinical evaluation, treatment planning, monitoring, and documentation of outcomes of children with a disability is the Pediatric Evaluation of Disabilities Inventory (PEDI). There are variations related to socio-cultural expectations as to when a child is expected to master certain everyday skills. There is also a variation of age when different children master the same skills. Therefore instruments needs to be investigated when used in another culture. The aim of this study was to develop specific Norwegian age-norms, so that Norwegian children with a disability can get a fair evaluation related to norms relevant for their own culture.

Methods: A total of 224 Norwegian children without a disability aged 1.0-5.9 years were investigated. ANOVA was used to investigate differences between age-groups. Construct validity was evaluated and each item’s contribution to a unidimensional scale was investigated with Rasch Model program WINSTEPS.

Results: The age means of the normative values for three functional skills scale increased well with scores and progressed with age. The internal construct validity of the Norwegian version was confirmed by good fit to the Rasch measurement model. There were some deviating items compared to the American norms such as grooming, tying shoelaces, buttoning, and outdoor mobility.

Conclusions: Results indicate that normative and scaled scores of the Norwegian version of PEDI are a valid instrument to use for children with a disability. The findings in this study highlight the need for cultural validation of instruments.

Abstract Id: 276

A Randomized Controlled Trial of Neurologic Music Therapy During a Functional Strengthening Program for Children with Cerebral Palsy

Wang TH¹, Peng YC¹, Chen YL², Lu TW¹, Liao HF^1,3, Tang PF¹, Shieh JY³

¹National Taiwan University, Taipei, Taiwan

²Chang-Gung Memorial Hospital, Taoyuan, Taiwan

³National Taiwan University Hospital, Taipei, Taiwan

Background and Aims: Motor functions of children with cerebral palsy are restricted by muscle weakness and impaired motor control. Neurologic music therapy uses rhythmic, pitch, and melodic patterns in music to cue timing, range, and force of movements. We hypothesized that listening to music during a functional strengthening program may help children regulate their movements. The aim of this study was to investigate the effects of Patterned Sensory Enhancement music combined with a loaded sit-to-stand resistance exercise on motor function for children with spastic diplegia.

Method: Twenty-nine children with spastic diplegia were recruited by convenient sampling. The inclusion criteria were aged between 5 and 12 years, able to stand up independently and walk with/without device. Children who had undergone surgery in the past 6 months were excluded. The sample size estimate was 16 children per group. Participants were randomly assigned to the exercise with music group (Music, n = 15) and exercise without music group (Control, n = 14). Children in both groups received a home-based loaded sit-to-stand exercise 3 times a week for 6 weeks. Children in the Music group were instructed to execute the exercise along with music composed by a music therapist after analyzing each individual’s loaded sit-to-stand movement with a physical therapist. The motor function was assessed by Gross Motor Function Measure (GMFM-88) at baseline, post-training, 6-week and 12-week follow-ups by a blind tester. Data were compared by 2 × 4 ANOVA.

Results: The score of GMFM increased in both groups. In addition, children in the Music group improved significantly greater than the Control group at post-training and 6-week follow-up. The improvement persisted until the 12-week follow-up for both groups.

Conclusion: Neurologic music therapy combined with functional strengthening exercise could improve motor function for children with spastic diplegia.

Theme: Gait Disorder

Abstract Id: 360

An Automated Gait Assessment Tool Based on Multi-Sensors Fusion and Fuzzy Information Granules

Alaqtash M¹, Sarkodie-Gyan T¹, Yu H¹, Abdelgawad A²

¹University of Texas at El Paso, El Paso, Texas, USA

²Texas Tech University Health Sciences Center, El Paso, Texas, USA

Background and Aims: Gait analysis has become a crucial assessment tool in clinics and hospitals. It provides new insights to help understand various human movement patterns corresponding to different gait pathology. Current limitations of gait analysis are variability and lack of reproducibility of gait measurements, in addition to the time and expense of gait studies. Therefore, this work aims to develop an automated gait assessment tool to manipulate the massive gait data in 3D (kinematic, kinetic, and electromyography [EMG]) and provide an objective and quantitative assessment of gait disorders.

Method: An intelligent system is proposed for the analysis of gait data based on the methods of multi-sensors fusion and fuzzy granulation. Two subject groups, healthy able-bodied subjects and relapsing remitting multiple sclerosis (MS) subjects, are recruited in this study for testing and evaluating the proposed method. For normal walking, the data acquisition process involves ground reaction forces (GRFs) in 3D using an instrumented treadmill, surface EMG for muscles activity, and 3D kinematic data using wearable inertial sensors. Fuzzy information granules were constructed to represent the gait data for both healthy subjects and MS patients. The degree of similarity of fuzzy granules is used to provide a quantitative comparison between the reference granules of able-bodied subjects and the input test granules of impaired subjects.

Result: Fuzzy information granules were constructed and the degree of similarity of fuzzy granules for both able-bodied and impaired MS subjects was determined. Significant differences were observed between the two groups with respect to limb-segments accelerations and GRF data throughout the gait cycle.

Conclusion: This work provides an automated gait assessment tool that can be useful for clinician and doctors to identify pathological gait impairments, prescribe treatment, and assess the improvements in response to therapeutic intervention.

Abstract Id: 401

Development and Implementation of an Instrumented Treadmill with Visual Context for Functional Gait Rehabilitation

Roerdink M¹, van Ooijen M¹, Janssen T^1,2, Beek P¹

¹Research Institute MOVE, Faculty of Human Movement Sciences, VU University, Amsterdam, the Netherlands

²Amsterdam Rehabilitation Research Institute | Reade, Amsterdam, the Netherlands

Background and Aim: Gait adaptability, including the ability to avoid obstacles, to change speed and to make visually guided steps, is essential to move safely through our cluttered world. This aspect of walking ability is often impaired in pathological gait. However, safe and controlled rehabilitation environments for gait adaptability training are scarce, which is unfortunate because the ability to modify gait is important for regaining independent mobility and confidence. We aim to develop and implement an innovative rehabilitation treadmill to help fill this lacuna.

Methods: We used an instrumented treadmill with a large force platform embedded, allowing for online detection of gait events and characteristics (e.g., heel-strike, step length). A projector was connected to this treadmill for presentation of meaningful visual context on the belt’s surface (e.g., obstacles or stepping targets) in a movement-dependent manner. For the so-obtained C-Mill (C for Context; ForceLink, Culemborg, the Netherlands), several gait adaptability training interventions with immediate feedback on performance were developed. Technical feasibility and clinical applicability of C-Mill therapy were evaluated and optimized through an implementation in rehabilitation practice.

Results: We succeeded to develop a safe, functional and therapy-friendly rehabilitation device for high-intensity, repetitive and task-specific gait adaptability training with feedback on performance, thereby adhering to the general recommendations for effective rehabilitation. Various patient groups (e.g., stroke, amputee, fall-prone elderly, CP-children) with different levels of walking ability successfully completed C-Mill therapy interventions, including visually guided stepping, speeding up/slowing down, obstacle negotiation and gait-adaptability games. Both therapists and patients were enthusiastic about C-Mill therapy.

Conclusion: C-Mill therapy—treadmill training with visual context to practice gait adaptability—is technically feasible and applicable as viable part of gait rehabilitation practice.

Abstract Id: 610

The Paediatric Lokomat: a Possibility to Treat Children with a Robotic-Assisted Locomotor Training Experiences After 190 Patients

Grieshofer P¹, Scherer R^1,2, Nowak T¹, Ranner S¹, Tanzer M¹

¹Clinic Judendorf-Strassengel, Judendorf-Strassengel, Austria

²Graz University of Technology, Graz, Austria

Objective: The concept of task-specific learning based on neuroplasticity suggests that acitivties of daily living may be trained and improved through numerous repetions in neurological patients. The paediatric lokomat is the first driven gait orthesis for children larger than 100 cm.

Methods: Since summer 2006, we have treated 190 paediatric patients with different diagnoses and ages, including 124 children with ICP, 30 children with stroke, 28 patients with incomplete spinal cord injury, and 8 children with neuromuscular diseases. The mean age of these children was 8.4 years. We treated children 3 times a week with the paediatric lokomat in addition to 60 minutes PT 5 times a week, 60 minutes OT 5 times a week, and neuropsychological and speech therapy if necessary. On average, we used the new method 13 times for each patient. The whole therapy time was on an average 4 weeks for every children. We we did a video documentation for all children.

Results: For all these children, we could see a clear improvement in walking function. The main problem was to find a outcome score that includes age and diagnosis of the children. Therefore we looked for the reduction of utilities to help children (wheel chair – keywalker; keywalker – sticks, sticks – free walking). Each child improved his or her walking capacity by at least one step (from wheelchair to keywalker etc.). We had to start very carefully in case of anxiety; after 2-3 therapy units, we did have any anxiety problems. After a couple of therapy units, the children were very motivated. We did not see any side effects.

Conclusion: The paediatric lokomat is an unique new possibility to improve the walking capacity of disabled children. We know that these data are first results, and we have to make further investigations.

Abstract Id: 48

Self-Selected Walking Speed Predicts Ability to Run Following Traumatic Brain Injury

Williams G^{1, 2}, Schache A², Morris ME²

¹Epworth Hospital, Melbourne, VIC, Australia

²The University of Melbourne. Melbourne, VIC, Australia

Background and Aims: The ability to run is important for participation in many day-to-day activities, yet the key predictors related to gait performance for running have not been determined. The aim of this study was to identify factors that predict running ability performance and determine whether performance thresholds exist for those predictors following TBI.

Method: Ninety-seven people with mobility limitations following TBI were assessed in a human movement laboratory for gait performance at their self-selected walking speed. Participants also performed a clinical test of high-level mobility, the High Level Mobility Scale (HiMAT), in order to determine if they could run. The key predictor variables investigated for the ability to run were postural stability, ankle power generation at push-off, quality of gait performance and self-selected walking speed.

Results: Postural stability, ankle power generation at push-off, quality of gait performance and self-selected walking speed were all strongly associated with the ability to run. When considered together, the full model was statistically significant, χ² (4, N = 94) = 53.83, p < .001, yet only self-selected walking speed contributed significantly to the final model. Investigation of performance thresholds for self-selected walking speed indicated that if a person with TBI walks at a self-selected speed ≥1.0 m/s, his or her odds of being able to run are 16.88 times greater than for people who walk <1.0 m/s.

Conclusions: Self-selected walking speeds higher than 1.0 m/s greatly increase the likelihood of running. The 1.0-m/s threshold, although slower than normal walking speeds, may be an important indicator of the ability to run.

Abstract Id: 301

Three-Dimensional Gait Analysis Before and After the Botulinum Toxin a Injection for Pes Equinovarus

Tanikawa H¹, Kagaya H², Saitoh E², Ozaki K³, Itoh N¹, Yamada J¹, Hyohdoh M¹, Tanabe S⁴, Ohtsuka K⁴, Aoki T⁵

¹Department of Rehabilitation, Fujita Health University Hospital, Toyoake, Aichi, Japan

²Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan

³Department of Rehabilitation Medicine, National Hospital for Geriatrics Medicine, Obu, Aichi, Japan

⁴Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, Toyoake, Aichi, Japan

⁵KISSEI COMTEC Co., Ltd, Matsumoto, Nagano, Japan

Background and Aim: The botulinum toxin A (BoNTA) injections for spasticity of the upper and lower extremities were approved by medical insurance in 2010 in Japan. Many studies showed the effectiveness of BoNTA for the treatment of pes equinovarus, but no reports evaluated gait pattern by kinematic analysis. The purpose of this study is to investigate the efficacy of BoNTA injection for the treatment of pes equinovarus during gait by using a 3-dimensional gait analysis system.

Methods: Subjects were 6 chronic stage stroke patients with an average age of 52 years old. The time after onset was 2,582 days on average (361-6,230). All patients showed pes equinovarus, especially during the swing phase of gait. They underwent the injection of BoNTA to the tibialis posterior, triceps surae, flexor hallucis longs and/or flexor digitorum longus muscles. The modified Ashworth scale (MAS) and gait velocity on the ground were measured. In addition, the varus angle during gait on the treadmill was evaluated by using a 3-dimensional motion analysis system (KinemaTracer: KISSEI COMTEC, Japan) before and 2, 6, and 12 weeks after the BoNTA injections.

Results: The MAS and the gait velocity on the ground were improved in all patients from 2 to 12 weeks after the injections. Four decreased the varus angle during the swing phase of gait in 2 weeks, but 3 of 4 returned to the same level before the injections by 12 weeks. Two complained the pain unrelated to the BoNTA injections during the follow-up and the varus angle became worse.

Conclusions: The BoNTA injection was effective for the treatment of pes equinovarus during gait. We could evaluate gait pattern by using the 3-dimensional gait analysis system.

Theme: Movement Disorder

Abstract Id: 101

The Efficacy of Laser Cane in Parkinson’S Disease with Freezing of Gait

Wannipat B¹, Roongroj B²

¹Chulalongkorn Center of Excellence for Parkinson’s Disease and Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand

²Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

Background and Aims: Freezing of gait (FOG) is a common symptom in advanced Parkinson’s disease (PD). It is characterized by problems in stepping forward. FOG appears both at the initiation and while continuing walking. FOG is generally dopaminergic resistant, and usually has a negative impact on the quality of the life of the patients. “Visual Cues” help alleviate gait disturbances. This study reviews the design of a laser cane that provides visual stimuli and tests its efficacy for reducing FOG in PD patients.

Methods: 20 PD patients participated in this study who were divided into 2 groups and required to walk two rounds on a 5-metre tracking sheet. Each of the tests was conducted during both “On time” and “Off time” in the 2 conditions: No cues (N) and Visual cues (V). They were tested in the time during 1.30-2.30 hours. The tests were recorded on a paper tracking sheet, VDO cam-recorder and counter. Data analysis considered the paired t test on number of freezes, stride length, velocity and cadence.

Results: The results demonstrate that the laser cane improved PD gait in the “Off” time more than in the “On” time. Patients who were suffering from moderate-level PD (H&Y > 2) showed greater improvement in gait than those at the mild level (H&Y = 2).

Conclusions: The laser cane is beneficial in overcoming FOG, and has the most beneficial effect during the “Off” medication time period of those patients functional at the moderate level as measured by the H&Y scale.

Abstract Id: 237

The Contribution of Motor Impairments to Muscle Power in People with Parkinson’S Disease

Paul S¹, Canning C¹, Sherrington C², Fung V^1,3

¹University of Sydney, Sydney, NSW, Australia

²The George Institute for Global Health, Sydney, NSW, Australia

³Westmead Hospital, Sydney, NSW, Australia

Background and Aim: Reduced muscle power (speed × strength) in Parkinson’s disease (PD) is associated with increased fall risk and reduced walking speed. The aim of this study was to investigate the relative contribution of the cardinal motor impairments to reduced leg muscle power in people with PD.

Method: Eighty-two people with PD were tested in a single assessment session while “on” medication. Lower limb bradykinesia, tremor and rigidity were rated using the Movement Disorders Society–sponsored version of the Unified Parkinson’s disease Rating Scale. Leg extensor muscle strength and muscle power were measured using pneumatic variable resistance equipment (Keiser Sports Health Equipment, Fresno, CA). Associations between motor impairments and leg muscle power were examined using linear regression.

Results: Univariate models revealed that muscle strength (r² = 0.84), bradykinesia (r² = 0.05) and rigidity (r² = 0.05) were significantly associated with leg extensor muscle power. A multivariable model examining the relative contributions of bradykinesia, tremor, rigidity and muscle strength explained 89% of the variance in leg extensor muscle power, after adjusting for age and gender. This model revealed that reduced muscle strength is the major determinant of reduced muscle power (standardised beta = 0.7), while bradykinesia is a minor contributor to reduced muscle power (standardised beta = −0.1). Tremor and rigidity did not make a significant contribution to leg muscle power (standardised beta = 0, p = 0.3 to 0.7).

Conclusions: Reduced muscle strength is the major contributor to reduced muscle power, while bradykinesia makes only a minor contribution. These results suggest that in addition to optimal medical management, exercise which targets muscle strength and/or muscle power may be beneficial for people with PD.

Theme: Multiple Sclerosis

Abstract Id: 525

Improving Motor Skills in Subjects with Multiple Sclerosis Using a Musical Keyboard: a Randomized Controlled Trial

Lambiase S^1,2, Nava C², Tettamanti A^1,2,3, Rossi P⁴, Comola M⁴, Gatti R^1,2,3

¹San Raffaele Hospital, Rehabilitation Department, Milan, Italy

²Vita-Salute University, School of Physiotherapy, Milan, Italy

³San Raffaele Scientific Institute, Division of Neuroscience, Milan, Italy

⁴San Raffaele Hospital, Neurorehabilitation Unit, Milan, Italy

Background and Aim: Playing an instrument implies a complex process with plastic adaptation in different cerebral regions. This phenomenon has been studied in subjects with stroke, proving that it could play an important role in the motor recovery of the hand. The aim of this study is to verify the effectiveness of playing a musical keyboard in improving hand motor skills in subjects with multiple sclerosis (MS).

Method: Adults with MS, with no relapses or pharmacological therapy variations in the last three months, with motor impairment of one or both upper limbs and with no previous musical experiences were included. Subjects were recruited between May 2009 and September 2011. 32 subjects (male/female: 11/21; mean age 45 ± 9) were randomized in two groups: 16 played repetitive sequences of fingers movements on a turned-on musical keyboard (Experimental Group = EG) and 16 played the same exercises on a turned-off musical keyboard (Control Group = CG); training was half an hour per day for 15 days. Primary outcome was the Abilhand Questionnaire; secondary outcomes were Nine-Hole Peg Test (9HPT), Jamar and Pinch dynamometers. Mann-Whitney and chi-square tests were used to evaluate the sample homogeneity. Two-way analyses of variance were used for data analysis (SPSS 13.0 software).

Results: Groups show a significant time effect for all outcomes (mean ± SD; EG: Abilhand pre 33 ± 7, post 37 ± 6; 9HPT pre 56 ± 36, post 45 ± 25; Jamar pre 19 ± 7, post 21 ± 7; Pinch pre 4.5 ± 1.8, post 5.0 ± 1.8; CG: Abilhand pre 35 ± 6, post 36 ± 7; 9HPT pre 39 ± 26, post 31 ± 16; Jamar pre 25 ± 13, post 26 ± 13; Pinch pre 4.5 ± 2.7, post 5.2 ± 2.4). The interaction time × group was significant (p = 0.001; 1 – β = 1.0) for Abilhand Questionnaire in favor of EG.

Conclusions: Playing a musical keyboard can be a valid method to train dexterity and strength of the hand in subjects with MS.

Abstract Id: 244

What Predicts Patient Response to Recommendations Following Neuropsychological Assessment? a Preliminary Analysis of Responses in Patients with Multiple Sclerosis

Longley W^1,2, Tate R¹, Shaw, T²

¹University of Sydney, Sydney, NSW, Australia

²MS Australia—ACT/NSW/VIC, Sydney, NSW, Australia

Background and Aims: Patient response to neuropsychological assessment with feedback has received limited attention in the scientific literature. This study investigated predictors of response to recommendations following assessment with feedback in a sample of patients with multiple sclerosis (MS).

Method: Thirty patients with MS referred for neuropsychological assessment were recruited. Average age was 48.1 years (SD = 12.0), 46.7% were female, and average duration of MS was 10.9 years (SD = 10.1). Patients completed a telephone-based questionnaire with a blind assessor before and after their assessment and feedback. The relationship between four domains of functioning (demographic, MS status, cognitive, and psychological) and two primary outcome measures (helpfulness of and adherence to recommendations) were examined.

Results: Patients received an average of 4.9 recommendations (SD = 1.8) during feedback, mostly relating to management of cognitive impairment (CI; 52.6% of recommendations), and psychological concerns (PC; 22.6%). At follow-up, patients rated the CI recommendations as “very helpful” (M = 2.5/3, SD = .8), and PC recommendations also as “very helpful” (M = 2.5/3, SD = .1). Most patients (91%) reported adhering to at least some CI recommendations, and 72% to at least some PC recommendations. None of the demographic, MS status, or cognitive variables (including performance on objective memory tests) predicted either helpfulness of, or adherence to, CI recommendations. However, coping style predicted helpfulness (r_sp = .47, p = .02), and MS self-efficacy (r_sp = –.44, p = .03) predicted adherence. A similar pattern of predictions was found for the PC recommendations, with the additional finding that, as well as coping style (r_sp = .02-.59, p = .00-.03), spontaneous use of memory compensation strategies (r_sp = .56-.67, p = .00-.01) predicted helpfulness, and a supportive relationship with the caregiver (r_sp = .59, p = .01) predicted adherence.

Conclusion: This study demonstrates the importance of considering patients’ psychological and cognitive characteristics when providing recommendations following neuropsychological assessment. The lack of influence of objective memory impairment in predicting patient response to recommendations requires further investigation.

Abstract Id: 170

Physiological and Neuropsychological Factors Associated with Falls in People with Multiple Sclerosis

Hoang P^1,2, Lord S¹, Cameron M³

¹Neuroscience Research Australia and University of New South Wales, Sydney, NSW, Australia

²Multiple Sclerosis Australia ACT/NSW/VIC, Australia

³Department of Neurology, Oregon Health & Science University, Portland, USA

Background and Aims: Injurious falls are common in people with multiple sclerosis (MS). Risk factors identified include reduced balance, gait impairment, and use of walking aids. However, there is limited information on the diverse physiological and neuropsychological factors associated with increased risks of falls in people with MS (PwMS). This study aims to determine whether impaired performance in tests of executive function, upper limb dexterity, vision, peripheral sensation, lower limb muscle strength, reaction time, walking and balance are associated with falls in a large community-dwelling population of PwMS.

Methods: Six-month prospective study.

Results: Results from the first 101 participants taking part in the study, aged from 21 to 74 years (mean age 52.9 years, SD = 11.2), who completed 6 monthly falls diaries are reported. In the 6-month follow-up period, 41 participants (40.6%) had no falls, 28 participants (27.7%) fell once or twice and 32 participants (31.7%) fell three or more times. Multiple falls (≥3) were associated with increased times for the Trails A and B neuropsychological tests and the 9-hole peg test, reduced lower limb strength and impaired balance (increased sway during standing with eyes open and eyes closed and reduced voluntary leaning capacity). Logistic regression analysis identified 9-hole peg test time, quadriceps strength, and sway test with eyes closed to best discriminate between participants who did and did not have multiple falls (model χ² = 27.4, df = 3, p < 0.001).

Conclusions: Frequent falls are associated with reduced dexterity, lower limb strength and increased sway during quite standing with eyes closed. These factors should be used to identify those likely to benefit from interventions to prevent falls and to guide the design of interventions.

Abstract Id: 281

The Influence of Hand Dominance on the Relationship Between Habitual Use and Measures for Arm Dysfunction in Ms

Lamers I^1,2, Gijbels D^1,2, Kerkhofs L³, Adriaenssens G⁴, Alders G¹, Cnuts K¹, Feys P^1,2

¹REVAL Rehabilitation Research Centre, PHL University College, Diepenbeek, Belgium

²BIOMED Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium

³Rehabilitation & MS Centre, Overpelt, Belgium

⁴De Mick, Brasschaat, Belgium

Background and Aim: In persons with multiple sclerosis (PwMS), more insights are needed regarding the use and functioning of the upper limbs in daily living. This study aimed to investigate the relationship between habitual use of the dominant and non-dominant arm and outcome measures at different ICF levels.

Methods: Thirty PwMS with unilateral or bilateral upper limb dysfunction were included. The habitual use of the upper limbs was measured by Motionloggers Actigraphy. The devices were bilaterally attached to the wrist during 1 week. Output of the Motionloggers was presented in 3 different modes: frequency of movement, time spent in motion and intensity of motion. Clinical outcome measures on function and activity level of the ICF were the Motricity Index (MI), the JAMAR hand grip strength, Brunnström Fugl Meyer (BFM), Action Research Arm test, Nine Hole Peg Test and the Motor Activity Log. A paired t test was used to investigate the differences between the dominant and non-dominant hand. Pearson correlation coefficients were calculated to quantify the relationship between the habitual upper limb use and frequently used clinical outcome measures.

Results: A significant difference (p < 0.005) was found between dominant and non-dominant hand for all outcome measures, except for the Motionloggers. For the dominant hand, correlations between Motionloggers and clinical outcome measures were remarkably lower (r < 0.50) compared to the non-dominant hand. The highest correlations for the non-dominant hand were found between the Motionloggers and function level outcome measures MI (r = 0.71) and BFM (r = 0.75). Outcome measures on activity level correlated moderately to high (r = 0.50-0.70) with the Motionloggers. Results of the multiple regressions analyses will be presented at the conference to reveal the most predictive outcome measure.

Conclusion: In MS, outcome measures of the ICF are more associated with the habitual use of the upper limbs for the non-dominant hand compared to the dominant hand.

Abstract Id: 331

Slower Walking Speed Is Associated with Reduced Health-Related Quality of Life in Patients with SPMS

Krishnan A¹, Goodman AD², Potts J³, Cohen J⁴

¹University of New South Wales, Sydney, NSW, Australia

²University of Rochester School of Medicine and Dentistry, Rochester, NY, USA

³Biogen Idec, Weston, MA, USA

⁴Cleveland Clinic, Cleveland, OH, USA

Background/Aim(s): IMPACT was a 2-year, randomised, double-blind study of intramuscular interferon beta-1a versus placebo in secondary-progressive multiple sclerosis (SPMS). The placebo arm of IMPACT provides data to assess the relationship between changes in walking speed (WS) and health-related quality of life (HRQoL) over time, which was the objective of this post hoc analysis.

Methods: Timed 25-foot Walk (T25FW; one component of the MS Functional Composite) and SF-36 physical component summary scale (PCS) data from the placebo arm of IMPACT (baseline, Months 12, 15, 24) were evaluated using a random intercept model.

Results: 219 patients with SPMS were randomised to placebo; 160 patients had both T25FW and SF-36 data. At baseline, mean EDSS was 5.2 (range: 3.5-6.5), mean (SD) WS was 0.86 (0.47) metres/second, and mean (SD) PCS score was 31.7 (8.1). At 2 years, patients walked on average 19% slower (mean change, −0.15 metres/second) and the PCS worsened by a mean (SD) of −0.70 (8.2) points. Mean raw changes and mean percent changes in WS over time were correlated with changes in overall PCS score (P < 0.001 and P = 0.002), Physical Function (both P < 0.001), Role Physical (P = 0.010 and P = 0.002), Bodily Pain (P = 0.008 and P = 0.137), and General Health (P = 0.010 and P = 0.060) subscale scores, respectively. Similar results were observed when analyses were adjusted for baseline WS or EDSS score. PCS scores declined over 2 years in patients who walked ≥0.15 metres/second slower (n = 56) at month 24 compared with baseline and improved in the small number who walked >0.15 metres/second faster (n = 11).

Conclusion(s): In placebo-treated SPMS patients, slower walking speed was associated with a decline in HRQoL over 2 years. Whether symptomatic treatments that improve walking also positively influence HRQoL is an intriguing question for future research.

Abstract Id: 536

Pain in Turkish Patients with Multiple Sclerosis: Preliminary Results

Salcı Y¹, Aydoğan S¹, Fil A¹, Keklicek H¹, Kurne A², Armutlu K¹, Karabudak R²

¹Hacettepe University Faculty of Health Sciences Department of Physiotherapy and Rehabilitation, Turkey

²Hacettepe University Faculty of Medicine Department of Neurology, Turkey

Background and Aim: With pain being a disabling symptom in patients with multiple sclerosis (MS), its prevalence and characteristics are not well established. The aim of this study is to describe the frequency, the characteristics and the effects of pain on quality of life, quality of sleep, daily living and emotional status.

Methods: 90 MS patients were included in the study. McGill Pain Questionnaire, Nottingham Health Profile (NHP), Barthel Index (BI), Pittsburg Sleep Quality Questionnaire (PSQQ), and Beck Depression Questionnaire (BDQ) were applied to all patients. The patients were divided into two groups according to pain complaints.

Results: In this total of 90 patients, 43.33% (39) had no pain (group I) and 56.66% (51) had several pain complaints (group II). In group II, 23.5% of patients had headache, 5.8% of patients had Lhermitte sign, 9.8% patients had trigeminal neuralgia, and 41.1% patients had spasms. All patients had musculoskeletal pain. BDQ score was 11.87 ± 9.93, and EDSS score was 3.80 ± 1.81 in group I. PSQQ score was 11.58 ± 8.43, BI score was 81.56 ± 24.21, NHP score was 229.01 ± 133.57, BDQ score was 13.60 ± 9.73, and EDSS score was 4.34 ± 1.77 in group II, respectively. When the groups were compared, significant difference was found in patients’ quality of sleep, quality of life, and activities of daily living (p < 0.05). There was no difference in the other parameters (p > 0.05).

Conclusions: Our results show that Turkish MS population has a substantial ratio of pain such as 56%. The pain problem is generally ignored because many other problems must be managed. Pain interferes significantly with quality of life, and quality of sleep and also many parameters are affected negatively. Sharing the data about pain prevalence and effects of pain will encourage health professionals about pain management and also will enhance the patient’s activity and participation.

Abstract Id: 182

Prevalence of Joint Contractures, Muscle Weakness, and Spasticity in Multiple Sclerosis

Hoang P^1,2, Herbert R³, Gandevia S¹

¹Neuroscience Research Australia and University of New South Wales, Australia

²Multiple Sclerosis Australia ACT/NSW/VIC, Australia

³The George Institute for Global Health, University of Sydney, NSW, Australia

Background and Aims: Spasticity and muscle weakness are very common in multiple sclerosis (MS). This may explain why joint contracture, which is often believed a consequence of these two problems, appears to be common among people with MS, especially those with advanced MS. However, prevalence of joint contracture has never been investigated in MS population. This study investigated the prevalence of joint contracture (defined as limited passive range of motion), muscle weakness and spasticity in a representative sample of MS population.

Methods: A random sample of 330 people with MS living in metropolitan Sydney on 23 July 2009 was identified from the database of MS Australia and invited to participate. Range of motion was measured on a four-point scale (0 = no contracture), weakness was defined as a manual muscle test score of 3 or less, and spasticity was quantified as a Tardieu score of 0-4 during fast stretch velocity.

Results: 156 invited participants (109 females, 47 males; mean age = 54.2; mean years since diagnosis = 14.9) agreed to participate and were assessed by a physiotherapist. Thirty-six (36) participants (23.5%) were wheelchair-dependent and 30 participants (19.6%) were able to walk normally. The rest (56.9%) had reduced mobility and some needed mobility aids (29.4%). Fifty-six percent (56%) of participants (95% CI = 48.6 to 63.9) had contracture in at least one major joint. The most common site of contracture was the ankle (43.9% of participants). Sixty-six percent (95% CI = 58.2 to 72.9) had signs of spasticity, most commonly in the ankle plantar flexors (48.4%) and knee extensors (40.7%), and 68.6% (95% CI = 60.9 to 75.3) of participants had muscle weakness in one or more large muscle groups.

Conclusions: These findings show that, in addition to spasticity and muscle weakness, joint contractures are common among people with MS.

Theme: Neuro-Oncology

Abstract Id: 172

Rehabilitation for Accessory Nerve Syndrome Following Neck Lymph Node Dissection for Head and Neck Cancers

Kimura S¹, Aoki K¹, Sogawa Y², Muraoka M³, Harigae T⁴, Endo N¹

¹Niigata University, Niigata, Niigata, Japan

²Rheumatic Center, Shibata, Niigata, Japan

³Kameda-daiichi Hospital, Niigata, Japan

⁴Kaetsu Hospital, Niigata, Niigata, Japan

Background and Aims: Accessory nerve syndrome following neck lymph node dissection in head and neck cancers is often accompanied by intractable pain and/or contracture of the shoulder joint. The aim of this study was to investigate the effect of rehabilitation with a physical therapist for patients with accessory nerve syndrome following neck lymph node dissection in the treatment of head and neck cancers.

Methods: Subjects comprised 10 patients (10 shoulders), including patients with cancer of the tongue (5 cases), parotid or submandibular gland (2), maxillary sinuses (2), and oral soft tissue (1). The surgical procedure included local removal of the cancer and neck lymph node dissection sacrificing the accessory nerve. The 10 patients were divided into two groups, a physical therapy (PT) group (5 cases) and self-therapy (ST) group (5 cases). The PT group performed a treatment regimen that included passive range of motion (ROM) exercises, massage, and education about active ROM exercises, while patients in the ST group were educated to perform active shoulder exercises and assistive ROM exercises with the unaffected hand. The angle of abduction and flexion of the shoulder joints and the Japanese Orthopaedic Association (JOA) score for shoulder diseases were compared between the PT and ST groups, pre- and post-rehabilitation.

Results: Prior to rehabilitation, neither the angle of abduction and flexion of the shoulder joints nor the JOA score differed significantly between groups. In contrast, following rehabilitation, these parameters were significantly improved in the PT group, but not in the ST group.

Conclusions: In a previous report, passive flexion, active movement, pain, and job- and recreation-related activities were significantly better than in an ST group compared to a non-treated group. The findings of the present study suggest that rehabilitation with a PT, however, is even more beneficial for shoulder impairment due to accessory nerve syndrome.

Theme: Service Delivery

Abstract Id: 347

Patients on a Neurorehabilitation Ward are Inactive for a Large Part of Each Day

Rice K¹, Kennedy G¹, Taylor N^1,2

¹Eastern Health, Peter James Centre, Melbourne, VIC, Australia

²School of Allied Health, La Trobe University, Melbourne, VIC, Australia

Background and Aims: Patients in inpatient rehabilitation often have extended periods of the day not engaged in any direct therapy; this can potentially have a negative impact on physical activity, which may affect progress. We aimed to determine the level of physical activity of patients in a neurorehabilitation unit.

Methods: An audit of activity of all patients in the unit by direct observation was conducted at 2-hour intervals from 9 am until 7 pm over four days from Friday to Monday. Location and activity were recorded at each time. Patients also completed the physical activity inpatient activity questionnaire and were interviewed. The direct observations and questionnaire were analysed descriptively. Interviews were recorded, transcribed, and coded in a thematic analysis.

Results: Twenty-nine patients were surveyed. Patients were active (moving about/standing) in 7% of observations (46/696 observations). Patients were less active on the weekend (5%) compared to weekdays (9%). On weekdays, 60% of activity was during therapy sessions. Patients were in bed for 44% of observation (306/696 observations), and were more likely to be in bed on the weekend (48%) compared to weekdays (34%). Most patients (69%) self-reported that they spent their time ‘mostly lying or sitting’. The qualitative analysis resulted in 2 key themes: patients perceived they do mostly passive activities (e.g. lying in bed, watching TV), and second, they wanted to move about and get out of their room more.

Conclusions: Direct observation and patient report confirmed that patient activity in the neurorehabilitation unit outside of structured therapy times was low, with patients spending a large amount of time in bed. Patients were less active during the day on weekends compared to weekdays. Innovative models involving cultural change that provide opportunities for unstructured physical activity are required to increase activity and optimise outcomes in the neurorehabilitation unit.

Abstract Id: 515

Comparison of Interventions for Post-Polio Syndrome

Koshiro S¹, Eiichi S¹, Fumi H¹, Yukari S², Motomi Y², Hitoshi K¹, Seiko S¹

¹Fujita Health University, School of Medicine, Toyoake, Aichi, Japan

²Fujita Health University, School of Health Science, Faculty of Rehabilitation, Toyoake, Aichi, Japan

Background and Aims: We started a program of post-polio (PPS) management and prevention (the BGraS Project) in 2006. In this project, we compared the influences of two interventions and just follow-up on symptoms and function of PPS patients. Period of interventions and follow-up was 2 years. After assessment of patients’ state (by questionnaire and medical examination), basic education, and feedback communication, they were eventually divided into three groups. That is, outpatient group (50 subjects), support, and education by mail group (48 subjects), and just follow-up without intervention group (17 subjects). For the outpatient group, lifestyle adjustment, exercise instruction, and orthotic therapy were provided according to individual needs.

Methods: We compared the differences in results of the questionnaires before and after the period among three groups. Of these subjects, changes in muscle strength and walking speed were compared between 14 in the outpatient and 35 in the mail groups who received medical examinations before and after the period.

Results: The improvements of subjective symptoms were observed in 22.0%, 12.5%, and 0% on fatigue; 24.0%, 8.3%, and 5.9% on muscle pain; and 26.0%, 12.5%, and 5.9% on articular pain in outpatient, mail, and just follow-up groups, respectively. The outpatient group showed the highest in the frequency of daily exercise. The changes of mean strength (Nm) of the lower extremity muscles (iliopsoas, gluteus maximum, gluteus medius, quadriceps, hamstrings, tibialis anterior, and triceps surae) on the stronger side were +3.9 and −13.0 (p < 0.05) and on the weaker side +20.1 and +11.0 in outpatient and mail groups, respectively. The changes of walking speed (km/h) were −0.1 in outpatient and −0.4 in mail groups (p < 0.05).

Conclusions: The results suggested that outpatient intervention for polio survivors were effective to prevent the development and progression of PPS. Further studies are needed for revealing contributing factors.

Abstract Id: 436

Designing a Touch-Screen Technology System to Engage Non-Professional Rehabilitation Workers in a 24/7 Rehabilitation Programme

Foster A, Buckley A, Cavit M

ABI Rehabilitation New Zealand, Ltd., Auckland, New Zealand

Background and Aims: Intensive inpatient neuro-rehabilitation is characterised by the client’s active engagement in a structured rehabilitation programme designed by professionals and implemented across a minimum number of hours per day. Rehabilitation providers are under increasing pressure from funders to increase intensity of rehabilitation, to focus on the ‘dosage’ of rehabilitation, and to reduce overall inpatient length of stay. Thus, there is pressure to make every intervention count. Rehabilitation programmes can become less effective if clients find themselves un-occupied during poorly planned downtime. Likewise, progress may slow if non-professional workers are unclear about applying rehabilitation protocols. Here, we describe a technology solution designed by one rehabilitation provider (ABI Rehabilitation) to address these issues within a client population comprised of moderate-to-severe traumatic brain injury clients with high medical needs.

Methods: We have designed a client time-table system based on touch-screen technology to schedule activities, guide staff, and track client outcomes. The system is designed to be used by non-professional rehabilitation workers, and integrates embedded protocols and other guidance documents to support the workers to deliver rehabilitation programme activities as prescribed and in a timely fashion. Real-time integrated feedback of client participation is captured hour-by-hour via a simple interactive interface.

Results: Results will present the results of a six-month pilot study including descriptors of actual vs. perceived service delivery, user acceptability testing, and client and family-whānau satisfaction.

Conclusions: This system was designed to be a tool to translate clients’ rehabilitation goals, strategies, and steps to a programme that can be applied by well-trained but non-professional staff across the course of a day and incorporating formal therapeutic interventions as well as activities of daily living. It enables clinical monitoring of client progress on a day-to-day basis, as well as providing a mechanism for communicating progress to the client and family-whānau.

Abstract Id: 462

Conductive Education, As the Pedagogy-Based Developmental System of Habilitation and Rehabilitation for Patients with Cerebral Palsy

Nádasi Zs, Feketéné Szabó É, Fehér M

András Pető Institute of Conductive Education and Conductor Training College, Budapest, Hungary

Our presentation will introduce the conductive pedagogical system associated with András Pető’s name, aimed at the complex development and habilitation/rehabilitation of children with motor disabilities originating from damage to the central nervous system, as a supplement to the system of medical rehabilitation. Pető’s assumption that a medical problem must be solved through pedagogy-based active learning has been proved by now. Brain neuroplasticity ensures that lost functions of damaged nerve areas are replaced and synaptic connections rearranged. Conductive education (CE) sees the personality as an integrity; in the course of developing, it is not divided into parts; education is employed for consistent and uniform development; the individual is approached integratively and each affected area influenced simultaneously. We aim to demonstrate the significance of active learning in developing persons with cerebral palsy (CP). The main aim of the conductor is to create achievable goals and to promote communication, intent, emotional and cognitive development through active behaviour and coordinated movements. Methods adopted by the complex conductive programme include the holistic approach, constant operative observation, facilitations as a system of instruments, group setting, an active daily routine implemented in the group, rhythmical intention and task performance based on motivation. Every year the International Pető Institute in Budapest, Hungary, provides for 350 children with CP, with ages ranging from 6 months to 18 years. Children’s condition and progress are documented continuously and systematically. We employ the GMFCS jointly with other professionals, have started to introduce the ICF, and use the School Social Behaviour Scales (SSBS-2) adapted for our motor-disabled school children, while data for the Peabody test (communication) and the WISC-IV (mental capacities) are collected together with a neuropsychologist. CE’s success has been proven worldwide: families’ satisfaction and afflicted children’s quality of life are improving continuously and gradually.

Theme: Spasticity

Abstract Id: 367

Interventions for Managing Skeletal Muscle Spasticity Following Traumatic Brain Injury: a Cochrane Systematic Review

Phillips K¹, Pitt V², O’Connor D¹, Gruen R², Chau M²

¹School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia

²National Trauma Research Institute, Alfred Hospital, Monash University, Melbourne, VIC, Australia

Background and Aims: Management of skeletal muscle spasticity following traumatic brain injury (TBI) varies from other clinical populations (e.g., stroke) due to the complexity of behavioural and cognitive issues. Although there is a range of interventions used to manage spasticity, inconsistent use of these interventions is observed in clinical practice. To date there has been no systematic review of all interventions to manage spasticity in TBI. The aim of this review is to assess the effectiveness of interventions for managing spasticity to inform clinical practice.

Methods: Ten electronic databases, three clinical trial registries, DARE and reference lists of included studies were searched for randomised, quasi-randomised and cross-over trials examining any intervention to manage spasticity. There were no language restrictions. Two authors independently selected trials for inclusion, performed data extraction and assessed risk of bias. Primary outcomes were spasticity measures and adverse effects. Secondary outcomes were body functions, activities and participation, classified according to the World Health Organisation International Classification of Functioning, Disability and Health. Included studies were grouped and assessed based on intervention (pharmacological or non-pharmacological or a combination) and comparison (no treatment, placebo or an alternative intervention). Outcome data were pooled from studies that were clinically and statistically homogeneous. Dichotomous outcomes were expressed as relative risk (RR) with 95% confidence intervals (CI) and continuous outcomes expressed as mean differences (MD) with 95% CIs. Where data couldn’t be pooled, a narrative summary was presented.

Results and Conclusions: Twenty four studies were included in the review. Interventions tested included botulinum toxin (50% of papers), splinting, casting, baclofen, oral medications and electrotherapy. Pooling was limited due to heterogeneity in dosage of interventions and timing of outcome measurement. An overview of the findings and their implications for practice will be presented.

Abstract Id: 465

The Promise and the Potential of Botulinum Toxin-A: an Australian Survey of Therapy Practices for the Management of Upper Limb Spasticity

Kinnear B^1,3, Lannin N^2,4, Cusick A¹

¹University of Wollongong, NSW, Australia

²The Alfred Hospital, VIC, Australia

³Hammond Care, NSW, Australia

⁴La Trobe University, VIC, Australia

Background and Aims: Botulinum toxin A (BoNT-A) is increasingly used to treat upper limb focal spasticity after stroke and neurological impairment. Evidence is accumulating regarding pre- and post-injection therapy and its augmentative effect. To date, little is known about the extent and type of therapy practice in post BoNT-A regimes. This national survey will assist with identifying what current practice is self-reported by therapists with spastcicity and post BoNT-A management in Australia.

Aim: To describe the practice experience of rehabilitation therapists who work with patients with neurological impairment and spasticity receiving BoNT-A, including triage, assessment, goals and management.

Method: Anonymous survey (fixed choice and open questions) distributed to occupational therapists and physiotherapists through professional associations, and thence snowball sampling. Questions covered pre-injection assessment, clinic policies, post-injection therapy and assessment.

Results: 100 therapists demonstrated limited knowledge regarding goal development and assessment. Sixty percent of clinics did not have protocols for monitoring post-BoNT-A outcomes, or staffing to offer more than one follow-up therapy session. 80% of clinicians working with neurological patients and spasticicty management feel that therapy provision is inadequate for post BoNT-A. Reported practices were significantly different from Australian National Stroke Foundation published clinical guidelines.

Conclusion: Evidence-based professional development is required to increase therapist knowledge and skill regarding assessment, goal setting, management and outcome evaluation for this patient population. Increased service capacity is critical so that short-term pharmacologic benefits can be harnessed to produce longer term functional outcomes.

Abstract Id: 513

Botulinophilia: an Unusual Case Involving Botulinum Toxin

Graham A

Frenchay Brain Injury Rehabilitation Centre, Bristol, UK

Background and Aims: Botulinum toxin (BTX) is a well-established treatment for many different indications both medically and cosmetically. I present a case of a patient who sought botulinum toxin (BTX) treatments for a number of different indications from many different professionals for head and neck complaints over a 7-year period. I propose that this is a case of botulinophilia: a persistent demand for BTX therapy despite normal findings and debatable benefit.

Methods: The history and clinical data were ascertained from the hospital and general practitioner’s notes, clinical examination, the patient himself and his correspondence.

Results: Following a reported episode of minor trauma 7 years ago, this 43-year-old male nurse has seen a multiplicity of professionals from an oromaxillary surgeon and a restorative dentist through to neurologists, a physiotherapist and finally a neurological rehabilitationist, in a number of different centres in the south of England. Complaint diagnoses have included myofacial pain, bruxism and cervical dystonia. Examinations and investigations, including electromyography and MRI scans, were normal. Despite his repeated insistence for BTX injections, no clear benefit was demonstrated. He described his symptoms as totally dominating his life being so severe that he was incapable of enjoying normal relationships, even making him contemplate self-harm. Exploration of a more psychological approach was uniformly refused, and if requests for more BTX injections were not met, the history suggests that different professionals were then approached either privately or through the general practitioner.

Conclusion: In this unusual case, I propose that this patient’s BTX-seeking behaviour (botulinophilia) challenges the normal doctor-patient paradigm and suggests he may be better managed through a more psychological approach. Clinicians may then be able to exercise the maxim, ‘primum non noscere’.

Abstract Id: 604

Resource Utilization By Patients with Adult Focal Spasticity (AFS) and Cerebral Palsy (CP) Receiving Botulinum Toxin Type a (Botox) in a Prospective Observational Cohort Study: Mobility Study

Wein T¹, Beauchamp R², Ismail F³, Jog M⁴, Miller R⁵, Huang B⁶, Bhogal M⁷, Simonyi S⁷

¹McGill University, Montreal, QC, Canada, Canada

²Children’s & Women’s Health Centre of B.C., Vancouver, BC, Canada

³West Park Health Centre, Toronto, ON, Canada

⁴London Health Sciences Centre, London, ON, Canada

⁵Dalhousie University, Halifax, NS, Canada

⁶McKesson Specialty, Toronto, ON, Canada

⁷Allergan Inc., Markham, ON, Canada

Background and Aims: MOBILITY is an ongoing observational study in patients receiving Botox for various therapeutic uses, and provides an opportunity to evaluate healthcare resource utilization by this patient cohort.

Methods: In this study, demographic, diagnostic and treatment data were collected from newly treated (naive) patients and previously treated (maintenance) patients who received at least one dose of Botox.

Results: This interim analysis describes medication use, frequency of surgeries related to the condition treated with Botox, and types of rehabilitation services used by patients with adult focal spasticity (AFS; n = 360, 49% female, mean age 54 years) and cerebral palsy (CP; n = 64, 48% female, mean age 28 years). Among AFS patients, 44% received concomitant medications and 11% had surgery. Rehabilitation services were used by 50% of AFS patients, including one or more of the following: physiotherapy (34%), occupational therapy (14%), nursing support (4%), casting/splinting (16%), and admission to a long-term care facility (1%). Among CP patients, 41% received concomitant medications, 55% had surgery, and 50% received one or more of the following rehabilitation services: physiotherapy (28%), occupational therapy (8%), casting/splinting (19%), and admission to a long-term care facility (5%). The most frequently prescribed medications for AFS patients were baclofen (73%), gabapentin (16%), and dantrolene (12%), and for CP patients, baclofen (73%) and gabapentin (8%).

Conclusion: Patients with spasticity receiving Botox utilize a diversity of healthcare resources, supporting the need for ongoing multidisciplinary collaboration as part of their long-term management plan.

Abstract Id: 481

Functional Evaluation of Upper Limb Performance Following Botulinum Toxin-A Injections

Crippin W¹, Ranka J¹, Nott M^1,2, Barden H^1,2, Baguley I^1,2

¹The University of Sydney, NSW, Australia

²Westmead Hospital Brain Injury Rehabilitation Service, NSW, Australia

Introduction: The efficacy of botulinum toxin-A (BoNT-A) in reducing upper limb (UL) spasticity has been consistently demonstrated. Concomitant improvement in UL function has not. Measures of UL functional performance that are sensitive to intervention such as BoNT-A are critical to progress research in this area.

Aims: This study aims to investigate the functional UL changes of adults with acquired brain injury following BoNT-A injections using an ecologically valid outcome measure, the Upper Limb Performance Assessment (ULPA).

Instrument: The ULPA is a recently developed method of assessing UL performance using task analytic methodology. The assessment is carried out in two stages. Stage 1 is used to identify errors in UL performance during a client-selected functional task. Stage 2 uses Comparative Analysis of Performance–Motor (CAP-M) to systematically identify the underlying motor impairments that impact on task performance; these impairments are categorised as primarily influenced by either positive or negative features of the upper-motor neuron syndrome (UMNS).

Methods: 25 community-dwelling adults with acquired brain injury were recruited from three spasticity clinics. Participants developed goals in collaboration with clinicians. Performance was videotaped and analysed using the ULPA at baseline (pre-injection) and one month following BoNT-A injections. Goal attainment scaling was used to evaluate achievement of goals.

Results: Significant reduction in motor errors was observed (mean reduction 4.5 errors to 2.7 errors; p = 0.003). This error reduction was associated with reduced “excessive/compensatory” actions (p = 0.036) and fewer “missing/absent” motor actions (p = 0.004). These Stage 2 improvements were evidenced by a reduction in positive and negative upper motor neuron features. Positive gains on the GAS were observed and achieved statistical significant (GAS T-score change 14 points; p = 0.001).

Conclusion: The ULPA is a recently developed ecological UL assessment that enables evaluation of performance on client-selected functional tasks. The ULPA effectively measures change following UL BoNT-A injections, highlighting gains at a functional level that have not be previously demonstrated.

Abstract Id: 96

Useful Combination of Botulinum Toxin Type a Injection and Occupational Therapy to Improve the Active Muscle Function of Patients with Upper Limb Spasticity

Abo M, Kakuda W, Sase Y, Taguchi K, Ishikawa A, Kamide A, Takekawa T

The Jikei University School of Medicine, Tokyo, Japan

Background and Aim: The efficacy of botulinum toxin type A injection in improving passive spasticity and the range of motion of upper limbs has been reported in a number of randomized controlled studies. However, few studies have reported improvement of active muscle function. The aim of the present study was to assess clinical effects of injection of botulinum toxin type A into the muscles of the upper extremity, including the pectoralis major muscle, as a treatment for upper limb spasticity in poststroke patients with severe paralysis of the hand. The injections were followed by instructions only for self-training through occupational therapy. The active function of upper limb muscles was evaluated at 4 weeks after the intervention.

Methods: The study subjects were 80 adult poststroke patients at >10 months after the onset of upper limb spasticity with Brunnstrom stage 3 in the hands and fingers among 158 patients who underwent botulinum toxin type A injection for upper limb spasticity. The modified Ashworth scale (MAS), range of motion (ROM), Fugl-Meyer Assessment (FMA), Wolf Motor Function Test (WMFT), and VAS were evaluated before and at 4 weeks after injection of botulinum toxin type A plus one-on-one instructions on self-training through occupational therapy.

Results: Significant improvement was observed in the total upper limb and in sub-items A and B of FMA, FAS of WMFT, VAS, MAS of upper limb, and ROM.

Conclusion: Our method seems potentially effective in improving the active motor function of the upper limbs, especially the proximal arm. This combination reduced pain and improved active motor function in poststroke patients with severe hemiplegia. Our protocol of local intramuscular injection botulinum toxin type A and active instructions are potentially useful therapeutically in this patient population.

Abstract Id: 273

Prospective Study of Quality of Life in Caregivers of Patients Treated with Intrathecal Baclofen

de Leonni Stanonik M¹, Kofler M², D’Aleo G³, Licata C⁴, Saltuari L^2,5, Bramanti P³, Rifici C³

¹Department of Neurology, George Washington University, Washington, DC, USA

²Department of Neurology, Hospital Hochzirl, Zirl, Austria

³IRCCS Centro Neurolesi “Bonino-Pulejo,” Messina, Italy

⁴Sleep Associates of East Tennessee, Knoxville, TN, USA

⁵Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy

Introduction: No study to date has investigated quality-of-life (QoL) issues of caregivers of patients treated with intrathecal baclofen (ITB).

Materials and Methods: We assessed 51 caregivers of patients who were considered to be candidates for ITB pump implantation. Clinical examination of the patients included Modified Ashworth Scale (MAS), Spasm Frequency Scale (SFS), and spasticity assessed by Visual Analog Scale (VASspasticity). Rehabilitative goal attainment (positioning, ambulation with or without assistance, facilitation of nursing care, rehabilitative treatment participation, and perineal hygiene) was noted. Caregiver stress was assessed by Zarit’s Burden Inventory (ZBI) and by Visual Analog Scale (VAScaregiver). All scales were assessed one month before (pre-ITB) and six months after (post-ITB) implantation of a Synchromed pump. Statistical analyses were performed using non-parametric testing, regression, and factor analysis.

Results: Patients showed significant score improvement in MAS, VASspasticity, SFS, and rehabilitation goals. Post-ITB caregiver ZBI scores had a significant reduction from pre-ITB ZBI. Similar findings were found in both para and tetra groups. Regression analysis found that assisted and independent gait were predictors of reduced ZBI scores. An exploratory principal component factor analysis produced 4 factors which accounted for 86.6% of the variance.

Conclusions: ITB treatment significantly reduces caregiver stress. Furthermore, caregiver stress relates strongly to a patient’s level of assisted and independent gait. The defined ZBI factors suggest that caregivers stress can be strongly influenced by feelings of how well they have the situation under control, what the future may bring, and how effective they are in overall care of the patient.

Abstract Id: 27

Neurodynamics Is No Different From Random Passive Movements in Reducing Spasticity

Lorentzen J^1,2, Nielsen D¹, Holm K¹, Baagøe S¹, Grey MJ^2,3, Nielsen JB^2,3

¹Department of Physiotherapy, Hvidovre Hospital/Department of Neurorehabilitation TBI Unit, Copenhagen University Hospital, Glostrup, Denmark

²Department of Exercise and Sport Sciences, University of Copenhagen, Copenhagen, Denmark

³Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark

Background and Aims: Neurodynamics (ND) is a therapy believed to reduce spasticity and to increase range of motion (ROM). This study compared the ability of ND and random passive movements (RPM) to reduce spasticity in the knee flexors in 10 spastic patients with brain injury.

Methods: A randomized control study with crossover design was used to evaluate muscle tone and ROM. Outcome measures included 1) instrumented stiffness measurements with a hand-held dynamometer at high and low velocities; 2) Modified Ashworth Score (MAS); 3) ROM; 4) angles of resistance onset (R1) and compensatory movement/pain R2; and 5) the raters’ subjectively perceived reduction in muscle tone. Outcome measures were recorded by three raters before and after a single treatment session.

Results: Objective stiffness parameters measured with the hand-held device showed no significant changes for the ND or RPM (p ≥ 0.09-0.79), and no differences between the intervention effects were found (p > 0.80). The subjective measures showed significant changes after the ND for the non-blinded rater (MAS: p < 0.05; R1: p < 0.05; R2: p < 0.05) but for the blinded rater a significant reduction was found only for R1 (p < 0.05) and R2 (p < 0.05). For the non-blinded rater, intervention effects were found for R1 (p < 0.01), R2 (p < 0.01) and subjectively perceived reduction in muscle tone (p < 0.01). For the blinded rater, no significant intervention effect was found for any of the parameters.

Conclusion: ND seems not to be effective in reducing spasticity when evaluated objectively, but may increase ROM in the knee flexors with the same effect as random passive movements.

Abstract Id: 482

Goal Attainment Following Upper-Limb Botulinum Toxin-A Injections: are we Facilitating Achievement of Client-Centred Goals?

Nott M^1,2, Barden H^1,2, Baguley I^1,2

¹The University of Sydney, NSW, Australia

²Westmead Hospital Brain Injury Rehabilitation Service, NSW, Australia

Introduction: The need for client-centred outcome measures following upper-limb (UL) botulinum toxin-A (BoNT-A) injections is being increasingly understood.

Aims: Evaluate UL goal attainment following BoNT-A injections and describe client-centred goals of adults with UL spasticity following brain impairment.

Methods: 28 community-dwelling adults with acquired brain injury were recruited from three spasticity clinics. A pre-test/post-test design evaluated UL spasticity using the Modified Ashworth Scale (MAS), Tardieu Spasticity Angle (TSA), Action Research Arm Test (ARAT) and Goal Attainment Scale (GAS) prior to and 4 weeks after injections. Non-parametric statistical analysis was performed.

Results: Client, therapist and family/carers negotiated realistic goals in the ICF domain areas of Body Function and Activity-Participation. Approximately half the goals were achieved at 4 weeks post injection. Activity-Participation goals were equally likely to be achieved as Body Function goals. GAS T-scores improved significantly following BoNT-A injections (p < .001). MAS scores at the elbow, wrist and fingers reduced significantly (p < .05), with concomitant reduction in TSA at all joints (ranging from 5° to 15° reduction). Changes in UL function measured by the ARAT were not statistically different following BoNT-A injection.

Conclusion: Consideration of goal attainment following BoNT-A injections for UL spasticity provides a client-centred process for measuring outcome and broadens the focus of spasticity outcome measurement to include Activity-Participation goals as well as more traditional Body Structure/Function goals. Improvements in GAS T-scores related to reduction in spasticity, as measured by the MAS and TSA, but were not associated with improvements in UL performance, as measured by the ARAT.

Abstract Id: 370

Active Exercise for Individuals with Cervical Dystonia: a Pilot Randomised Controlled Trial

Boyce MJ^1,2, Canning CG², Mahant N^1,2, Morris J^1,2, Latimer J³, Fung VSC^1,2

¹Westmead Hospital, Sydney, NSW, Australia

²The University of Sydney, Sydney, NSW, Australia

³The George Institute of Global Health, Sydney, NSW, Australia

Background and Aims: Cervical dystonia is most commonly treated by botulinum toxin injections into the dystonic neck muscles, but exercise is emerging as a potentially effective adjunct to this medical management. The aim of this study was to investigate the feasibility and effectiveness of an active exercise program for cervical dystonia.

Methods: A pilot randomized controlled trial of a 12-week intervention followed by a further 4-week follow-up period was undertaken. Twenty participants (14 female, 6 male) with idiopathic cervical dystonia were randomised into an experimental or control group. The experimental group undertook a semi-supervised active exercise program aimed at correcting the dystonic head position plus relaxation. The control group undertook a semi-supervised relaxation program. The feasibility of the intervention was assessed by recording adherence, muscle soreness and adverse events. The primary outcome measure was the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) score.

Results: Eight participants were receiving botulinum toxin injections every three months during the study, and these participants commenced the study on the same day as their injection. Two participants from the experimental group and one from the control group dropped out. The active exercise program was feasible and safe with participants completing 87% (SD 26) of prescribed supervised sessions and 84 % (SD 58) of prescribed training sessions. Two-thirds of participants in the experimental group reported mild muscle soreness which did not interfere with continuing active exercise. There was no significant difference between groups at post-test or follow-up, but the group undertaking the active exercise showed a greater trend towards improvement in TWSTRS score than the control group.

Conclusion: Active exercise for people with cervical dystonia is feasible and can be completed with good adherence and no adverse effects. Further investigation using a larger active exercise dose in a larger sample is warranted.

Abstract Id: 38

Categorisation of Goal Attainment Scale-Derived Goals and Assessing the Effectiveness of the Use of Botulinum Toxin Within These Categories

Wild D¹, Aldous S¹, Fini N¹, Dixon C¹, Winter A¹, Palit M¹, Holland AE²

¹Caulfield Hospital, Alfred Health, Caulfield, VIC, Australia

²La Trobe University and Alfred Health, VIC, Australia

Background and Aims: There is strong evidence to support the use of botulinum toxin (BoNT) injections to reduce focal spasticity. The Goal Attainment Scale (GAS) may be useful in measuring change after BoNT injections. The aim of this study was to determine which GAS goals are most commonly achieved in patients undergoing BoNT injection for spasticity.

Method: Sixty-seven clients (46 with stroke) who received BoNT injections for spasticity management were included. Median time since onset of spasticity was 2.38 years. Goals were set by clients and/or carer prior to injection. One month post injection, goal achievement was rated on the GAS. Individualized goals were categorized into mobility/transfers, pain/comfort, upper limb use, hygiene, and cosmesis.

Results: A total of 35 mobility/transfer goals were set with 19 responders (54%). For upper limb use, there were a total of 24 goals with 10 responders (42%). Thirty-three cosmesis goals were set with a total of 28 responders (85%). A total of 15 pain/comfort goals were set with twelve responders (80%). Eight hygiene goals were established and all were achieved (100%). Responders for mobility and transfer goals tended to be further post injury or disease onset than non-responders (median 5.9 vs 1.2 years, p = 0.06). Those with a diagnosis of stroke were less likely than other participants (for example, traumatic brain injury and multiple sclerosis) to achieve mobility and transfer goals (p = 0.02).

Conclusion: Passive goals such as hygiene and pain/comfort were more likely to be achieved, although active goals are more commonly identified. Mobility and transfer goals are more likely to be achieved in those without a diagnosis of stroke and in those who are further post injury or disease onset.

Abstract Id: 558

Demographic Profile of Spasticity Within a Cohort of Post-Stroke Survivors

Wein T¹, Manack A², Sucharew H³, Gillard P², Alwell K⁴, Moomaw C⁴, Woo D⁴, Khatri P⁴, Flaherty M⁴, Adeoye O⁴, Ferioli S⁴, Broderick J⁴, Kleindorfer D⁴, Kissela B⁴

¹Montreal General Hospital, Division of Neurology, McGill University, Montreal, Canada

²Allergan, Irvine, CA, USA

³Cincinnati Children’s Hospital Medical Center, Division of Biostatistics and Epidemiology, Cincinnati, OH, USA

⁴University of Cincinnati Department of Neurology, Cincinnati, OH, USA

Background and Aims: Post-stroke spasticity (PSS) is a significant cause of post-stroke disability, leading to physical pain and deformity. Despite this, there is a paucity of literature describing these patients. Our objective was to identify differences in demographic and baseline stroke characteristics between those with PSS and those without (no-PSS) within a stroke cohort.

Methods: Data from the 2005 Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS), a 5-county longitudinal study designed to characterize a stroke (defined as verified ischemic stroke) population, were utilized. PSS was defined as patient-reported spasticity at 3-month or 1-year assessments, while no-PSS was defined as no report of spasticity at either assessment. Data were collected via direct patient interview or chart extraction on post-stroke day 1 and were investigated for an association with subsequent spasticity. Groups were compared using chi-square, Fisher’s exact, t test or Wilcoxon rank-sum test, as appropriate. Logistic regression was used to compare groups while adjusting for key variables.

Results: Of those completing the initial interview and reporting spasticity status at subsequent assessments, 33% (78/236) reported spasticity. Significant differences were detected when comparing age, race, employment status, smoking status and median NIHSS, where PSS patients were younger (mean ± SD = 60.9 ± 13.9 years vs 67.5 ± 13.5 years), more likely to be non-Caucasian (36 vs 23%), more commonly on disability (17 vs 6%), more likely to report currently smoking (38 vs 22%), and had higher NIHSS (5 vs 4). Although not statistically significant (p = 0.08), PSS patients tended to be more likely to have a history of prior stroke after adjusting for age, gender, and race (OR = 1.84, 95% CI: 0.93-3.66).

Conclusions: Our data characterize the profile of patients with PSS. Further analyses are needed to identify potential confounders and explore causal relationships between stroke and spasticity development.

Abstract Id: 582

Comorbidity Profile of Spasticity Within a Cohort of Post-Stroke Survivors

Wein T¹, Manack A², Sucharew H³, Gillard P², Alwell K⁴, Moomaw C⁴, Woo D⁴, Khatri P⁴, Flaherty M⁴, Adeoye, O⁴, Ferioli S⁴, Broderick J⁴, Kleindorfer D⁴, Kissela B⁴

¹Montreal General Hospital, Division of Neurology, McGill University, Montreal, Canada

²Allergan, Irvine, CA, USA

³Cincinnati Children’s Hospital Medical Center, Division of Biostatistics and Epidemiology, Cincinnati, OH, USA

⁴University of Cincinnati Department of Neurology, Cincinnati, OH, USA

Background and Aims: While multiple comorbidities have been associated with stroke, there is a relative paucity of literature on comorbidity rates in the post-stroke spasticity (PSS) population. This study aims to identify differences in baseline comorbidity profiles between those with PSS and those without (no-PSS) within a stroke cohort.

Methods: Data from the 2005 Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS), a 5-county longitudinal study designed to characterize a stroke (defined as verified ischemic stroke) population, were utilized. PSS was defined as patient-reported spasticity at 3 months or 1 year, while no-PSS was defined as no report of spasticity at either assessment. Baseline comorbidities, which were collected via direct patient interview or chart extraction on post-stroke day 1, were investigated for an association with subsequent spasticity. Groups were compared using chi-square or Fisher’s exact t test, as appropriate.

Results: Of the 236 patients who completed the initial interview and reported spasticity status at subsequent assessments, 78 (33%) reported spasticity. Demographic data revealed that PSS patients were younger, more likely to be non-Caucasian, and had higher NIHSS. Comorbidities occurring at ≥10% in PSS or no-PSS groups are presented in Table 1.

Table 1.

Comorbidity Profiles

	PSS (n = 78)	No-PSS (n = 158)	Significant P-Value
Ischemic stroke	21%	18%
TIA	18%	8%	0.03
Hypertension	83%	70%	0.03
Heart disease	23%	27%
Heart attack	64%	57%
Carotid artery disease	18%	6%	<0.01
Seizure	10%	4%
Pain disorders	53%	58%
Depression	33%	21%	0.04
Migraine	23%	6%
Neuropathy	74%	77%
Diabetes	41%	32%
Cancer	13%	14%
Visual loss/blindness	17%	13%
Infection (<2 weeks)	15%	18%

Conclusions: Our data provide comorbidities associated with PSS in a US cohort that to date has never been reported. Comorbidities identified with PSS are useful in identifying patients at risk for spasticity development and, hopefully, will help with the development of preventative measures to reduce overall burden.

Abstract Id: 193

Development of Functional Reorganization with Triple-Element Protocol of Botulinum Toxin Type a Injection, Low-Frequency rTMS, and Intensive Occupational Therapy: a Follow-Up Study Using Functional MRI in Post-Stroke Patients

Yamada N^1,2, Kakuda W², Abo M², Shimizu M¹, Sageshima T¹, Saeki H¹, Kondou T¹, Mitani S¹, Senoo K¹, Nakanishi K¹, Akahori R¹, Senoo A³

¹Shimizu Hospital, Kurayoshi-City, Tottori, Japan

²Department of Rehabilitation Medicine, Jikei University School of Medicine, Tokyo, Japan

³Division of Radiological Sciences, Faculty of Health Sciences, Tokyo Metropolitan University, Tokyo, Japan

Background and Aims: For spastic upper limb hemiparesis after stroke, we recently developed triple-element protocol of botulinum toxin type A (BoNTA) injection, low-frequency repetitive transcranial magnetic stimulation (LF-rTMS), and intensive occupational therapy (OT). The purpose of this study is to investigate the influence of the protocol on neural networks in the brain using functional MRI (fMRI) as well as that on motor function of the affected upper limb.

Methods: Sixteen post-stroke patients with spastic upper limb hemiparesis were subjected (age: 61 ± 8 years old, time after onset: 75 ± 53 months). After BoNTA was injected into spastic muscles of the affected upper limb (maximum total dose: 240 units), they were hospitalized to receive 12 sessions of 40-min LF-rTMS over the non-lesional hemisphere and 240-min intensive OT (40-min one-to-one training × 3 times and 120-min self-training) daily over 15 days. Motor function of the affected upper limb was serially evaluated with Fugl-Meyer Assessment and Wolf Motor Function Test. In addition, fMRI with motor tasks for the affected upper limb was performed on the day of admission/discharge. Subsequently, the laterality index (LI) of activated voxel number in the sensorimotor cortex and premotor cortex on fMRI was calculated (range of LI: −1 to +1; LI of +1 and −1 means that all activation was found in the lesional and in the non-lesional hemisphere, respectively).

Results: The changes in FMA and WMFT showed significant improvement of motor function of the affected upper limb (all p < 0.05). The LI showed the tendency to increase with the intervention (from 0.484 ± 0.280 to 0.656 ± 0.358, p = 0.146).

Conclusions: The change in fMRI findings suggests that activated areas in the brain tend to accumulate in the lesional cerebral hemisphere with the functional improvement of the affected upper limb. Our proposed triple-element protocol seems to have a potential to cause beneficial functional reorganization leading to the motor recovery after stroke.

Abstract Id: 608

Effect of Intrathecal Baclofen Concentration and Mode of Administration on H-Reflex in Patients with Acquired Brain Injury

Stokic DS¹, Yablon SA²

¹Methodist Rehabilitation Center, Jackson, MS, USA

²Glenrose Rehabilitation Hospital, Edmonton, AB, Canada

Background and Aims: Intrathecal baclofen (ITB) administration via programmable pump allows manipulation of several parameters, but adjustments are mainly limited to dose with concentration increase made to lower the frequency of reservoir refill. A few anecdotal reports suggest that lowering concentration may result in better clinical response, but these observations remain without neurophysiological support. Thus, the aim of this study was to assess changes in spinal reflex excitability after manipulation of ITB concentration and mode of administration in people with acquired brain injury.

Methods: The effect of ITB concentration on soleus H-reflex (H/M ratio) was assessed 1-6 hours after a 50-µg bolus at 50 µg/ml concentration administered manually via lumbar puncture (LP, duration 1-2 min) during a screening trial (n = 25) in comparison to a 50-µg bolus at 500 µg/ml concentration programmed through the pump and delivered via intrathecal catheter (IC, duration 10 min) over a simple continuous dose (25-100 µg/day, n = 16). The effect of mode of administration was assessed when peak changes in H/M ratio after the same 50-µg IC bolus given over simple continuous dose (complex mode) were compared to the equivalent total dose delivered in simple continuous mode only (75-150 µg/day, n = 22).

Results: The decrease in H/M ratio was faster and greater after LP than IC bolus (mean decrease over 1-6 hours 90% vs 82%, p < 0.001; 1 hour, 76% vs 63%, respectively, p < 0.03). H/M ratio also decreased significantly more with complex than simple continuous mode of ITB administration (91% vs 78%, respectively, p < 0.05). The latter finding was not related to the total daily dose.

Conclusions: Within the dose ranges evaluated, lowering ITB concentration and programming complex continuous mode of administration led to greater decrease in spinal reflex excitability. Manipulation of drug and pump parameters to increase ITB flow may lead to better clinical response, which warrants further studies.

Abstract Id: 546

Botulin Toxin in the Treatment of Axial Disorders in Parkinson Disease

Tassorelli C^1a, Sandrini G^1a, Bolla M^1a, De Icco R^1a, Allena M^1a, Cristina S^1a, Pacchetti C^1b, Alfonsi E^1c, Bartolo M², Nappi G¹

¹Research Centre on Parkinson and Alzheimer Disease (CRIMPA): ^aNeurological Rehabilitation Unit, ^bParkinson and Movement Disorder Unit, and ^cNeurophysiology Unit, IRCCS “National Neurological Institute C. Mondino” Foundation, Dept. of Public Health and Neurosciences, University of Pavia, Italy

²IRCCS INM Neuromed, Pozzilli, IS, Italy

Background: Abnormal postures of the trunk are a typical feature of Parkinson’s disease (PD). Pisa syndrome (PS) is a tonic lateral flexion of the trunk associated with slight rotation along the sagittal plane. As previously described by our group, PS may represent a complication of advanced PD in patients with hyperactivity of the dorsal paravertebral muscles on the less affected side. Conventional rehabilitation treatment (CT) ameliorates axial posture and trunk mobility in PD patients, but the improvement tends to wane in the subsequent 4-6 months. Botulin toxin (BT) may reduce muscle hyperactivity improving CT, also reducing pain, a symptom often associated to this condition. The aim of our study was to investigate the association of BT injection to CT (BT+CT) in PS.

Methods: Twenty PD patients were enrolled and randomly assigned to CT or BT+CT treatment. The kinematic behavior of the trunk was recorded by an optoelectronic system to determine a) trunk flexion, inclination and rotation values in the erect standing posture and b) ranges of trunk flexion and inclination during trunk movements before and after a 4-week rehabilitative program with/without BT injection and at 3- and 6-month follow-up. Presence and intensity of pain was evaluated with the visual analog scale (VAS).

Results: Both CT and BT+CT treatments significantly decreased trunk flexion and inclination in the static condition and increased range of motion in both groups. At 3- and 6-month follow-up, the BT+CT group tended to keep more marked benefits than the CT group. Furthermore, the BT+CT group showed a significant pain reduction in VAS score as compared with the CT group.

Conclusions: Our preliminary data suggest that BT may be considered an important support to conventional rehabilitation treatment in improving axial posture and trunk mobility of PS and even more so in the control of pain symptoms associated with this condition.

Abstract Id: 200

The Gas-Eous Tool: a Framework for Evaluation of Outcome in Upper Limb Spasticity

Turner-Stokes L^1,2, Ashford S², De Graaff S³, Baguley IJ⁴

¹Department of Palliative Care, Policy and Rehabilitation, King’s College London, UK

²Regional Rehabilitation Unit, Northwick Park Hospital, London, UK

³Epworth Healthcare, Camberwell, Australia

⁴Westmead Hospital and The University of Sydney, Australia

Background and Aims: Goal attainment scaling (GAS) is increasingly used as an outcome measure for evaluation of focal interventions for upper limb spasticity. However, clinicians frequently report that recording of GAS can be too time-consuming for use in clinical practice. Concerns have also been raised about lack of standardization in individual goal setting, which limits the comparability of GAS across different populations and settings. In this presentation, we report the development of a new standardized framework for goal setting and evaluation of treatment for upper limb spasticity.

Methods: A total of 832 individualised goals for treatment for upper limb spasticity using botulinum toxin injection were analysed from three multicentre studies, spanning a total of 15 centres (9 in the UK and 6 in Australia). Goals were categorised and mapped onto the closest matching domains of the WHO International Classification of Functioning.

Results: Goal categories fell into two key domains, each subdivided into four main goal areas:

• Domain 1: Symptoms/impairment—a) pain/discomfort, b) involuntary movements, c) range of movement/contracture prevention, and d) body image.

• Domain 2: Activities function—a) passive function (ease of caring for the affected limb), b) active function (using the affected limb in active tasks), c) mobility, and d) facilitation of therapy.

The GAS-eous tool was constructed as a checklist based on this framework, with sub-categories labeled with ICF codes and prompts for the construction of clearly defined goals. Verbal rating of goal attainment, based on a limited number of standard measures, translates automatically to a standard 5-point rating scale and a combined T-score.

Conclusions: Designed to assist timely and targeted application of GAS in routine clinical settings, the GAS-eous tool is now undergoing further evaluation, together with further validation through goals analysis from a large international cohort study involving 79 centres from 22 countries.

Abstract Id: 636

Spasticity: a Favorable or Unfavorable Syndrome for Allowing Artificial Induced Walking in Paraplegics?

Cerrel Bazo HA^1,3, Rizzetto A², Nicolotti D³, Bocchi R³, Epifani P³, Verderosa F³, Orsi M³, Gambretti S³

¹Self-Sufficiency and Rehabilitation, AUSL, Piacenza, Italy

²Villa Margherita Neurorehabilitation and Research Center, Arcugnano, Vicenza, Italy

³Spinal Cord Injury Unit, HUB in Emilia Romagna Network Health System—Giuseppe Verdi Hospital, Villanova Sull’Arda, Piacenza, Italy

Background and Aims: The purpose of this work is to determine if spasticity (SPS) and/or residual voluntary motor activity (VMA) in gait-trained (GT) complete spinal cord injury (SCI) patients through electrically induced (EI) or mechanically induced (MI) walking can inhibit or facilitate prolonged walking. We hypothesize that walking may be perturbed by spasticity, and the latter may be the reason for the increase in power requirements and oxygen consumption.

Methods: Design: SCI gait-trained individuals, sample comparison. Setting: Neurorehabilitation research center. Participants: Two groups of SCI subjects and able-bodied (AB): 10 (5+5) paraplegics and 5 control AB. Intervention: Three trials at 45 minutes walking on a treadmill at the preferred maximum speed in m/min at zero degrees of inclination. Main outcome measures: Power requirement (PR; VO₂ mL/kg/min), work intensity or physiological cost (PC)(VO₂ mL/kg/m), oxygen uptake (O₂up; mL/min). Asworth scale (SPS) was represented by ROM assessment average values of 6 different joint comprehensive of hip flex/ext, hip abduction/adduction, knee ext/flex, ankle dorsiflex/plantarflex, and VMA.

Results: Significant (p ≤ 0.001; p ≤ 0.01; p ≤ 0.05) differences were noted for PR, PC, VMA, SPS, and O₂up higher for the EI group. O₂up (p ≤ 0.001) between the research groups was present and was higher for the EI-group compared with the MI-group. Within-group correlation was found between O₂up and level of injury (higher for the lower SCI). PR showed differences (p ≤ 0.001) between the research groups that were higher for the EI-group compared with the MI-group. The MI demonstrated that PR was related to level of injury and VMA. Within the EI-group, a higher variation was identified. SPS vs PR confirmed that a higher PR in the MI-group seems related to the higher degree of SPS but was not considered significant. The EI-group instead reported a higher correlation between degree of spasticity vs PR, with the higher the degree of spasticity, the lower the PR.

Conclusions: Our results seems to sustain the hypothesis that spasticity on SCI subjects up to an Ashworth scale degree of 3 may facilitate EI walking, decreasing the PR need for walking. The contrary was observed for the MI-group. Spasticity seems to play an important role in walking. Despite the good quality of our laboratory-controlled study, the tedious preparation and training of SCI subjects to walk for 45 minutes was not easy, and this was the reason for the small sample size. As a result, our findings may not be able assert final conclusions, and further studies may be needed.

Theme: Spinal Cord Injury

Abstract Id: 174

Rehabilitation of Sportsmen with Robotic Reconstruction Walk After Spinal Cord Injury

Zimina E, Daminov V, Uvarova O, Kuznetsov A

National Pirogov Centre of Therapy and Surgery, Russia, Moscow

Introduction: The aim of our research was to develop methods of physical rehabilitation and robotic complexes Erigo and Lokomat and evaluate the effectiveness of this in sportsmen with traumatic spinal cord disease.

Materials and Methods: 88 patients in the intermediate period of spinal cord trauma in motor-incomplete spinal cord injury were examined. All patients underwent surgery for spinal cord decompression and spine stabilization. The cohort of patients was divided into two groups: the first one, including 51 patients, had a standard rehabilitation program and trained with the help of Erigo and Lokomat; the second control group (37 patients) had only the rehabilitation program. The duration of rehabilitation course was 2 months. We used scales—six marks paresis degree, ASIA, Beck depression, Hauser Gate Index—to estimate the effectiveness of rehabilitation.

Results: In patients of group 1, against the background of the robot, there was a significant increase in mechanotherapy muscle strength by 1.0-1.5 points. Indicators on the ASIA scale increased by 24% in group 1 and by 12% in group 2. In group 1, the use of robotic rehabilitation kinesiotherapy resulted in an increase in patients’ mobility that was 2-3.5 times that compared with group 2. Decreased depression scores of 6.0 points were noted in group 1 and 0.6 points in group 2.

Conclusions: It was found that effectiveness of locomotor training with the help of Erigo and Lokomat surpassed the effects of traditional kinesiotherapy.

Abstract Id: 157

Differential Effect of Intrathecal Baclofen Bolus on Cortical and Cutaneous Silent Periods

Stetkarova I ^1,2, Kofler M³

¹Department of Neurology, 3^rd Medical Faculty, Prague, Czech Republic

²Na Homolce Hospital, Prague, Czech Republic

³Department of Neurology, Hochzirl Hospital, Zirl, Austria

Background and Aims: Painful digital nerve stimulation leads to transient suppression of electromyographic (EMG) activity in isometrically contracted hand muscles, designated the cutaneous silent period (CSP). This reflex, mediated by A-delta afferent impulses, enters the spinal dorsal horn and suppresses activity in spinal motor nuclei. Transcranial magnetic stimulation (TMS) of the contralateral motor cortex elicits a cortical silent period (CoSP), which is defined as a post-excitatory interruption of EMG activity in the target muscle. CoSP is thought to represent GABA_B receptor-mediated inhibition of cortical excitability. To date, only scarce information is available about potential modulation of CSP and CoSP by the inhibitory GABA_B agonist baclofen.

Methods: We evaluated clinical and neurophysiological effects of intrathecal baclofen (ITB) in ten patients with severe spasticity due to spinal cord injury (n = 9) and chronic progressive multiple sclerosis (n = 1). Patients underwent serial clinical evaluation of modified Ashworth Scale (MAS) in the lower extremities, and serial neurophysiological assessment, including CSPs in thenar muscle following digit II stimulation, CoSPs in thenar muscle following contralateral TMS, and H-reflex in soleus muscle before and 30, 60, 90, 120, and 180 minutes after ITB bolus administration.

Results: CSP onset latency, CSP end latency, and CSP duration did not change significantly following ITB administration. In contrast, CoSP duration increased progressively with a maximum 3 hours following ITB bolus. ITB suppressed soleus H reflex as early as 30 minutes after lumbar bolus injection.

Conclusion: The present findings suggest that the GABA_B agonist baclofen does not affect the CSP, but prolongs the CoSP, in line with GABA_B receptor-mediated inhibition of cortical excitability. The spinal inhibitory circuitry of the CSP is not modulated by GABA.

Abstract Id: 209

Rehabilitation Outcomes From Spinal Cord Infections

New PW^1,2, Astrakhantseva I¹

¹Spinal Rehabilitation Unit, Caulfield Hospital, Alfred Health, Melbourne, VIC, Australia

²Epworth-Monash Rehabilitation Medicine Unit, Melbourne, VIC, Australia

Infections causing spinal cord damage are rare. Previous outcome studies of outcomes in these patients have many limitations. The aim of this project was to study the functional and rehabilitation outcomes in patients with spinal cord infection admitted for rehabilitation. A retrospective chart review was performed of consecutive admissions to a spinal rehabilitation unit in Melbourne, Australia. Only patients discharged between 1st January 1997 and 31st December 2010 with a recent onset of spinal cord damage due to infection were included. Patients readmitted for late complications were excluded. Outcome measures included demographic characteristics and aetiology of infection and length of stay (LOS). The American Spinal Injury Association (ASIA) Impairment Scale (AIS) and Functional Independence Measure (FIM) motor subscale scores were recorded at admission and discharge. 49 patients were admitted over the study period (males = 33, 67%). Median age was 64 years (interquartile range [IQR] 52-72, range 22-89). There was no relationship between age and gender (χ = 2.1, P = 0.1). Most infections were bacterial (n = 46, 94%), viral in two (4%), and tuberculosis in one (2%). No cases had fungal or parasitic aetiology. Most patients (n = 36, 73%) had a paraplegia level of damage. The median LOS was 105 days (IQR 65-133). On admission, 5 (10%) patients had AIS grade A, 10 (20%) AIS grade B, 22 (45%) AIS grade C, and 12 (24%) AIS D. There was a significant (χ = 58.8, P = 0.000) improvement by discharge, with three (6%) remaining AIS A, 6 (12%) AIS B, 19 (39%) AIS C, and 21 (43%) AIS D. There was a significant improvement (Wilcoxon Z = −5.7, P = 0.0000) in the FIM motor score between admission (median = 27.5, IQR 21-34) and discharge (median 66, IQR 41-75). There was a significant neurological and functional improvement observed during the course of rehabilitation. Research on long-term outcomes and survival is needed.

Abstract Id: 458

Our Experience Using Therapy with Interferential Medium-Frequency Currents in the Rehabilitation of Micturition Control in Patients with Neurogenic Bladder, Mainly Post SCI

Onose G^1,2, Daia C^1,2, Anghelescu A^1,2, Onose L³, Spircu T², Lapadat M¹, Popescu C¹ Neculaie M¹

¹The Teaching Emergency Hospital “Bagdasar-Arseni,” Bucharest, Romania

²The University of Medicine and Pharmacy “Carol Davila,” Bucharest, Romania

³The Medical Service of Metrorex, Bucharest, Romania

Background and Aim(s): To emphasize the therapeutic efficiency of an Interferential Medium Frequency Currents (IMFES) standardized method in neurogenic bladder (NB).

Method: Prospective study on 332 inpatients at the Physical and (neural-muscular) Rehabilitation Medicine Clinic Division of our hospital, between September 2006 and April 2011 with NB, most of them with post spinal cord injury (SCI), divided in two lots: IMFES (162 cases, 53 females, 109 males, mean age 39.63 years, standard deviation [SD] 17.06) and control (170 cases, 44 females, 126 males, mean age 39.96 years, SD 17.58), considering IMFES administration need in NB (aside from similar standard treatments) as a major inclusion criterion. Evaluation of the micturition control (MC) was based on an adapted retention/incontinence assessment scale.

Results: The number of inpatients that significantly improved their MC was overall higher in the IMFES lot CIMF (mean 365.80, SD 488.61) compared to controls (mean 824.94, SD 63.22), p = 0.000. The AIS A patients with Sensory Score (SS) below 89 points MC gain was comparable between the lots (IMFES: mean 960, SD 485.210; controls mean 1131.91, SD 548.95; p = 0.3). For the AIS A and/or B cases, at admission, with SS between 89 and 160 (IMFES: mean 555.71, SD 530.19; control 888, SD 710.45; p = 0.035), AIS B with SS between 160 and 224 (IMFES: mean 283.09, SD 403; control: 1061.29, SD 437.17; p = 0.000), AIS C with SS between 160 and 224, and Motor Score (MS) below 40 (IMFES: 229.63, SD 389; control: mean 694.14, SD 671.89; p = 0.000), the method is effective. For the AIS C and/or D patients, with SS between 160 and 224 and MS over 40, the method is useless (IMFES: mean 131.98, SD 128.54; control: mean 130.37, SD 137.49; p = 0.9).

Conclusions: The IMFES method is useful in rehabilitation of incomplete patients with NB.

Abstract Id: 345

Feasibility of Technology-Assisted Task-Oriented Skill Training in Spinal Cord Injury

Spooren A^1,2, Vanmulken D³, Bongers H³, Seelen H^1,2, Timmermans A^1,2

¹Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands

²Maastricht University, Research School CAPHRI, Department of Rehabilitation Medicine, Maastricht, The Netherlands

³Adelante Rehabilitation Centre, Hoensbroek, The Netherlands

Background/Aim: For patients with cervical spinal cord injury (C-SCI), a task-oriented client-centered upper skilled training (ToCUEST) was developed and proven beneficial, but little experience with task-oriented technology-assisted training is available in C-SCI. For stroke patients, a Technology-assisted Task-Oriented-Arm-training concept (T-TOAT) was developed to improve upper extremity functioning, which may be used in combination with the Haptic Master robot (HM). This study aims to assess the feasibility of the T-TOAT training with the HM in C-SCI persons.

Methods: A pilot-study in which C-SCI patients, who have finished rehabilitation more than one year ago, were trained with the HM for 6 weeks. The training system consisted of 1) a computer-screen and PC, 2) video-instructions of a tailor-made arm-hand training, 3) Haptic TOAT software, and 4) an HM robot that may assist the patient’s arm movement. Measurements were taken before training, after 4 weeks of training and after the training stopped.

Results: 5 C-SCI patients participated (mean age: 47 year; 3 ASIA Impairment Scale [AIS] AB, 2 AIS CD; lesion level between C5 and C7). No significant progress was demonstrated at the ICF function level (measured by the Microfet) and ICF activity level (measured by the Van Lieshout Test and the Spinal Cord Independence Measure). Patients scored the credibility better than the expectancy (mean item-score on Credibility and Expectancy Questionnaire 6.6 and 4.3 out of 9 respectively). All items of the Intrinsic Motivational Inventory scored more than the neutral score of 3.5, with the exception of the pressure/tension item (mean of 1.5 out of 7). System usability was rated to be moderate (mean of 4.7 out of 7 on USE).

Conclusion: It is feasible to train C-SCI persons with the HM. Further research is needed to assess in which group of C-SCI and in which stage of the rehabilitation HM training is most beneficial.

Abstract Id: 294

Epidemiology of Urinary Tract Infection Among Spinal Cord Injured Patients in a Rehabilitation Ward

Ploypetch T¹, Dajpratham P¹, Assanasen S², Thanakiatpinyo T¹, Tanvijit P¹, Karawek J¹

¹Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

²Division of Infectious Disease, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Background and Aims: A prophylactic antibiotic in retrograde investigations (Ix) such as urodynamic study was suggested by European Association of Urology in order to prevent urinary tract infection (UTI) in neurogenic bladder. However, an appropriate antibiotic is questionable since bacterial types and their sensitivities are variable in different settings. Therefore, this study aimed to find out the epidemiology of UTI in spinal cord injured (SCI) patients within our rehabilitation ward.

Methods: It was a retrospective chart review of 100 SCI patients who were admitted to the rehabilitation ward between 2006 and 2010. Symptomatic UTI events, urine cultures and sensitivities (C/S) were reviewed. Demographic data and possible UTI-associated factors were collected and examined the association with the occurrence of UTI.

Results: There were 64 males and 36 females with mean age 42.9 (SD 15.8) years. Most of them (77%) were injured at cervical and thoracic spinal cords. Forty-five patients had 57 UTI episodes. Escherichia coli was the most common isolated pathogen (50%), followed by Pseudomonas aeruginosa (17.3%) and Enterococcus faecalis (7.7%), which was similar to the pattern of urine C/S prior to retrograde Ix. Three ranks of most sensitive antibiotics were imipenem, amikacin and piperacillin/tazobactam. Unfortunately, gentamicin, ceftriaxone and ciprofloxacin, which were frequently used as a prophylactic antibiotic, were susceptible only 40.9-54.3%, 50% and 18.2-24.3%, respectively. The mean length of stay of patients with UTI was far greater than non-UTI patients with 45.5 (SD 24.4) and 30.4 (SD 14.8) days. Vesicoureteric reflux (VUR) was a significant risk factor of post investigation UTI (OR 21.2, 95% CI 2.1 to 214.2).

Conclusions: UTI was commonly observed in SCI patients within the rehabilitation ward. The most common uropathogen was Escherichia coli. Unfortunately, most susceptible antibiotics were expensive. Therefore, a prophylactic antibiotic might be preserved for high-risk patients such as those with VUR.

Abstract Id: 78

The Effect of Singing on Respiratory and Voice Function Following Cervical Spinal Cord Injury: a Randomized Controlled Trial

Tamplin J^1,2,3, Baker F⁴, Grocke D³, Pretto J^1,5, Brazzale D¹, Ruehland W¹, Buttifant M⁶, Brown D^2,3, Berlowitz D^1,3

¹Institute for Breathing and Sleep, Austin Health, Melbourne, VIC Australia

²Victorian Spinal Cord Service, Austin Health, Melbourne, VIC, Australia

³University of Melbourne, Parkville, VIC, Australia

⁴University of Queensland, St Lucia, QLD, Australia

⁵Dept of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia

⁶Voice Analysis Clinic, Austin Health, Melbourne, VIC, Australia

Background and Aims: Reduced lung function and diminished voice projection are common following quadriplegia. Respiratory muscle training has been shown to improve respiratory function but is limited by poor compliance and carryover. Singing training has facilitated improved respiratory capacity and voice projection in other populations and may be a more motivating way to train the respiratory muscles. We therefore aimed to examine the effect of a group therapeutic singing intervention on respiratory function, voice quality and mood in people with quadriplegia.

Method: Twenty-four participants with chronic quadriplegia (C4-C7, ASIA A & B) were randomly assigned to experimental or active control groups. The experimental group (n = 13) received group singing training 3 times weekly for 12 weeks. The control group (n = 11) received group music appreciation and relaxation for 12 weeks. Assessments were conducted pre, mid, immediately post and 6 months post intervention. Assessments included respiratory function tests, electromyography, voice recording and analysis, in addition to mood, voice, and quality of life questionnaires.

Results: The singing group achieved a significant increase in projected speech intensity (p = 0.028) and maximum phonation length (p = 0.007). Trends for improvements in respiratory function, muscle strength and recruitment were also evident for the singing group. These effects were limited by small sample sizes with large inter-subject variability. Both music therapy groups demonstrated an improvement in mood (p = 0.002) and this improvement was maintained by the music appreciation and relaxation group after 6 months (p = 0.017).

Conclusions: Group music therapy can have a positive effect on not only physical outcomes, but also can improve mood, energy, social participation and quality of life for an at-risk population such as those with quadriplegia. Specific singing therapy can augment these general improvements by improving vocal intensity. Further research could examine the longer-term, community effects of this training on respiratory complications and voice function.

Abstract Id: 395

Spinal Community Integration Model in Victoria

Rickard B¹, Hilton G¹, New P³, Olver J²

¹Austin Health, Royal Talbot Rehabilitation Centre, Spinal Rehabilitation Facility, Kew, VIC, Australia

²University of Melbourne, Department of Psychiatry, Austin Hospital, Heidelberg, VIC, Australia

³Alfred Health, Caulfield Rehabilitation Centre, Spinal Unit, Caulfield, VIC, Australia

Background and Aims: A 2007 review of Victorian spinal cord injury (SCI) services found that these “lacked a strong, consistent focus on community reintegration outcomes for SCI people and their families . . . the system lacked an effective transitional rehabilitation program and appropriate vocational services” (Leggat, S, 2007, Latrobe Uni p.3). An inter-disciplinary team was formed with funding from the Transport Accident Commission (TAC) and Department of Health (DH) to pilot a model of care known as the Spinal Community Integration Service (SCIS) to address the main life areas for individuals with SCI—these being, physical, psychological, vocational, social functioning and economic independence. A single standard model of care for compensable, non-compensable, traumatic and non-traumatic SCI clients has been developed, piloted and is undergoing evaluation.

Methods: This research of pre and post study design compares SCI patients receiving standard care with those involved in a pilot program providing targeted community integration intervention. The study recruited a retrospective control group of SCI patients who underwent inpatient rehabilitation prior to the SCIS pilot and a prospective group case managed by SCIS.

Results: There were clinically significant changes in self-perception of occupational performance in 61% of SCIS participants in the 6 months following discharge from inpatient rehabilitation. Vocational outcomes within the SCIS participants showed an increase in return to study and a decrease in the unemployment in comparison to the control group. Independent sample t-testing was used for the majority of comparisons between groups at six and twelve months following discharge from inpatient rehabilitation. There were no statistically significant differences between groups on measures of anxiety, depression and quality of life.

Conclusions: The current results are an interim assessment as data collection is not yet complete. The early outcomes for vocational and occupational performance are trending positively. It is too early to draw conclusions regarding basic psychological wellbeing.

Abstract Id: 403

Connecting and Collaborating: the Future of Spinal Cord Injury Information and Education

Hilton G¹, Fraser R²

¹Austin Health, Royal Talbot Rehabilitation Centre, Spinal Rehabilitation Facility, Kew, VIC, Australia

²Transport Accident Commission, 60 Brougham Street, Geelong, VIC, Australia

Background and Aims: In early 2010, a collaborative group was formed from across the Victorian health, disability and community sectors to address the lack of targeted information and education available for individuals with spinal cord injury (SCI). One-off funding from the Department of Health Victoria was committed to develop a new SCI educational resource as part of the Victorian Spinal Cord Injury Program. Persons with SCI have a lifelong need for information and education to support effective community integration and social inclusion. The purpose of this project was to design, develop and implement a web-based resource that would help people with SCI:

• to learn about their injury,

• talk to each other,

• connect with their community.

Methods: Mixed method evaluation was used to assess the project against funder guidelines of budget, timeline, design and content. Needs-based assessment was used to determine usefulness of the site through focus groups and user feedback with a particular focus on the navigation and design, and the helpfulness of the content. Objective assessment of the site’s effectiveness in engaging and sustaining interest of website users was conducted through website statistics and analytics.

Results: Early feedback from focus groups has demonstrated that project objectives have been met. One hundred percent of participants indicated information was easy to find and understand, that they would recommend the site to others, that the information was helpful, and that they would use the site again. Results obtained through website analytics, account statistics and further user feedback will also be presented.

Conclusion: SpinalHub has been a unique project that has highlighted the value and strength in cross-sectoral collaboration. SpinalHub has demonstrated the benefits of everyday technology in enabling people to connect with their communities and each other and access SCI information at any time in a way that meets their individual needs.

Abstract Id: 35

Exploring the Experience of Clients with Tetraplegia Involved in Computer Access Interventions During Rehabilitation

Folan A¹, Barclay L¹, Robinson M², Cooper C²

¹Monash University, Melbourne, VIC, Australia

²Austin Health, Melbourne, VIC, Australia

Background: Following a spinal cord injury (SCI), individuals are commonly left with a range of debilitating changes and losses affecting their participation, independence, and quality of life. These losses impact on their ability to participate in life roles such as paid work or leisure activities. Computer access interventions may be used to enable people with a severe physical disability to utilize mainstream computer applications. Examples of computer access interventions are devices or adaptations such as a modified mouse or voice recognition software. Individuals who utilise computers through assistive/adaptive technology may have an enhanced potential for personal and vocational pursuits.

Aim: To explore and gain an understanding of the experiences of clients with tetraplegia participating in computer access interventions during different stages of rehabilitation.

Method: Using purposive sampling seven participants aged over 18 years who have a diagnosis of tetraplegia with significant upper limb impairments were recruited. Inpatients and outpatients of the Victorian Spinal Cord Service were included in the sample. Data was collected using semi-structured interviews. The interviews were recorded and transcribed, and emergent themes derived from these interview transcripts.

Results: This paper will outline the findings identified through the interview process. Four emergent themes were identified: getting back into everyday life, understanding my injury and ability, assisting in adjusting and coping with injury and learning new skills. These themes will be discussed in detail, together with clinical implications.

Conclusions: The results are significant to occupational therapists and other health professionals in understanding service needs of clients with SCI. Implications and recommendations made for best practice in the area of computer access interventions will be discussed.

Abstract Id: 613

Posture and Upper Quarter Pain: Individualized Wheelchair Seating Intervention for Subjects with Thoracic SCI: a Case Series

Prusynski R, Collins E, Stabler A, Bartel H, Hastings J

University of Puget Sound, Tacoma, WA, USA

Background and Aims: Poor posture in people with thoracic spinal cord injury (SCI) leads to upper quarter pain, but little research has linked wheelchair configuration with posture and upper quarter pain. This study aimed to investigate whether specific wheelchair configurations improved posture, measured by seated height, and then apply seating interventions to determine how individualized seating relates to changes in seated height and upper quarter pain.

Methods: A retrospective chart review of 15 wheelchair seating interventions performed on adults with thoracic SCI by a seating expert examined changes in wheelchair seat-to-back angle and subjects’ seated height by measuring photographs pre and post-intervention, and comparing values using paired t-tests. A four-week A-B-A-B case series then applied individualized wheelchair seating interventions for three adult male subjects with thoracic SCI, with the option to return to the original configuration after study completion. Photos from each phase were measured for seated height and values were analyzed for change between phases. Percent body area in pain and VAS scores collected from pain diaries filled out by subjects at each phase were graphed with linear regression lines. Graphs were analyzed for changes in regression slope and level between phases.

Results: The review found a significant decrease in seat-to-back angles (p = 0.001) and increase in seated height (p = 0.003) post-intervention. During the case series, wheelchair configuration interventions varied depending on individual subject needs and subjects showed variable response in pain and height measures between phases. All subjects reported satisfaction with the interventions and none chose to return to their original configurations.

Conclusions: This study reinforced the importance of individualized wheelchair seating for this heterogeneous population, as there is no strong relationship between specific wheelchair configurations and posture or objective measures of upper quarter pain.

Theme: Stroke

Abstract Id: 378

The Use of an Enriched Environment Post Stroke: Translating From Bench to Bedside

Janssen H^1,2,3, Ada L⁴, Bernhardt J⁵, Karayanidis F^1,2, Drysdale K^1,2, McElduff P^1,2, Pollack M^1,3, Nilsson M^1,2, Spratt N^1,2,3

¹University of Newcastle, Newcastle, NSW, Australia

²Hunter Medical Research Institute, Newcastle, NSW, Australia

³Hunter New England Health, Newcastle, NSW, Australia

⁴University of Sydney, Sydney, NSW, Australia

⁵National Stroke Research Institute, Melbourne, VIC, Australia

Background and Aims: Stroke patients spend much time inactive and alone when in rehabilitation. An enriched environment facilitates sensorimotor, cognitive and social activity and has been shown to improve motor and cognitive function in experimental stroke. This is the first study to test the feasibility and effectiveness of enriching a rehabilitation environment for stroke patients.

Methods: Prospective non-randomised block-design intervention study. Direct observation was used to quantify and compare the change in activity levels (physical, cognitive and social) of stroke patients recovering in either a typical rehabilitation environment versus an enriched one. Activity was recorded every 10 minutes over one 12-hour weekday and one weekend day. The rehabilitation environment was enriched by including access to both individual (i.e. music and puzzles) and communal (i.e. interactive gaming, computer and books) activities.

Results: Stroke patients in the enriched environment (n = 15) were 19% (95% CI 3 to 36, p = 0.02) more likely to be engaged in activity compared with those in a typical rehabilitation setting (n = 14). In terms of type of activity, patients in the enriched environment were 67% (95% CI 10 to 152, p = 0.02) more likely to be engaged in cognitive activities and 22% (95% CI 1 to 48, p = 0.04) more likely to be engaged in social activities. They were less likely to be inactive and alone (29%, 95% CI 14 to 41, p < 0.001) or asleep (46%, 95% CI 26 to 60, p < 0.001).

Conclusions: Our simple model of environmental enrichment was feasible and appears to be an effective way of increasing activity in stroke patients and reducing the time spent alone and inactive, without high additional expense. A large randomised trial is warranted to investigate the efficacy of enriching the rehabilitation environment on outcome of stroke survivors, including quality of life.

Abstract Id: 183

Improving Walking After Stroke: the Ambulate Trial

Ada L¹, Dean CM^1,2, Lindley R¹, Vargas J¹

¹The University of Sydney, Sydney, NSW, Australia

²Macquarie University, Sydney, NSW, Australia

Background and Aims: After stroke, many people are unable to walk at a level commensurate with community participation. The main aim of the AMBULATE trial was to determine the effect of a community treadmill walking program in improving community ambulation.

Methods: A prospective randomised controlled trial of unsupported treadmill training with a 12-month follow-up with concealed allocation and blinded assessment was conducted. Community-dwelling people after stroke who were able to walk independently but slowly were randomly allocated to either a 4-month training group, 2-month training group or the control (no intervention) group. Measurements of walking capacity (six-minute walk test) were taken at baseline, 2 months, 4 months, 6 months and 12 months.

Results: 102 people with stroke living in the community were recruited. For both groups that received treadmill intervention, six-minute walk distance improved more than the control group during the intervention phase (p < 0.05). However, at 12 months there was no difference between the groups.

Conclusions: The community-dwelling people with stroke in this study improved their walking capacity during training, providing evidence that walking can be improved with intervention even years after stroke. However, the increase in walking capacity was not maintained when intervention was removed. Therefore, the challenge is to provide community-based opportunities for ongoing walking training. Sustainable long-term access to exercise could reduce the burden of care on family and friends. Development of such services should be a priority as part of the promotion of healthy ageing of people with stroke.

Abstract Id: 219

What are the Long-Term Benefits of Progressive Resistance Training in Chronic Stroke? a 4-Year Follow-Up

Lexell J^1,2, Flansbjer UB^1,2, Brogårdh C^1,2

¹Department of Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden

²Department of Health Sciences, Lund University, Lund, Sweden

Background and Aim: Muscle weakness in the lower limbs is common after stroke. Progressive resistance training (PRT), using free weights or specific strength training equipment with loads of 70% or more of maximum strength, has proven effective to counteract this post-stroke weakness. In a randomized controlled trial (RCT), we showed that knee muscle strength increased significantly after 10 weeks of PRT. The aim of this study was to evaluate the long-term benefits of PRT in chronic stroke.

Method: The study was a 4-year follow-up of the previous RCT of PRT in chronic stroke. Eighteen women and men (mean age 66 ± 4 years) from the original group of 24 post-stroke participants were reassessed four years after the RCT. The training group (TG; n = 11) had participated in supervised PRT of the knee extensors and flexors (80% of maximum) twice weekly for 10 weeks, whereas the control group (CG; n = 7) had continued their usual daily activities. Muscle strength was evaluated isotonically and isokinetically (60°/s; Biodex); muscle tone with the Modified Ashworth Scale; gait performance by the Timed “Up & Go” test, the Fast Gait Speed test and 6-Minute Walk test; and perceived participation with the Stroke Impact Scale (Participation domain).

Results: Four years after the intervention, the improvements in muscle strength in the TG were maintained, and there was no reduction in strength in the CG. Compared to baseline, there were significant between-group differences for both isotonic and isokinetic strength. No significant between-group differences were found for muscle tone, gait performance or perceived participation.

Conclusions: The results indicate that there is a long-term benefit of PRT in chronic stroke. This implies that PRT could be an effective training method to improve and maintain muscle strength in a long-term perspective.

Abstract Id: 211

Responsiveness and Change Over Time in Postural Control Using Clinical Measurements—Postural Stroke Study in Gothenburg (Postgot)

Persson CU, Grimby-Ekman A, Danielsson A, Sunnerhagen KS, Hansson PO

Sahlgrenska Academy, the University of Gothenburg, Göteborg, Sweden

Background and Aims: The objective was to evaluate the responsiveness of the modified version of Postural Assessment Scale for Stroke Patients (SwePASS) and the Timed Up & Go (TUG) from the first week until 3 months after stroke. If acceptable responsiveness, an additional aim was to estimate change in postural control, using SwePASS and TUG, between the first week and 12 months after the stroke.

Methods: SwePASS and TUG were conducted at the first week and at 3, 6 and 12 months after a first event of stroke in 96 patients. Paired t-test was used to estimate responsiveness for the TUG. The progress in mean change in TUG from first week to 12 months after stroke was analyzed using a mixed model approach, a linear regression for repeated measurements. For the SwePASS, E Svensson’s method, estimating Relative Position (RP), Relative Concentration (RC), was used to estimate responsiveness and change over time.

Results: Using SwePASS, 74% of the patients received higher scores while 10% received lower scores, RP 0.31 (95% CI 0.219-0.402), between the first week and 3 months. Corresponding figures for 3 to 6 months and for 6 to 12 months were 37%, 16%, RP 0.09 (95% CI 0.030-0.152) and 18%, 26%, RP -0.07 (95% CI −0.134 to −0.010) respectively. Also, TUG was responsive, with a mean decrease by 5.3 seconds (95% CI 2.95-7.60). In the regression model for TUG, the mean time decreased by 2.4 seconds (p < 0.05) between 3 and 6 months, while no clear trend was seen between 6 and 12 months (mean difference 1.0 seconds, 95% CI −0.59 to 2.58).

Conclusion: SwePASS and TUG are responsive. Both tests show improvement in postural control during the first 6 months after stroke onset.

Figure 1.

Lesion overlap for patients with identification impairments for anger (red), fear (blue), disgust (green), and all-threat emotion (yellow).

Abstract Id: 269

Trajectories of Psychological Distress: a Longitudinal Cohort Study

White J^1,2, Magin P², Attia J², Sturm J², Carter G², McElduff P², Pollack M^1,2

¹Hunter Stroke Service, Hunter New England Local Health District NSW, Australia

²University of Newcastle, NSW, Australia

Background: There has been little exploration of the distinct trajectories of psychological distress after stroke and the factors which predict recovery from distress, as compared to other chronic disease research. The establishment of trajectories may assist neurorehabilitation clinicians by providing insight into disease onset, progression, and resolution and may be a useful way to conceptualize and understand the pattern of psychological morbidity in stroke over time. We undertook a longitudinal qualitative study to explore post-stroke psychological trajectories.

Methods: The primary data collection method was semi-structured interviewing with community-dwelling stroke survivors in metropolitan Newcastle, NSW, Australia. Our sample included 23 participants (12 men, 10 women; age range 37-94 years) discharged from a tertiary referral hospital after a stroke who subsequently participated in a total of 106 interviews, over 12 months. Qualitative outcomes were participants’ perceptions at baseline, 3, 6, 9, and 12 months. Thematic saturation was achieved.

Results: The majority of participants were male (54%) and had a Partial Anterior Circulation Infarction stroke sub-type (57%). Four different longitudinal trajectories were identified: resilience (n = 5), ongoing crisis (n = 5), emergent mood disturbance (n = 3) and recovery from mood disturbance (n = 10). Recovery from mood disturbance was facilitated by gains in independence, self-esteem and by having an internal health locus of control.

Conclusions: Stroke survivors experienced a variety of psychological trajectories. Identifying distinct trajectories of psychological morbidity may help neurorehabilitation clinicians develop appropriately timed interventions to promote better mental health. Interventions require implementation over a longer duration than current outpatient services, which, in Australia, are typically provided in the first few months after stroke.

Abstract Id: 46

Communication and Low Mood (Calm) Study: a Randomised Controlled Trial of Behaviour Therapy for Low Mood in People with Aphasia After Stroke

Lincoln NB, Thomas SA, Walker MF, Macniven J, Howarth H

University of Nottingham, Nottingham, UK

Background and Aims: Low mood is common in people with aphasia. Studies of psychological treatments have excluded people with aphasia. Our study aimed to evaluate behaviour therapy for low mood in stroke patients with aphasia.

Methods: This multicentre trial recruited patients with aphasia from hospital and community settings. Mood was screened using the Stroke Aphasic Depression Questionnaire (SADQ-H10) and Visual Analog Mood Scales sad item (VAMS). Patients with low mood were randomly allocated to receive up to three months of behaviour therapy from an assistant psychologist, or usual care. Blind outcome assessments of mood (SADQH-21, VAMS), self-esteem (Visual Analogue Self-Esteem Scale; VASES) and leisure activities (Nottingham Leisure Questionnaire; NLQ) were completed three and six months after randomisation.

Results: One hundred and five patients were randomised (66 men, mean age 67 years) at a median of 9 months post-stroke. Groups were comparable at baseline. Results were analysed using hierarchical linear regression controlling for baseline values of each outcome variable and severity of language impairment. At three months, allocation to behaviour therapy was a significant predictor of VAMS sad (beta = −0.224, p = 0.033) and VASES (beta = 0.264, p = 0.004) scores. Group allocation was not a significant predictor of scores on the SADQH-21 (p = 0.052) or NLQ (p = 0.275). At 6 months, group allocation was a significant predictor of the SADQH-21 (beta = −2.23, p = 0.045) but there was no significant effect of group allocation on VAMS sad, VASES or NLQ.

Conclusions: This multicentre trial of a psychological intervention for patients with aphasia showed that behaviour therapy improved mood in aphasic patients. Results will inform futures studies, which should recruit a larger sample size.

Abstract Id: 169

A Consensus on Stroke Early Supported Discharge

Fisher R¹, Gaynor C², Kerr M¹, Langhorne P³, Anderson C⁴, Bautz-Holter E⁵, Indredavik B⁶, Mayo N⁷, Power M⁸, Rodgers H⁹, Morten Rønning O¹⁰, Widén Holmqvist L¹¹, Wolfe C¹², Walker MF¹

¹Division of Rehabilitation and Ageing, Community Health Sciences, University of Nottingham, UK

²Nottingham University Hospitals NHS Trust, UK

³Division of Cardiovascular and Medical Sciences, University of Glasgow, UK

⁴The George Institute for International Health, Royal Prince Alfred Hospital and University of Sydney, Australia

⁵Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Ulleval and University of Oslo, Norway

⁶St Olavs Hospital, Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway

⁷Division of Clinical Epidemiology, McGill University, Health Center, Montreal, Canada

⁸Queen’s University Belfast and the Stroke Unit, Ulster Hospital, UK

⁹Institute for Ageing and Health, Newcastle University, UK

¹⁰Department of Neurology, Akershus University Hospital, Norway

¹¹Division of Physiotherapy and Division of Neurology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden

¹²Division of Health and Social Care, Kings College London and Guy’s and St Thomas’ NHS Trust, UK

Background and Aim: Research evidence supporting Early Supported Discharge (ESD) services has been summarised in a Cochrane Systematic Review. Trials have shown that ESD can reduce long-term dependency and admission to institutional care and reduce the length of hospital stay. No adverse impact on the mood or well-being of patients or carers has been reported. With the implementation of many national and international stroke initiatives, we felt it timely to reach consensus about ESD amongst trialists who contributed to the review.

Method: We used a modified Delphi approach with 10 ESD trialists. An agreed list of statements about ESD was generated from the Cochrane review and three rounds of consultation completed. ESD trialists rated statements regarding team composition, model of team working, intervention and success.

Results: Consensus of opinion (>75% agreement) was obtained on 47 of the 56 statements. Multidisciplinary, specialist stroke ESD teams should plan and coordinate both discharge from hospital and provide rehabilitation in the community. Specific eligibility criteria (safety, practicality, medical stability, disability) need to be followed to ensure this service is provided for mild to moderate stroke patients who can benefit from ESD. Length of stay in hospital, patient and carer outcome measures and cost, need to be routinely audited.

Conclusion: We have created a consensus document that can be used by commissioners and service providers in implementing ESD services. Our aim is to promote the use of recommendations derived from research findings to facilitate successful implementation of stroke services nationally and internationally.

Abstract Id: 29

Driving After a Neurologic Condition

Akinwuntan AE

Georgia Health Sciences University, Augusta, GA, USA

Background and Aims: Driving is a complex but very important activity of daily living that is frequently impacted by the sequelae of neurological conditions such as stroke, multiple sclerosis (MS), and Parkinson’s disease (PD). Predictors of driving after these neurologic conditions have been identified in several studies. In three different studies, we investigated the effect of rehabilitating driving-related skills that are affected after three neurologic conditions.

Methods: In the first study, 83 first-ever stroke survivors were randomly allocated to either a simulator-based driving or a cognitive training group. All participants received 15 hours of training (1 hr/session × 3 sessions/week × 5 weeks) in addition to regular therapy at a rehabilitation facility. In the second study, 40 individuals with MS received 5 hours of simulator training (1 hr/session × 5 weeks). In the third study, 15 individuals with PD received 10 hours of simulator training (1 hr/session × 10 weeks). In all three studies, participants’ performances in an on-road, visual, and cognitive tests were evaluated before and after training.

Results: In the first study, both groups improved in the on-road test, a visual test, and several cognitive tests immediately after training. Significantly (p = 0.03) more participants in the simulator (73%) compared to the cognitive group (42%) passed an official on-road driving evaluation administered three months after training. In the second study, participants showed improvements in many cognitive tests. No improvements were observed in the third study. In the second and third studies, all participants who passed the on-road test pre-training remained good drivers post-training while those who failed showed clinically but not statistically significant improvements post-training.

Conclusion: Drivers who have experienced a neurologic event, especially stroke survivors, appear to benefit from simulator-based rehabilitation of impaired driving related-skills. More studies are needed to further confirm if the same is true for drivers with MS and PD.

Abstract Id: 154

Constraint-Induced Movement Therapy for the Upper Paretic Limb Early Post Stroke: a Systematic Review

Nijland R¹, van Wegen E¹, Kwakkel G^1,2

¹Dept Rehabilitation Medicine, Research Institute MOVE, VU University Medical Center, Amsterdam, the Netherlands

²Dept Rehabilitation Medicine, Rudolf Magnus Institute of Neuroscience, University Medical Centre, Utrecht, The Netherlands

Background and Aims: Constraint-induced movement therapy (CIMT) is a commonly used intervention to improve upper limb function after stroke. The effectiveness of CIMT and its optimal dosage during acute or subacute stroke is still under debate, however. The aim of the present study was to examine the literature on the effects of CIMT in acute or subacute stroke.

Methods: A literature search was performed to identify randomized, controlled trials (RCTs). Studies with the same outcome measure were pooled by calculating the mean difference (MD). Separate quantitative analyses for high intensity (HI) and low intensity (LO) CIMT were applied when possible.

Results: Five RCTs were included, comprising 106 participants. The meta-analysis demonstrated significant MDs in favor of CIMT for the Fugl-Meyer arm, the Motor Activity Log, Quality of Movement, and the Grooved Pegboard Test. Non-significant MDs in favor of CIMT were found for the Action Research Arm Test and the Motor Activity Log, Amount of Use. Separate analyses for HI and LO CIMT resulted in significant favorable MDs for LO CIMT for all outcome measures, in contrast to HI CIMT.

Conclusions: This meta-analysis demonstrates a trend towards positive effects of CIMT in acute or subacute stroke, but also suggests that LO CIMT may be more beneficial during this period than HI CIMT. These finding are in line with several animal studies, which have found that intensive practice of the affected limb in rats is detrimental if it occurs too soon after the infarction, when cells in the penumbral tissue are presumably still vulnerable. On the other hand, other studies have indicated that a critical period of heightened neuroplasticity may exist in the first few weeks post stroke by an upregulation of growth promoting factors during the process of spontaneous neurological recovery.

Abstract Id: 618

Brain Plasticity and Motor Function in Stroke Patients: an Interventional Study Applying a New Test Paradigm and Repeated fMRI

Bergfeldt U

Department of Rehabilitation Medicine, Danderyd University Hospital

Background and Aims: Functional improvement after focal spasticity therapy is often accompanied by positive “side effects” with regard to social and cognitive function suggesting central effects. Brain activity was therefore followed during therapy with repeated fMRI and compared with healthy controls.

Methods: Six first-time stroke patients (4 women) with right-sided hand paresis and spasticity were studied. Peripheral effects after focal spasticity management including intramuscular BoNT injections were assessed on 3 occasions (baseline, 6 and 12 weeks) with functional tests. Brain effects were assessed in parallel by fMRI BOLD technique during a standardized motor task. For comparison 10 healthy individuals (5 women) were studied twice with ≥6 weeks interval.

Results: There was a significant reduction in spasticity and functional improvement in 5 patients. In response to the motor task there was on all occasions a ~1.5-3% increase in BOLD activity in the motor and pre-motor cortex (BA4a, BA4p & BA6). At baseline, this increase was larger in the right (non-injured) than in the left hemisphere. Compared with controls the patients showed a significantly (2-4.5 times) higher brain activity. After therapy, there was a minor decrease in the left-sided and a larger decrease in the right-sided response, leading to a clear lateralization of left-to-right >1 (i.e., in a normalizing direction) in all areas.

Conclusions: Comprehensive focal spasticity management was associated with brain reorganization in a “normalizing” direction in addition to an improved motor function. Reduced neuronal “over-activity” in the injured brain after therapy might explain some of the observed “positive side-effects.”

Abstract Id: 449

Accessing Inpatient Rehabilitation After Severe Stroke: Age, Mobility, Pre-Stroke Function and Acute Hospital Unit are Associated with Discharge to Rehabilitation

Hakkennes S^1,2, Hill K^3,4,5, Brock K⁶, Bernhardt J^1,7, Churilov L^7,8

¹Faculty of Health Sciences, La Trobe University, Bundoora, Victoria, Australia

²Barwon Health, Geelong, Victoria, Australia

³School of Physiotherapy, Curtin University, Perth, Australia

⁴Division of Allied Health, Northern Health, Epping, Victoria, Australia

⁵Preventive and Public Health Division, National Ageing Research Institute, Parkville, Victoria, Australia

⁶St Vincent’s Hospital, Fitzroy, Victoria, Australia

⁷National Stroke Research Institute, Florey Neuroscience Institutes, Heidelberg, Victoria, Australia

⁸Department of Mathematics and Statistics, The University of Melbourne, Victoria, Australia

Background and Aims: There are no published studies that have identified variables associated with discharge to rehabilitation after severe stroke, a group for which there is significant variation in practice with regards to access. This study aimed to identify variables associated with acceptance for inpatient rehabilitation after severe stroke and to determine if hospital unit contributed to acceptance.

Methods: Five acute hospitals in Victoria, Australia participated in this study. Patients were eligible for inclusion if they had suffered an acute severe stroke (Mobility Scale for Acute Stroke score ≤15) and survived acute hospital admission. Physiotherapists assessed patients on day three post stroke collecting demographic information and information relating to the patient’s pre-morbid status, social status and current status. Step-wise logistic-regression modeling was used to examine the association between age, type of stroke, pre-stroke living situation, co-morbidities, availability of carer on discharge, current mobility, bladder continence, bowel continence, cognition and communication and the dependent variable, discharge destination (rehabilitation/other). The resulting model was analysed using hierarchical logistic regression with hospital site as the clustering variable. Of the 108 patients meeting the inclusion criteria, 70 (64.8%) were discharged to rehabilitation. The average age of included patients was 74.9 years (SD = 10.9) and 53 (49.1%) were male.

Results: The variables independently associated with discharge to rehabilitation were younger age (odds ratio [OR] = 0.89, 95% CI = 0.83-0.95, p = 0.001), independent pre-morbid functional status (OR = 14.92, 95% CI = 2.43-91.60, p = 0.004), and higher level of current mobility (OR = 1.31, 95% CI = 1.02-1.66, p < 0.03). The multilevel model estimated that 12% of total variability in discharge destination was explained by differences between the hospital units (rho = 0.12, 95% CI = 0.02-0.55, p = 0.048).

Conclusions: Variables associated with admission to rehabilitation after severe stroke are younger age, independent pre-morbid functional status and higher level of current mobility. In addition, organisational factors play a role in selection for rehabilitation, suggesting inequity in access for this patient group.

Abstract Id: 98

What Is Preferable: Treadmill or Walking Outdoors in Order to Improve Walking Ability After Stroke?

Langhammer B^1,2, Stanghelle JK^2,3

¹Faculty of Health, Oslo and Akershus University College

²Sunnaas Rehabilitation Hospital

³Faculty of Medicine, University of Oslo

Introduction: The main aim of the study was to evaluate treadmill training versus walking outdoors.

Methods: A total of 39 persons with stroke were included in this randomized controlled trial; five persons dropped out. The treadmill exercises and the walking outdoors groups were planned to do a maximum 30 minutes exercise 5 days a week, in addition to other therapies and activities as long as they stayed at the center.

Results: The included participants were active in their respective programs and compliance to the program was 100%. Time after stroke was 480 days in the treadmill group and 300 days in the outdoor walking group. There were no baseline differences between the groups and length of stay was approximately 2.5 weeks in each group. Both groups did exercised equally frequent, but the amount of time exercising on the treadmill was significantly less than time spent doing walking exercise outdoors (107 versus 316 minutes, p = 0.002). There was a significant difference between the groups on walking speed (6MWT, p = 0.01, 10 m, p = 0.009), distance (6MWT, p = 0.01) and step length (right leg, p = 0.09; left leg, p = 0.07) in favor of the treadmill group at follow-up. Step length on the left leg improved to a higher degree in the treadmill group than in the walking outdoor group indicating a more symmetrical use of the legs in the treadmill group (1.02 to 1.10 versus 0.97 to 0.96). There were no differences in step width, cadence, and use of assistive devices between the groups.

Conclusions: The main results of this study are threefold. First, the treadmill group gained increase in walking speed and distance, equally long and longer step length bilaterally in less time than the outdoor walking class supports the notion exercises on a treadmill walking is an effective and important tool in rehabilitation. Secondly, the fact that exercises on a treadmill transfers over in to improved walking on flat surface makes this type of exercise an excellent tool in regions of the world where the climate often hinders outdoor activities. Thirdly, our patients were well past the acute period of time after stroke with a mean of approximately 480 and 300 days post stroke, mainly first time strokes with moderate deficits in motor function. The fact that both treadmill and walking outdoors did improve in functional activities supports the importance of “booster doses” of rehabilitation in order to maintain physical function levels.

Abstract Id: 188

Transcranial Direct Current Stimulation (TDCS) for Improving Upper Limb (UL) and Lower Limb (LL) Motor Function After Stroke: a Systematic Cochrane Review

Elsner B^1,3, Mehrholz J^2,3,4

¹Neuromuskuläres Therapiezentrum Dresden, Dresden, Sachsen, Germany

²Wissenschaftliches Institut, private europäische medizinische Akademie der Klinik Bavaria in Kreischa GmbH, Kreischa, Sachsen, Germany

³SRH Hochschule für Gesundheit Gera gGmbH, Gera, Thüringen, Germany

⁴Medizinische Fakultät der Technischen Universität Dresden, Dresden, Sachsen, Germany

Background and Aims: Transcranial direct current stimulation (TDCS) is seen as a present non-invasive approach to alter brain excitability. Recent studies suggest that TDCS might improve upper and lower limb (UL and LL) function after stroke. However, until now it lacks on a systematic review of the effectiveness of this promising intervention.

Methods: In our review, we included only randomised controlled trials (RCTs), which investigated TDCS either with conventional motor rehabilitation or no intervention versus sham-TDCS and/or conventional motor rehabilitation or no intervention in people with stroke according to the criteria of the World Health Organization (WHO). We searched the following databases: The Cochrane Stroke Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, latest issue), MEDLINE (from 1948), EMBASE (from 1980), CINAHL (from 1982), AMED (from 1985), Science Citation Index (from 1899), the Physiotherapy Evidence Database (PEDro, http://www.pedro.org.au/), Rehabdata (from 1956), and the Engineering databases Compendex and Inspec (from 1969). Two review authors used the PEDro-Scale in order to assess the methodological quality of the included trials independently. We quantified heterogeneity across the included studies by using I² statistics. For all statistic comparisons, we used the current version of the Cochrane Review Manager Software, RevMan 5.1.

Results: We included 8 RCTs in our analysis. The methodological quality of the included trials was good (median 6 out of 10 points PEDRO). We found 7 studies investigating UL and 2 studies investigating LL motor improvement. TDCS increased the chance to improve arm function, especially in not severely affected patients. We could not, however, estimate a pooled effect for the lower limb due to small sample size. The effect of TDCS on LL motor function remains therefore unclear. At least a more detailed review will be published and updated in the Cochrane Database of Systematic Reviews.

Conclusion: TDCS might facilitate motor learning of the UL, at least for some patients groups after stroke. However, it is still unclear which frequency, intensity and which kind of stimulation and in which combination TDCS should be used in practice; further research therefore seems to be needed.

Abstract Id: 60

Effects of Cardiovascular Exercise Early After Stroke: Systematic Review and Meta-Analysis

Stoller OA^1,2, de Bruin ED³, Knols RH⁴, Hunt KJ¹

¹Institute for Rehabilitation and Performance Technology, Bern University of Applied Sciences, Burgdorf, Switzerland

²Department of Epidemiology, Maastricht University and Caphri Research School, Maastricht, Netherlands

³Institute of Human Movement Sciences and Sport, ETH Zurich, Switzerland

⁴Department of Rheumatology and Institute of Physical Medicine, University Hospital Zurich, Zurich, Switzerland

Background: Previous studies have shown the beneficial effects of aerobic exercise in chronic stroke. Given the fact that most motor and functional recovery occurs in the first 3 months after stroke, there could be a hitherto neglected potential to precipitate motor recovery by improving cardiovascular capacity during acute stroke rehabilitation. However, less is known about the effects of early cardiovascular exercise in stroke survivors. The aim of this review was to evaluate the effectiveness of aerobic exercise early after stroke.

Methods: A systematic literature search was performed. For this review, only randomised controlled trials using a cardiovascular, cardiopulmonary or aerobic training intervention starting within six-month post stroke were considered. The PEDro scale was used to detect risk of bias in individual studies. Meta-analysis was performed using random-effects model.

Results: A total of 11 trials were identified for inclusion. Interrater agreement was considered to be “very good” (kappa: 0.81, standard error: 0.06, 95% CI: 0.70-0.92), and the methodological quality was “good” (7 studies) to “fair” (4 studies). Peak-oxygen uptake data were available for 168 subjects. Pooled analysis showed homogeneous effects favouring the intervention group (standardised effects size [SES] = 0.78, 95% CI = 0.47-1.10, Z = 4.86, P < 0.01). Moreover, walking endurance assessed with the 6-Minutes-Walk-Test included 278 subjects. Pooled analysis revealed homogeneous effects favouring the cardiovascular training intervention group (SES = 0.69, 95% CI = 0.45-0.94, Z = 5.58, P < 0.01). Gait speed, measured in 243 subjects, did not show significant results (SES = 0.51, 95% CI = −0.25 to 1.26, Z = 1.31, P = 0.19) in favour of early cardiovascular exercise.

Conclusion: There is good evidence that aerobic exercise is beneficial for improving peak-oxygen uptake and walking distance in patients with acute stroke. Aerobic exercise should be considered in acute stroke rehabilitation.

Abstract Id: 616

Constraint-Induced Movement Therapy (CIMT) Compared with Intensive Bimanual Training for Hemiplegic Children: What Is More Effective? a Randomized Controlled Trial

Deppe W, Thuemmler K, Fleischer J, Berger C, Meyer S

Neurological Rehabilitation Center for Children and Adolescents Klinik Bavaria, Kreischa, Saxonia, Germany

Background and Aim: Effectiveness of CIMT in children with unilateral cerebral palsy has been proven in several studies. Yet it is unclear whether it is due to the restriction of the non-involved arm or to high therapy intensity. Therefore we have compared the effectiveness of an interdisciplinary CIMT program (kid-CIMT) with an equally intensive bimanual training (IBT) and ask whether restriction is really necessary.

Method:

• Randomized trial

• 47 children, 3.4 to 11.5 years, with central hemiplegia (cerebral palsy or acquired brain injury longer than 2 years ago)

• Randomization into two groups: CIMT or IBT

• CIMT (n = 25): 4 hrs daily therapy over 3 weeks. In week 4, bimanual training of everyday life activities.

• BT (n = 22): 4 hrs daily therapy over 4 weeks with emphasis on bimanual activities

• Primary outcome measures: Melbourne Assessment of Unilateral Upper Limb Function (MA) and Assisting Hand Assessment (AHA)

• Statistical analysis with ANOVA and Pearson’s correlation

Results: For isolated motor functions of the affected arm (MA), we found significant superiority of CIMT over IBT: +6.6 (CI 3.8-9.4) vs. +2.3 (CI 0.3-4.3) percent score pre-post difference (p = 0.033 for group effect). Concerning bimanual everyday life and playing activities (AHA), we could not find a better outcome with CIMT: +6.2 (CI 3.6-8.8) vs. +4.6 (CI 2.9-6.3) (p = 0.58). A negative correlation for the AHA assessment turned out (r = –.50, p < 0.02) regarding impairment severity. Children with more pronounced hand motor dysfunction took more benefit, especially in the CIMT group: + 9.1 (SD = 8.5) vs. + 4.1 (SD = 2.7) (p < 0.05) comparing 50% pat. with lesser than median initial AHA vs. 50% with more than median initial AHA score.

Conclusion: CIMT yields better results than IBT for isolated motor functions, but not for integration of the hemiplegic hand in everyday life and playing activities. These results are in accordance with other recently published studies. Thus restriction is not really necessary for efficient hand-motor training. However, children with more pronounced hand dysfunction might take more benefit from CIMT.

Abstract Id: 371

Wii-Based Movement Therapy Benefits Patients with Very Low Function Post-Stroke

McNulty PA, Shiner CT, Thompson-Butel AG

Neuroscience Research Australia and University of New South Wales, Sydney, NSW, Australia

Background and Aims: Stroke patients with very low function frequently do not meet the inclusion criteria for upper-limb rehabilitation programs. Without therapy the more-affected hand and arm lose any residual functional ability, further increasing disability and reducing independence. This study investigated whether Wii-based movement therapy was suitable and beneficial for stroke patients with very low function.

Methods: 7 males and 6 females (mean age 59, range 22-77 years; and 47 months post-stroke, range 3 months to 21 years) with very low function completed the standard 2-week Wii-based movement therapy protocol with 1 hour of formal therapy on 10 consecutive weekdays augmented by home practice. Functional ability was assessed using the Wolf Motor Function Test (WMFT), upper-limb motor subscale of the Fugl-Meyer Assessment (FMA), Motor Activity Log (MAL), Berg Balance Scale, Box and Block Test of gross dexterity, and passive and active joint range-of-motion. Data are presented as mean ± SEM.

Results: The WMFT timed-tasks improved from 1491 ± 74.5 s pre-therapy to 1419 ± 89.0 s post-therapy (p = 0.02); FMA scores increased from 16.7 ± 3.9 to 22.2 ± 4.6 (p = 0.001); balance from 37.2 ± 4.1 to 40.4 ± 3.5 points (p = 0.01); and MAL scores from 11.7 ± 4.9 to 28.4 ± 6.4 (p < 0.001). Active and passive range-of-motion increased by 12.2 ± 2.2° and 8.1 ± 1.6°, respectively, but dexterity did not improve. We noted qualitative improvements in concentration and motivation.

Conclusions: With only minor modifications, every patient was able to complete Wii therapy and all benefited from participation. The pattern of improvements was qualitatively and quantitatively different to that of patients with high and moderate function (n = 24). Most low-functioning patients were able to complete half the required home practice, but almost all the ancillary simple tasks of daily living. These results suggest that while patients with high or moderate function after stroke become more functionally independent after Wii-based movement therapy, those with low and very low function become less disabled.

Abstract Id: 213

Impact of Stroke on Health-Related Quality of Life in Diverse Cultures: the Berlin-Ibadan Multicenter International Study

Owolabi MO ^1,2

¹Neurology Unit, Department of Medicine, University College Hospital, Ibadan, Nigeria

²World Federation for WFNR-Blossom Specialist Medical Center

Background and Aims: Various studies have reported discordant profiles of health-related quality of life (HRQOL) after stroke. The aims of this study, the first of its kind, were to determine the real impact of stroke on HRQOL across diverse cultures; and to compare HRQOL between stroke patients and healthy adults, and across stroke severity strata.

Methods: 100 stroke patients and 100 apparently healthy adults (AHAs) in Nigeria; as well as 103 stroke and 50 AHAs in Germany participated. Stroke severity was measured using the National Institute of Health Stroke Scale, Stroke Levity Scale and modified Rankin scale. HRQOL was evaluated using the HRQOL In Stroke Patients (HRQOLISP) measure, a holistic multiculturally validated measure with seven therapeutically relevant domains distributed into two spheres.

Results: Domains within the spiritual sphere were considered more important by stroke patients. In both countries, stroke patients significantly (0.00001 < p < 0.004) had worse HRQOL than AHAs in all domains within the physical sphere. This was not so for the spiritual sphere. Consistently, stroke severity correlated significantly with all domains in the physical sphere unlike the spiritual sphere. In diverse cultures, the correlation coefficients between HRQOL and all indices of stroke severity revealed a decremental trend from the physical domain (rho = 0.77, p < 0.00001) to the spiritual domain (rho = 0.01, p = 0.893).

Conclusions: Consistently, stroke elicited a decremental response across domains, with domains in the spiritual sphere being relatively stroke-resilient. The potential utility of the relatively preserved spiritual sphere in facilitating stroke rehabilitation requires evaluation in diverse cultures.

Abstract Id: 300

The Act Now Study: a Randomised Controlled Trial of Speech and Language Therapy Early After Stroke

Bowen A¹, on behalf of the ACT NoW Investigators

¹University of Manchester MAHSC, Manchester, England, UK

Background and Aims: Although the research evidence for the rehabilitation of post-stroke aphasia and dysarthria is unclear there is consensus for early and intensive intervention by a speech and language (SL) therapist. We aimed to assess the effectiveness of early, enhanced SL therapy compared with attention control.

Method: The study used an externally randomised, multi-centre controlled trial with blinded primary outcome assessment using the Therapy Outcome Measure (TOM). Participants were 170 adults (mean age 70) within two weeks of hospital admission. This sample size gave 80% power at the 5% significance level to detect a 0.5 point difference, allowing for 10% attrition. The primary analysis used regression methods to estimate group differences in outcomes after adjustment for the intended stratification criteria, using the intention-to-treat approach. Secondary outcomes, subgroup and sensitivity analyses were pre-planned. The control group received similarly resourced attention, but from employed visitors not therapists.

Results: Both groups improved on the TOM. The estimated six months group difference (95% CI) was 0.25 (−0.19 to 0.69) favouring SL Therapy but with a confidence interval that included zero. There was no evidence of added benefit of therapy on any secondary outcome measure, serious adverse events, subgroup or sensitivity analyses.

Conclusions: The findings exclude the possibility of a clinically significant difference. There was no evidence of added benefit of early SL therapy beyond that from attention control. Interpretation was enriched by a nested qualitative study’s findings that early, frequent contact (from therapist or visitor) was highly valued, had good uptake and had positive impacts on confidence and mood. These studies support reorganising early SL Therapy services using skill mix and timing within a stepped care model, ideally within a trial.

Abstract Id: 506

Evaluation of Compliance to the Clinical Guidelines for Stroke Rehabilitation and Recovery in Western Australian Stroke Services Using an Early Supported Discharge Program

Bishop M

Rehabilitation in the Home, South Metropolitan Area Health Service, WA, Australia

Background and Objectives: To compare current stroke practice in an early supported discharge (ESD) service to best practice outlined in the 2010 clinical guidelines for Stroke Rehabilitation and Recovery. To determine if key characteristics deemed effective from the guidelines were. ESD enables accelerated discharge of stroke patients however with this comes a responsibility of ensuring the continuity and consistency of care across service transitions.

Method: Data were collected from the ESD teams and referring hospitals medical files and compared to the guidelines. Three sites comprising the South Metropolitan Area Health Service (SMAHS) early supported discharge team took part in the audit. In 6 months the service sees a total of 200 stoke patients for stroke rehabilitation and 50 were randomly selected for the audit.

Results: To date, 20% of the data have been collected with final data available in the next few months. Numerous areas pertaining to the management of stroke consequences have not been met and the possible reasons and implications of these will be discussed. 70% of patients were admitted to the ESD service from a stroke unit whilst the remainders came from general wards. Of interest, 80% patients did not receive education acutely this is consistent with findings of the national stroke foundation acute audit. Only 40% remained without education on conclusion of ESD intervention. Patients screened automatically for bladder and bowel dysfunction, nutritional status and provided standardly with information on driving received best practice care 100% of the time. In general, it would appear better organization and use of standardized processes is associated with better provision of best practice.

Conclusion: The final results on the audit will inform health practitioners where best-practice, cost-effective, and time-efficient services are being applied in ESD stroke care and identify areas where further development of strategies to adopt best practice principles is required.

Abstract Id: 51

Cost-Effectiveness of an Adjustment Group for People with Multiple Sclerosis and Low Mood: a Randomised Controlled Trial

Lincoln NB¹, Drummond AER¹, Constantinescu, C¹, Armstrong S¹, Humphreys I², Phillips C²

¹School of Community Health Sciences, University of Nottingham, Nottingham, UK

²School of Human and Health Sciences, Swansea University, Swansea, UK

Background and Aims: Mood problems affect many people with multiple sclerosis. The aim of the study was to evaluate the cost effectiveness of a group treatment based on cognitive behavioural principles for people with multiple sclerosis (MS) and low mood.

Methods: People with MS were screened on the General Health Questionnaire 12 (GHQ-12) and Hospital Anxiety and Depression Scale (HAD). Those identified with low mood were invited to take part in a randomised controlled trial comparing the effect of attending an adjustment group with a waiting list control. Patients allocated to the adjustment group received six 2-hour group treatment sessions in 12 weeks. Outcomes were assessed 4 and 8 months after randomisation, blind to group allocation.

Results: Of the 311 patients identified, 221 (71%) met the criteria for low mood and 151 (68%) agreed to take part. Hierarchical regression analyses were conducted to compare the two groups, correcting for baseline mood and disability. At four months, group allocation alone was a significant predictor of the primary outcome measure, the GHQ-12. At eight months, group allocation alone was no longer a significant predictor for GHQ-12 scores but was when baseline GHQ-12 and Guys Neurological Disability Scale scores were controlled for. Cost data also showed the groups were cost effective. There was a decrease in the intervention groups total costs compared with an increase in the control group costs, which was statistically significant (p = 0.033, 95% confidence levels −931.995 to −53.616).

Conclusions: Patients receiving treatment were less distressed and had less depression and anxiety. Group treatment led to a reduction in costs of £493 per patient. This group intervention would be cost effective to implement in clinical practice.

Theme: Traumatic Brain Injury

Abstract Id: 467

Predictors of Post-Concussive Symptoms Three Months Following Mild Traumatic Brain Injury

Ponsford J^1,2,4, Cameron P^1,3,4, Fitzgerald M^1,3,4, Grant M^1,2,4, Mikocka-Walus A^1,2,4, Schönberger M^1,2

¹Monash University, Melbourne, VIC, Australia

²Monash-Epworth Rehabilitation Research Centre, Epworth Hospital, Melbourne, VIC, Australia

³Alfred Hospital, Melbourne, VIC, Australia

⁴National Trauma Research Institute, Melbourne, VIC, Australia

Background and Aims: There is continuing controversy regarding predictors of poor outcome following mild traumatic brain injury (mTBI). This study aimed to prospectively examine the influence of pre-injury demographic, physical and mental health factors, injury severity, cognitive impairments, pain, post-traumatic stress and litigation on outcome following mTBI.

Methods: Participants were 123 patients with mTBI and 100 trauma patient controls recruited and assessed in the Emergency Department and followed up one week and three months post-injury. Outcome was measured in terms of reported post-concussional symptoms. Measures included the ImPACT Post-Concussional Symptom Scale and cognitive concussion battery, pre- and post-injury SF-36 and MINI Psychiatric status ratings, Functional Assessment Scale, VAS Pain Inventory, Hospital Anxiety and Depression Scale, PTSD Checklist–Specific and Revised Social Readjustment Scale.

Results: Post-concussional symptoms persisting one week post-injury were predicted by presence of mTBI, being female and premorbid psychiatric history, with elevated HADS anxiety a concurrent indicator. At three months, pre-injury physical or psychiatric problems but not mTBI most strongly predicted continuing symptoms, with concurrent indicators including HADS anxiety, PTSD symptoms, other life stressors and pain. The predictors of PCS differed between the mTBI and trauma control groups at three months with PTSD symptoms and other life stressors most significant for the controls, but presence of anxiety on the HADS and older age showing a stronger association for mTBI participants. Cognitive measures were not predictive of PCS at one week or three months.

Conclusions: Given the evident influence of both pre-morbid and concurrent psychiatric problems, especially anxiety, on post-injury symptoms, managing the anxiety response in vulnerable individuals with mTBI may be important to minimize ongoing sequelae.

Abstract Id: 123

Effect of Comt Val/Met Genotype on Attention and Response to Methylphendiate Following Traumatic Brain Injury

Willmott C^1,2, Ponsford J^1,2,3, McAllister T⁴, Burke, R⁵

¹School of Psychology & Psychiatry, Monash University, VIC, Australia

²Monash-Epworth Rehabilitation Research Centre, VIC, Australia

³National Trauma Research Institute, VIC, Australia

⁴Dartmouth Medical School, Lebanon, NH, USA

⁵School of Biological Sciences, Monash University, VIC, Australia

Background and Aims: The present study aimed to investigate whether catechol-O-methyltransferase (COMT Val158Met) allele status was associated with i) attentional performance and ii) response to methylphenidate (MP), following traumatic brain injury (TBI).

Methods: 40 healthy controls and 32 moderate-severe TBI patients (Mean time post-injury = 68 days) participated in an initial baseline cognitive assessment. The TBI cohort then participated in a randomised, crossover, double blind, placebo-controlled 2-week MP trial. MP was administered at a dose of 0.3 mg/kg bd.

Results: TBI genotype distribution: val/val n = 11; val/met n = 14; met/met n = 7. There were no significant differences across genotypes with regard to demographics or injury severity (p > .05 for all). There were no significant differences across genotypes on baseline attentional measures, but there was an overall trend for the met/met group to demonstrate faster performance. When compared with healthy controls, the val/val group performed significantly more poorly on nearly all measures. The met/met group performed more poorly than controls on measures of speed, but not on tasks requiring strategic control of attention. MP resulted in significantly faster speed of information processing across a range of measures. Repeated measures mixed ANOVAs found only one significant drug × genotype interaction: (F_(2,29) = 4.257, p = .024) the met/met group demonstrated a greater response to MP on the Symbol Digit Modalities Test.

Conclusions: COMT allele status was not strongly associated with attentional performance or response to MP in the TBI sample. There was some suggestion that the met/met group, whilst slow, had relatively preserved strategic control of attention.

Abstract Id: 551

Accuracy and Speed of Processing Facial Expression After Severe Traumatic Brain Injury

Douglas J¹, Vassallo S², White E¹

¹Department of Communication sciences, La Trobe University, VIC, Australia

²Department of Clinical Vision Sciences, La Trobe University, VIC, Australia

Background and Aim: The ability to perceive the human face and interpret its emotional context is central to social interaction. People with TBI consistently perform more poorly than controls on tasks requiring interpretation of facial expression. Determination of the emotional significance of facial expressions is dependent not only on the accuracy but also the efficiency of processing. In this study, our aim was to compare the accuracy and the time taken by adults with TBI to determine the emotional significance of facial expressions with neurologically normal matched controls. We hypothesised that adults with TBI would make significantly more errors and take significantly more time when processing facial expressions.

Method: Participants were 13 males with severe TBI (posttraumatic amnesia >14 days) and 13 male controls matched for age and education. All participants were required to have no less than 6/12 vision (corrected or uncorrected). Stimuli were 18 pictures of facial expressions depicting the six basic emotions. The Tobii 1750 binocular infrared eye tracker (Tobii Technology, Stockholm, Sweden) recorded eye movements and response latency as participants viewed facial expressions.

Results: Overall, accuracy of the TBI group (mean 11.4) was significantly less than the accuracy of the control group (mean 15; p < .05). In addition, response latency for the TBI group (mean 8.7 secs) was significantly longer than the control group (mean 2.1 secs; p < .01). Mean latency between the groups differed significantly, regardless of accuracy.

Conclusion: These results indicate that adults with TBI are not only significantly less accurate but take up to 4 times longer than neurologically normal controls to process facial expressions. Given that facial expressions generally remain unchanged for less than 4 secs during day-to-day interaction, it is clear that accuracy rates alone overestimate the functional ability of people with TBI to interpret emotional facial expression during social interactions.

Abstract Id: 494

Rehabilitation of Everyday Memory Problems in a Memory Aids Clinic

Dewar BK¹, Kapur N², Kopelman M¹

¹Kings College London, Institute of Psychiatry, London, UK

²University College, London, UK

Background and Aims: There is growing evidence that compensatory memory aids are effective in the rehabilitation of memory impairment secondary to acquired brain injury. We report the preliminary findings from an outpatient Memory Aids Clinic programme, a structured approach to training the use of memory aids to improve everyday memory functioning.

Methods: Subjects were referred following complaints of everyday memory problems secondary to a variety of neurological conditions. Comparison was made between a treatment group (n = 63) and a waiting list control group (n = 24). The Memory Aids Clinic programme consisted of a baseline session (clinical interview, neuropsychological assessment, and questionnaires), three training sessions over a six-week period and follow-up (including reassessment) after three months. More specifically, treatment attempted to match memory aids to individual memory goals and then train patients in the effective use of the memory aids. After an initial provision of written information, the control group received treatment after an 18-week wait. In this presentation, we report functional goal attainment data as measured by a daily memory diary. Outcomes were also measured with neuropsychological tests, psychosocial measures, rating scales and a problem solving inventory.

Results: In the case of diary-based records of memory lapses, there was a nonsignificant treatment effect after training, and this reached significance at follow-up, three months after training.

Conclusions: Our study provides support for the longer-term benefits of compensatory memory aids within a specialised Memory Aids Clinic, and points to a number of issues which need to be addressed in establishing the effectiveness of external memory aids.

Abstract Id: 478

Linguistic Processing Difficulties in Adult Survivors of Paediatric Traumatic Brain Injury: Age-Of-Acquisition and the N400

Knuepffer C¹, Murdoch B¹, Lloyd D¹, Hinchliffe F², Lewis F¹

¹The University of Queensland, Brisbane, QLD, Australia

²Mater Medical Research Institute, Brisbane, QLD, Australia

Objectives: Given the excellent temporal resolution of ERP recordings and the repeated criticism regarding the limited sensitivity of traditional language tests to reveal the often subtle language deficits associated with paediatric TBI, it is hypothesised that event-related potential (ERP) recordings might aid in identifying linguistic processing deviations between early and late acquired words in former paediatric TBI patients, which might not have been readily detected by behavioural tests.

Methods: ERPs during a picture-word matching task were recorded from Native English speakers, 15 of which were TBI survivors (11 females) aged 30 to 55 years and 15 control participants (11 females) aged 29 to 56 years matched for age, education, gender and handedness. The ERP response of interest was the N400 Mean Amplitude (MA) in response to early (<5 years) versus late acquired words (5 years, one month to 14 years). The N400 was defined as the MA during an interval of 300-500 ms post-target stimulus onset for the average waveforms. Participants in the TBI group were additionally assessed with standardised language tests.

Results: As a group, TBI participants scored within the average range on the behavioural language tests. However, the N400 responses to early- versus late-acquired words deviated from those recorded in the control group. While the control group showed a reduced N400 to early-acquired words compared to late-acquired words, reflecting larger ease of processing, these effects were reduced in the TBI group. Further analysis revealed that the processing of early-acquired words showed a trend towards a disruption in the ease of processing of those words that are typically acquired around the time of injury and immediately after.

Conclusion: The current data provide preliminary support for the hypothesis that ERPs in adult survivors of paediatric TBI can show deviations in language processing that might be too subtle to be revealed by behavioural tests only.

Abstract Id: 181

The Association Between Cognitive Performance and Functional Outcome Following Traumatic Brain Injury: a Longitudinal Multilevel Examination

Spitz G^1,2, Ponsford JL^1,2, Rudzki D³, McGuigan S⁴, Maller JJ⁵

¹School of Psychology and Psychiatry, Monash University, VIC, Australia

²Monash-Epworth Rehabilitation Research Centre, Epworth Hospital, VIC, Australia

³Southern Health, VIC, Australia

⁴Epworth Hospital, VIC, Australia

⁵Monash Alfred Psychiatry Research Centre, Alfred Hospital, VIC, Australia

Background and Aims: Long-lasting impairments in memory, information processing, and executive functions have been found to persist for years following a traumatic brain injury (TBI), while at the same time individuals face challenges reintegrating back into the community and re-entering employment. The current study investigated whether the initial status and trajectory of functional outcome was associated with individuals’ cognitive abilities over the initial year following TBI.

Method: Ninety TBI participants with a mean age of 33 years (SD = 14.1) and 55 healthy controls with a mean age of 29 years (SD = 11) were followed-up at three, six and 12 months post-injury and administered a battery of cognitive tests—assessing information processing, memory, and executive functions—as well as the Mayo-Portland Adaptability Inventory (MPAI) to assess functional outcome. Multilevel modelling was used to model the trajectory of MPAI score over the initial year—both in terms of initial status and slope trajectory.

Results: TBI participants reported significantly greater functional difficulties on the MPAI, and displayed poorer cognitive performance compared to controls. In addition, greater time post-injury (t(54) = −3.4, p < .01), younger age (t(22) = 2.5, p < .05), and fewer days of post-traumatic amnesia (PTA) (t(22) = 3.7, p < .01) were associated with better functional outcomes. However, the addition of measures of information processing (χ²(3) = 152.1, p < .001) and executive functions (χ²(3) = 107.1, p < .001) resulted in better models, compared to the initial model that included only age and PTA, with individuals performing poorly in these cognitive domains likely to experience poorer functional outcomes.

Conclusions: Functional outcomes improved over the initial year following TBI, being influenced both by demographic and cognitive factors. Individuals with better information processing and executive functions reported fewer functional difficulties over the initial year post-injury. These results suggest that cognitive impairment continues to be a source of difficulty for individuals following TBI, a factor that should be detected and dealt with in the acute stage.

Abstract Id: 151

Feasibility of the Nintendo Wii-Fit and Its Effect on Endurance, Gait and Balance in People with an Acquired Brain Injury

McClanachan NJ^1,2, Kuys SS^3,4, Gesch J⁵, Fleming J^2,5

¹Redcliffe Hospital, Redcliffe, QLD, Australia

²School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, QLD, Australia

³Allied Health Research Collaborative, Metro North (Northern) Health Service District, Brisbane, QLD, Australia

⁴School of Physiotherapy and Exercise Science, Griffith University, Gold Coast, QLD, Australia

⁵Princess Alexandra Hospital, Brisbane, QLD, Australia

Background and Aims: A lack of age-appropriate activities during inpatient brain injury rehabilitation contributes to boredom, isolation and a lack of engagement in rehabilitation. The Nintendo-Wii has been successfully marketed as a computer gaming console encouraging participation in activities, social interaction and physical movement, which has been embraced by young people. This project aims to determine if the use of the Nintendo Wii-Fit is feasible, can improve endurance, gait and balance in individuals with brain injury admitted for rehabilitation.

Method: A randomised 8-week crossover trial was conducted with a convenient sample of 21 people following a traumatic brain injury or stroke. Participants completed two four-week blocks of therapy in a randomised order; Wii-Fit in addition to usual therapy and usual therapy alone. Feasibility was measured by examining compliance (number and duration of sessions completed), adverse events and heart rate during sessions. Endurance was measured using a six-minute walk test, spatiotemporal gait parameters using a GAITRite system and balance using the Balance Outcome Measure for Elder Rehabilitation (BOOMER). Within- and between-group analyses were conducted for all measures.

Results: Compliance with the Wii-Fit sessions was high (99%), the majority of sessions reached the target duration (82%), and there were no adverse events. Heart rate was within the recommended intensity for cardiovascular fitness. Following Wii-Fit, six-minute walk distance improved 18 m (95% CI −33 to 69) more compared to usual therapy. Comfortable and fast gait speed improved 0.23 m/s (95% CI −0.08 to 0.54) and 0.04 m/s (95% CI −0.22 to 0.3) more, respectively. BOOMER score improved 2 points (z = −1.46, p = 0.14) more following Wii-Fit.

Conclusions: Wii-Fit is feasible to use in people with an acquired brain injury. Four weeks of Wii-Fit, in addition to usual therapy, appears to improve endurance, gait and balance.

Abstract Id: 236

Coordination of Dynamic Balance During Gait Training in People with Acquired Brain Injury

Clark RA¹, Williams G^1,2, Fini NA³, Moore L², Bryant AL¹

¹Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Melbourne, VIC, Australia

²Epworth Healthcare, Melbourne, VIC, Australia

³Caulfield Hospital, Alfred Health, Melbourne, VIC, Australia

Background and Aims: Retraining gait is a major focus of neurological rehabilitation. Despite a considerable number of studies investigating different approaches to gait retraining, no optimal method has been identified. Mediolateral movement of the centre of mass (COM) during gait is representative of dynamic balance and postural control. The aim of this study was to investigate mediolateral displacement of the COM during seven different, but commonly used gait training methods in people with acquired brain injury (ABI).

Method: Seventeen people who required assistance to walk due to an ABI (11 traumatic brain injury, 5 stroke, 1 multiple sclerosis) were recruited. The participants performed seven gait training methods in a randomized order. These were therapist manual facilitation, use of a gait assistive device, treadmill walking with handrail support, and four variations of body weight support (BWS) treadmill training (BWSTT) with combinations of handrail and/or therapist support. Mediolateral COM movement was analysed in terms of displacement amplitude (overall range of motion), timing (relative to stride time) and stability (steadiness of the movement). Normative values for these measures were acquired from 25 healthy participants walking at a self-selected speed.

Results: BWSTT without any additional support resulted in significantly (p < 0.05) greater amplitude, altered timing and reduced movement stability of the mediolateral COM compared to healthy gait. Allowing handrail support or therapist facilitation reduced this effect, and resulted in treadmill training (±BWS) having lower movement amplitudes when compared to other training methods. Therapist manual facilitation most closely matched healthy gait for timing and stability of COM displacement.

Conclusions: No single method of gait training was superior when the three aspects of COM displacement were analysed. Further investigations are required to determine which aspect of COM displacement is most important to consider when implementing a gait training program.

Abstract Id: 523

Mobility Skills Following Childhood Traumatic Brain Injury

Kissane A^1,2, Eldridge B², Williams G³, Kelly S², Galea M^4,5

¹Murdoch Children’s Research Institute, Melbourne, VIC Australia

²Royal Children’s Hospital, Melbourne, VIC Australia

³Epworth Hospital, Melbourne, VIC Australia

⁴University of Melbourne, Melbourne, VIC Australia

⁵Austin Health, Melbourne, VIC Australia

Background and Aims: Mobility skills including walking, running and jumping are fundamental to the leisure and sporting pursuits of children and adolescents. However, little is known about recovery of these skills after childhood traumatic brain injury (TBI). This study aimed to evaluate the reliability, validity and sensitivity of the High-Level Mobility Assessment Tool (HiMAT) in children and adolescents with traumatic brain injury (TBI) and to compare the mobility of children with TBI to healthy age and gender-matched peers.

Methods: Participants included 52 ambulant children with moderate and severe TBI, aged 6-16 years (mean 12.0 years (SD 3.3)). Inter-rater reliability was evaluated in 17 children by comparing results scored concurrently by three physiotherapists. Retest reliability was evaluated in 12 children by comparing results scored by one physiotherapist at two time-points. Concurrent validity of the HiMAT and the Pediatric Evaluation of Disability Inventory (PEDI) was evaluated by comparing the scores of 52 children with TBI. The sensitivity of the HiMAT and the PEDI was evaluated in 12 children with TBI by comparing results scored at two time-points during the first 12 months post-injury. The mobility skills of 41 children with TBI were compared with those of 41 healthy age and gender-matched children.

Results: Inter-rater reliability (ICC = 0.93) and retest reliability (ICC = 0.98) were excellent. A moderate positive correlation between the HiMAT and the PEDI (r = 0.69) was demonstrated. The HiMAT was more sensitive to change in mobility than the PEDI. HiMAT results demonstrate strong evidence of difference between the mobility skills of children and adolescents with TBI and their peers (p < 0.001).

Conclusions: The HiMAT is a reliable, valid and responsive measure of mobility following childhood TBI. This measure may be used to quantify performance of age-appropriate mobility skills following childhood TBI and inform clinicians of change over time and with physical rehabilitation.

Abstract Id: 144

Grading Research Evidence in Clinical Guidelines for a Complex Therapy Intervention: the Prescription of a Wheelchair or Scooter for People with Traumatic Brain Injury (TBI) or Spinal Cord Injury (SCI)

Lukersmith S

Lifetime Care & Support Authority and EnableNSW, University of Sydney, Lukersmith & Associates, NSW, Australia

Background: The development of quality evidence based clinical guidelines demands rigorous research methodology. The standard methodology is limited when applied to complex therapy interventions. Complex interventions, like the prescription of a wheelchair are by definition influenced by the client’s contextual factors. There is limited quantitative research evidence on wheelchair prescription. Existing hierarchical guideline grading systems do not include qualitative research methodology. If a range of research designs were to be included for a rigorous evidence base the grading system needs to be adapted.

Aim: To develop and use a grading system for recommendations, which recognises the complexity of the intervention and utilizes all relevant sources of research evidence.

Method: The scope of the guideline was established and 44 clinical questions developed by the working party. Systematic search on these questions revealed a research of mixed methodologies, relevant statutory literature and regulations. Various grading systems were considered for adaptation. The NHMRC guideline recommendation-grading matrix (FORM) was chosen and adapted for the development of the recommendations in the Guidelines for the Prescription of Wheelchairs for People With a TBI or SCI.

Results: Five additional grades were adopted: 2 evidence-based grades and 3 grades which recognised different information sources. Each grade had specific criteria. Quantitative and qualitative research, consensus opinions, grey literature and statutory regulations were used in the development of the recommendations.

Conclusion: An existing grading system can be adapted to accommodate the synthesis and grading of research evidence for guideline recommendations on complex interventions. Seventy-six recommendations using 9 grades were developed to provide guidance for therapists on key areas of the prescription of a wheelchair or scooter.

Abstract Id: 162

A Multi-Professional Client-Centred Model for the Use of Compensatory Strategies in Brain Injury Rehabilitation

Boman IL, Bartfai A

Department of Clinical Sciences, Karolinska Institutet, Danderyds Hospital, Stockholm, Sweden

Background: For the majority of patients with acquired brain injury, the use of compensatory strategies is recommended. In clinical practice, rehabilitation professionals routinely provide compensatory strategies and devices, requiring new learning to make the most of the patients’ ability to perform everyday activities. New learning is, however, restricted in a number of different ways by the residual symptoms after brain injury. Although the importance of learning is undisputed, most therapists lack formal training in teaching techniques and rely to great extent on their own and their peers’ clinical experience. Despite the fact that patient learning is a basic element of rehabilitation practices, systematic research on this topic has been scarce.

Aim: To present a client-centred model based on multi-professional methodology to enable the successful implementation of compensatory strategies and devices.

Methods: A qualitative process in several steps was used for the model building. Neuropsychological and occupational therapy models and methods for assessment, evaluation and teaching were analysed. Model building was a stepwise process using the ICF framework and was corroborated by triangulation.

Results: A multi-professional model consisting of seven steps was developed. The model includes goal-driven assessment of needs and limitations, the choice of relevant compensatory strategies, its teaching, training and evaluation of individual needs and limitations.

Conclusion: The model describes tools for occupational therapists and neuropsychologists to develop a multi-professional client-centred method for learning, training and long-term use of compensatory strategies and devices.

Abstract Id: 348

Guidelines: Traumatic Brain Injury Rehabilitation in Adults

Sales VC, Almeida TLT, Falkenburg L, Nascimento RZR, Reis CA, Pedroso TD

Lucy Montoro Rehabilitation Institute, São Paulo, SP, Brazil

Background and Aims: Traumatic brain injury can lead to cognition, behavioral, emotional or physical impairments which modify patients’ independence, quality of life and socioeconomic aspects. This study aims to answer the most common questions about rehabilitation techniques and their effects.

Methods: Firstly, physical therapists and occupational therapists elaborated on fifteen questions based on concerns in rehabilitation. Secondly, research was done in a Pubmed Database where high-quality methodology articles were selected and then reviewed to answer the questions. The subjects of the questions were: conventional therapy; sensorial stimulation during coma; early rehabilitation; aerobic exercises; cognitive rehabilitation; virtual reality; body weight support; activities of daily living training; constraint-induced therapy; intensive physiotherapy; upper and lower limb orthoses; functional electrical stimulation and biofeedback.

Results: Techniques that are frequently used in rehabilitation show questionable and controversial results. Nevertheless, others show great benefits, improving strength, stretch, mobility, balance and gait.

Conclusion: It was possible to create a guideline to traumatic brain injury rehabilitation. However, there are few studies in this field, which may make it difficult to determine the best approaches in patients who had this type of injury. Thus, more studies are required.

Abstract Id: 16

The Incidence of Benign Paroxysmal Positional Vertigo (BPPV) in Patients Admitted to the Acquired Brain Injury Unit

Packer R

Royal Talbot Rehabilitation Hospital—Austin Health, Melbourne, VIC, Australia

Background and Aims: Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo in adults that, if detected, can be treated quickly and with good outcomes. Head trauma has been described as a cause of BPPV, but little has been described in the literature regarding the actual incidence in the head injured population or the pattern of recovery. The aims of this retrospective review were to

1. Determine the incidence and type of BPPV in patients admitted to the Acquired Brain Injury (ABI) Unit over a one-year period.

2. To document the response to treatment.

Method: Data were collected from physiotherapy assessment and treatment notes for all patients admitted to the ABI unit. Specific details regarding the type of BPPV, treatment techniques and response to treatment were collated.

Results: Data from 89 patients were collated. Forty-eight percent of all patients reported dizziness at some point during their inpatient stay, with 30% of this group clinically diagnosed with BPPV. All cases of BPPV were related to patients with traumatic brain injury with 17.8% of this diagnostic group affected. Fifty-four percent of patients with BPPV had bilateral symptoms. Thirty percent of the patients treated had a resolution of symptoms after a single treatment while 70% required multiple treatment sessions.

Conclusion: The incidence of BPPV in this cohort of patients was higher than an incidence of 2.4% that has been suggested for the general adult population. The results highlight the potential prevalence for BPPV as a cause of dizziness in the traumatic brain injured population. The degree of bilateral BPPV and the high percentage of patients requiring multiple treatment interventions highlight the increased complexity of treating BPPV in this population.

Abstract Id: 136

Hydrocephalus Following Severe Traumatic Brain Injury: Incidence, Relation to Functional Recovery, and Rehabilitation Stay

Linnemann M, Tibæk M, Kammersgaard LP

Department of Neurorehabilitation, TBI Unit, Copenhagen University Hospital, Glostrup, Denmark

Background and Aims: Hydrocephalus (HC) is reported in 1% to 50% following traumatic brain injury. Albeit treatable with shunting, HC may slow down functional recovery and require extended rehabilitation.

Methods: We studied 301 patients with severe TBI admitted consecutively to a single neurorehabilitation facility serving eastern Denmark (population 2.5 mill.). Demographics, clinical characteristics (GCS on admission for rehabilitation, admission FIM, and posttraumatic amnesia [PTA]), functional recovery (FIM), and rehabilitation length of stay were recorded prospectively. HC was diagnosed according to CT and subsequent shunting. Univariately, direct comparisons of clinical characteristics and demographics were performed between HC and non-HC patients. Adjusted multiple linear regression models were employed to evaluate the independent relation to FIM at discharge and rehabilitation length in relation to HC.

Results: Overall, 13% had HC. HC patients had longer median PTA (176 days [IQR 68 to 278] vs. 49 days [IQR 32 to 96], p < 0.001), lower median GCS on admission for rehabilitation (9 [IQR 7 to 12] vs. 12 [IQR 9 to 14], p = 0.001), and median admission FIM score (18 [IQR 18 to 18] vs. 18 [IQR 18 to 35], p < 0.001) than did patients without. No differences were found regarding gender, whereas patients with HC tended to be older than patients without (p = 0.05). At discharge, patients with HC had significantly lower median FIM scores (60 [IQR 23 to 95] vs. 105 [IQR 69 to 118]) and required longer rehabilitation (24 weeks [IQR 19 to 34] vs. 11 weeks [IQR 6 to 19]). After adjustment, HC was independently associated with longer rehabilitation stay (mean B = 4.8 days [95% CI 1.5 to 8.1 days]), whereas HC was not associated with discharge FIM.

Conclusions: In this study of severe TBI patients, HC was more prevalent than reported previously. HC does not seem to hinder functional recovery per se but requires longer rehabilitation.

Abstract Id: 417

From Hospital to Home: a New Conceptual Framework for Transition-Based Service Delivery Following Acquired Brain Injury

Turner B^1,2, Fleming J^1,3,4, Ownsworth T⁵, Cornwell P^6,7

¹School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, QLD, Australia

²Acquired Brain Injury Outreach Service, Princess Alexandra Hospital, Brisbane, QLD, Australia

³Centre for Functioning and Health Research, Metro South Health Service District, Queensland Health, Brisbane, QLD, Australia

⁴Occupational Therapy Department, Princess Alexandra Hospital, Brisbane, QLD, Australia

⁵School of Psychology, Griffith University, Mt Gravatt, QLD, Australia

⁶Metro North Health Service District, Queensland Health, Brisbane, QLD, Australia

⁷Behavioural Basis of Health Program, Griffith Health Institute, Griffith University, Brisbane, QLD, Australia

Background and Aims: The transition from hospital to home has been identified as an important phase of the rehabilitation continuum following acquired brain injury (ABI). The primary aim of this research was to explore the transition experiences and outcomes of individuals with ABI and their family caregivers. The research was conducted to provide an enhanced conceptual understanding of the transition phase, including implications for future service delivery.

Methods: The study utilised a multiple methods prospective longitudinal research design. The first phase involved a quantitative investigation to profile early transition outcomes. Participants, including 26 individuals with ABI and their family caregivers, completed measures of global functioning, psychosocial reintegration, health-related quality-of-life and emotional wellbeing at three time points: pre-discharge and 1- and 3-months post-discharge. Changes in outcomes over time and between group comparisons were examined using repeated measures ANOVAs and post-hoc analyses. The second phase involved a qualitative exploration of the lived transition experiences of 20 individuals with ABI and their family caregivers. Participants completed in-depth semi-structured interviews prior to discharge, and 1- and 3-months post-discharge. The interview transcripts were thematically analysed using open, axial and selective coding techniques.

Results: The research findings resulted in the compilation of a new conceptual framework for transition based service delivery following ABI. The framework highlights the key indicators and outcomes of transition success, including: (1) goal development and attainment; (2) adjustment and awareness; and (3) participation in meaningful occupations. Additionally, the framework addresses the key service system related facilitators of transition success including: (1) ongoing rehabilitation; (2) service support and co-ordination; (3) informal support networks; and (4) environment/context. A dynamic relationship between the various components of the framework is emphasised.

Conclusions: The holistic nature of the conceptual framework provides a guide for the development of innovative transition-based interventions and service approaches.

Abstract Id: 566

Educational Professionals’ Understanding of Childhood Brain Injury

Linden MA¹, Braiden, H-J²

¹Queen’s University Belfast, Belfast, United Kingdom

²Western Education and Library Board, Omagh, United Kingdom

Background and Aim: Recovery following brain injury is facilitated by including individuals who have significant influence on the child’s life. Teachers spend a great deal of time with children throughout their day and thus represent an important and yet under researched population. This research sought to investigate the level of understanding teachers possessed in regard to paediatric brain injury.

Method: A postal survey questionnaire was distributed to 1216 schools throughout one region of the UK. Forty questions covered topics such as brain injury outcomes, recovery, rehabilitation and injury prevention. Approximately one third (n = 369) of schools returned the questionnaire. Findings were analysed by means of descriptive statistics and analysis of variance (ANOVA).

Results: When asked about the lasting effects of being knocked unconscious, 110 participants agreed that most children would have no lasting effects, 97 felt there would be some effects, and 161 stated that they didn’t know. 197 educators agreed with the statement that childhood survivors of brain injury lacked awareness of its effect on their behaviour, but 27 disagreed with this statement and a further 143 didn’t know. One-way ANOVA showed statistically significant differences between educators who knew someone who had sustained a brain injury [F(1, 365) = 26.837, p < 0.001; Knowledge mean = 147.68, No knowledge mean = 142.57] or who had experience of teaching a child with brain injury [F(1, 366) = 14.329, p < 0.001; Experience mean = 147.86, No experience mean = 143.59].

Conclusions: Educational professionals received no formal training in how to work with childhood survivors of brain injury and demonstrated a general lack of understanding of the condition. Given the importance of a supportive school environment in return to life following hospitalisation, this lack of understanding may significantly impact on a successful return to school.

Abstract Id: 100

Efficacy of Using Handheld Computers Plus Occupational Therapy Training to Compensate for Memory and Planning Difficulties After Brain Injury: a Randomised Control Trial

Carr B¹, Allaous J¹, Lannin N^2,3, MacKenzie B¹, Falcon A¹, Tate R^1,3, Schmidt J^1,4, Irving I¹, Pearse S⁵

¹Royal Rehabilitation Centre, Sydney, Sydney, NSW, Australia

²Alfred Health, Melbourne, Victoria, Australia

³Rehabilitation Studies Unit, The University of Sydney, Sydney, NSW Australia

⁴The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia

⁵Westmead Brain Injury Rehabilitation Service, Westmead, NSW, Australia

Background: Using calendars or diaries are effective ways to compensate for memory and planning problems after brain injury. Mainstream technologies aimed at improving organisation, planning and memory skills in the general population, such as handheld computers or personal digital assistants (PDAs), have a potential to also assist people who have suffered a brain injury. The aim of this presentation is to evaluate whether PDAs that are customised by therapists improve the independence in people with memory problems and executive deficits after brain injury.

Methods: Randomised controlled trial of 42 participants with memory, planning and/or organisation difficulties. The experimental group used a PDA for 8 weeks coupled with individual training sessions with an occupational therapist; the control group used non-electronic aids and had individual occupational therapy sessions. All PDAs were customised for each participant by an occupational therapist. The training sessions used a behavioural approach as well as features of errorless learning.

Results: The frequency of forgetting, as described by carers, was reduced by an average of 9 points on the Memory Compensation Questionnaire (95% CI 0.3 to 18.4) in the group that used a PDA. This group also improved in goal-related performance on use of memory aids, use of prompts, memory failures, and punctuality (Goal Attainment Scale T-scores improved by an average of 7 points (95% CI −1.7 to 16.0).

Conclusion: This study is the first RCT to support the use of mainstream PDAs for people with memory impairments after brain injury. The study is particularly relevant given the extensive use and acceptance of smartphones in everyday life.

Abstract Id: 275

Light Therapy for Treatment of Fatigue and Sleepiness Following Acquired Brain Injury

Sinclair K¹, Ponsford J^1,2, Lockley SW^1,3, Rajaratnam, MW^1,3

¹School of Psychology & Psychiatry, Monash University, Clayton, VIC, Australia

²Monash-Epworth Rehabilitation Research Centre, Epworth Hospital, Melbourne, VIC, Australia

³Department of Medicine, Division of Sleep Medicine, Brigham & Women’s Hospital and Harvard Medical School, Boston, MA, USA

Introduction: Fatigue and sleepiness are some of the most pervasive complaints following traumatic brain injury (TBI). They occur chronically and negatively impact on acute recovery, long-term rehabilitation, mood and quality of life. Effective treatment is not well established. Recent research investigating short wavelength (blue) light exposure has demonstrated potency for acute subjective and physiological alerting effects, circadian phase shifting and enhancement of mood. The current study aimed to investigate the effects of 4 weeks of short-wavelength light therapy (LT) on fatigue and excessive daytime sleepiness (EDS) in individuals with TBI.

Materials and Methods: Using a randomised, placebo-controlled design, we investigated a 4-week, 45-min/day ‘at-home’ treatment with short wavelength (blue) light therapy (goLITE, Philips Lighting) (λ_max 465 nm, 85 µW/cm²) compared with yellow light therapy (λ_max 574 nm, 19 µW/cm²) designed specifically to be deficient in short wavelength blue light or treatment as usual in 30 individuals (10,10,10) with TBI who self-reported fatigue and/or EDS. Subjective assessments of fatigue and EDS were conducted at baseline and after 4 weeks of LT.

Results: When controlling for age, gender, and baseline anxiety and depression levels, we observed a trend for the mean decrease in fatigue (from baseline) after the 4-week treatment phase to be highest in the blue group (−1.32 ± .39), compared with yellow (–.24 ± .25) or treatment as usual (–.12 ± .24), (p = .02). The mean decrease in EDS was also highest in the blue group (–4.70 ± 1.66) compared with yellow (−3.00 ± .93) and treatment as usual (−1.20 ± 1.12), although group differences were not significant (p = .27).

Conclusion: Preliminary findings suggest that short wavelength light may be effective in alleviating fatigue and possibly EDS following TBI. The trial is ongoing.

Abstract Id: 34

Virtual Reality-Based Prospective Memory Training Program for Traumatic Brain Injury

Man D

Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong

Background and Aims: An intelligent virtual reality-based prospective memory (IVRPM) programme was developed to train everyday prospective memory in people with acquired brain injury (ABI).

Method: A single-blinded, pretest-posttest randomized controlled trial (RCT) was adopted. Fifty-six subjects were randomly assigned to an IVRPM treatment group (n = 18), a VRPM treatment group (n = 19), or a control group receiving no intervention (n = 18). Subjects who were assigned to the two treatment groups were provided with a 10-sessions training programme. Outcome measures included PM performance (Cambridge Prospective Memory Test/ CAMPROMPT), retrospective memory (RM; Hong Kong List Learning Test), frontal lobe functioning (Frontal Assessment Battery/FAB; Word Fluency Test/WFT), level of community integration (Community Integration Questionnaire/CIQ), and self-efficacy questionnaire in performing everyday prospective memory tasks. Subjects were assessed on these outcome measures by an assessor blinded to the treatment group allocation before and after the training period.

Results: Subjects in the IVRPM group performed significantly better than the VRPM group in PM functioning in a virtual environment (event-based PM, p < 0.001; time-based PM, p = 0.001). When comparing the other outcome measures among the three groups (i.e., IVRPM, VRPM and control group), the IVRPM group performed significantly better than both VRPM and control groups in time-based PM task accuracy in real environment (respectively p < 0.05, p < 0.001) and standardized PM assessment (CAMPROMPT) (respectively p < 0.05, p < 0.001). Moreover, this group performed significantly better than the control group in the level of community integration (CIQ) (p < 0.01) and self-efficacy score (p < 0.001). VRPM group performed better than the control group in WFT – CV (p < 0.05) and FAB (p < 0.05).

Conclusions: Findings from the present study showed that the combination of AI and VR can be a successful treatment strategy for PM rehabilitation of people with ABI. Further application of present training model to other patient groups should be encouraged.

Abstract Id: 97

Feedback Interventions for Impaired Self-Awareness Following Brain Injury: a Systematic Review

Schmidt J^1,2,3, Lannin N^4,5, Fleming J^2,3,6, Ownsworth T⁷

¹Royal Rehabilitation Centre, Sydney, Sydney, Australia

²The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia

³Centre for Functioning and Health Research, Metro South Health Services District, Brisbane, Australia

⁴Alfred Health, Melbourne, Victoria, Australia

⁵Rehabilitation Studies Unit, The University of Sydney; Sydney, NSW, Australia, and The Institute for Safety, Compensation and Recovery Research, Melbourne, Australia

⁶Princess Alexandra Hospital; Brisbane, Australia

⁷School of Psychology, Griffith University, Brisbane, Australia

Background: Self-awareness is a person’s understanding of his or her strengths and limitations and the impact of this on everyday functioning. Impaired self-awareness is one of the biggest obstacles to rehabilitation of a person with a brain injury, as it affects motivation and engagement in therapy. There is limited evidence to guide clinicians in remediating self-awareness in a person with a brain injury. The aim of the presentation is to summarise the evidence of self-awareness interventions, which involve a component of feedback, designed to improve self-awareness in adults with a brain injury.

Methods: Systematic review methodology. Electronic databases were searched and papers were critically appraised and summarised. Validated rating scales were used to determine study quality, including the physiotherapy evidence (PEDro) scale for randomised controlled trials and the single case experimental design (SCED) scale for single-case experimental designs. Revman software was used for analysis of the effectiveness of intervention.

Results: Twelve papers of varied quality met the inclusion criteria, of which only three were randomised controlled trials. Interventions and outcomes were heterogeneous. Feedback interventions produced small but statistically significant improvements in self-awareness; the pooled mean effects of feedback interventions on functional performance were 0.90 (95% CI 0.36 to 1.43, p = 0.01).

Conclusion: There is currently no agreement regarding best practice for adults with impaired self-awareness following brain injury. Using an evidence-based framework, this review demonstrates the efficacy of specific feedback interventions and highlights how these may be used in conjunction with standard therapy to improve self-awareness.

Abstract Id: 223

Rehabilitation of Retrograde Amnesia: a Case Study of Music Evoked Autobiographical Memory After Severe Traumatic Brain Injury

Baird A¹, Samson S²

¹Hunter Brain Injury Service, Newcastle, Australia

²Department of Psychology, University of Lille, France

Background and Aim: Music can elicit autobiographical memories and associated emotions. Music-evoked autobiographical memories (MEAMs) have been characterised in the healthy population and neuroimaging studies have identified prefrontal regions as their main neural correlate. Our aim was to explore if music is more efficient than words in eliciting autobiographical memories after traumatic brain injury (TBI).

Methods: A 60-year-old male (RG) with a severe TBI showed impaired verbal and autobiographical memory. The experimental music task comprised excerpts of 50 randomly presented songs (from 1960-2010, RG aged 10-60 years). After each excerpt, a written questionnaire was completed to verify how familiar each song was, how much it was liked (both using a rating scale), and if the song evoked a memory. A control participant, RG’s wife (aged 59 years), completed the task.

Results: The number of MEAMs in RG (54%) and his wife (58%) did not differ. Songs that evoked a memory were more positively rated than those that did not (mean ratings RG = 3.5, wife = 3.9 vs. RG = 1.7, wife = 2.3). The majority of evoked memories were of a person/people for both RG (48%) and his wife (66%), and were typically positive (RG = 3.5, wife = 4.1). RG’s evoked memories were less vivid than his wife’s (RG = 2.9 vs. wife = 4.1). RG and his wife showed the same temporal gradient of MEAMs with a clear ‘remiscence bump’ with songs from their youth evoking the most memories.

Conclusion: This is the first study of MEAMs after TBI to date. RG sustained a severe TBI and with the exception of reduced vividness, the frequency and nature of his MEAMs were in keeping with his healthy wife’s. His MEAMs were relatively preserved in the context of impaired verbal and autobiographical memory. This finding suggests that music is an effective stimulus to use in the rehabilitation of retrograde, specifically autobiographical amnesia.

Abstract Id: 153

Caregivers’ Experiences During Transition From Hospital to Home Following Brain Injury: a Mixed Methods Study

Nalder E¹, Fleming J^1-3, Cornwell P^4,5, Foster M⁶

¹School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia

²Occupational Therapy Department Princess Alexandra Hospital, Brisbane, QLD, Australia

³Centre for Functioning and Health Research, Queensland Health, Brisbane, QLD, Australia

⁴Griffith Health Institute, Behavioural Basis of Health, Griffith University, Brisbane, QLD, Australia

⁵Metro North Health Service District, Queensland Health, Brisbane, QLD, Australia

⁶School of Social Work and Human Services, The University of Queensland, Brisbane, QLD, Australia

Background and Aims: The transition from hospital to home following brain injury is critical for caregivers who are adopting new life roles. Quantitative studies have demonstrated that caregivers can experience many challenges including depression and caregiver burden. Despite recognising the important and challenging role of family caregiver few studies have investigated the perceptions and experiences of caregivers during the transition phase. This presentation aims to 1) explore the experiences of caregivers during the transition from hospital to home and 2) identify factors influencing perceived transition success.

Method: A sequential explanatory mixed methods investigation was conducted. A longitudinal cohort study with a consecutive sample of 83 caregivers completing self-report measures over the first 6 months post-discharge was conducted first. Caregivers rated the EQ-5D, Depression Anxiety Stress Scale and Caregiver Strain Index with respect to themselves, and the Sydney Psychosocial Reintegration Scale with respect to the individual with TBI. Mixed effect modelling was used to examine factors influencing perceived transition success. Subsequently, a qualitative investigation using semi-structured interviews with a purposive sample of 10 caregivers drawn from the larger sample were completed and analysed thematically.

Results: Lower ratings of transition success were related to higher stress levels among caregivers (p = 0.057) and lower levels of psychosocial integration for the individual with TBI (p = 0.002). Qualitative interviews highlighted that the weight of care responsibility experienced by most caregivers contributed to a desire to move past the injury. Caregivers hoped that individuals’ with TBI would regain a sense of normality in life. This was defined as resuming meaningful activities and regaining independence.

Conclusions: Services are required to support family caregivers. Further research examining caregivers’ experiences over a longer period is required to inform service development.

Abstract Id: 241

The Effect of Environmental Factors on Community Integration Following Traumatic Brain Injury

Fleming J^1,2,3, Alves-Stein S¹, Nalder, E¹

¹University of Queensland, Brisbane, QLD, Australia

²Princess Alexandra Hospital, Brisbane, QLD, Australia

³Centre for Functioning and Health Research, Metro South Health Services, Brisbane, QLD, Australia

Background and Aims: Reintegration into community living can be difficult following traumatic brain injury (TBI) due to the pervasive nature of physical, cognitive and behavioural changes. It is now recognised that environmental factors such as physical, attitudinal and policy barriers may also contribute to the experience of disability. The aim of this study was to describe the environmental barriers endorsed by individuals with TBI during the first 6 months after discharge and determine their effect on community integration.

Methods: Prospective longitudinal study with data collected at pre- discharge and 1, 3, and 6-months post-discharge. Participants were 135 adults (106 males, 29 females) with a diagnosed TBI consecutively recruited on discharge from a large metropolitan hospital. Exclusion criteria were: a hospital stay of less than 4 days, inability to give informed consent, and discharge to an institutional setting. The outcome variable was level of community integration at 6 months post-discharge measured by the Sydney Psychosocial Reintegration Scale (SPRS). Frequency and magnitude of environmental barriers was measured at each time-point using the Craig Hospital Inventory of Environmental Factors (CHIEF). Data were analysed using standard multiple regressions with level of disability controlled for using the Mayo-Portland Adaptability Index (MPAI-4) and length of hospital stay (LOS).

Results: Mean CHIEF total scores were 12.1 (SD = 14.5) at 1 month, 11.9 (SD = 14.4) at 3 months, and 11.7 (SD = 18.1) at 6 months post-discharge. SPRS scores at 6 months post-discharge were predicted by a combination of LOS, MPAI-4 and CHIEF total scores at 1 month (Adj R² = 0.52), 3 months (Adj R² = 0.64), and 6 months (Adj R² = 0.69) post-discharge. Secondary multiple regression analyses using CHIEF subscale scores indicated a significant correlation between SPRS scores and physical barriers at 3 months and 6 months (p < 0.01) and policy barriers at 3 months (p < 0.01) post-discharge.

Conclusion: Environmental barriers should be addressed in rehabilitation and considered in policy development for people with TBI.

Abstract Id: 278

Proprioceptive Perception: a Behavioral and Functional MRI Study of Its Hemispheric Dominance

Ben-Shabat E^1,2, Brodtmann A¹, Matyas TA^1,2, Pell GS³, Carey LM^1,2

¹National Stroke Research Institute, Florey Neuroscience Institutes, Melbourne, Victoria, Australia

²La Trobe University, Melbourne, Victoria, Australia

³Brain Research Institute, Florey Neuroscience Institutes, Melbourne, Victoria, Australia

Background: Proprioceptive perception is essential for motor control, yet its central processing remains unclear. Emerging evidence from behavioural studies suggests hemispheric asymmetry for proprioceptive perception. We aimed to investigate asymmetry of proprioceptive performance in a behavioural study; characterise brain activation during conscious proprioceptive perception; and test for hemispheric asymmetry.

Method: Thirty-seven healthy right-handed participants (mean age 49.8, SD 18.4, 22 female) performed the Wrist Position Sense Test for both wrists. Twelve healthy right-handed participants (mean age 23.4, SD 3.3, 6 female) underwent functional MRI scans during an original event-related proprioceptive experimental design with vision occluded. Each proprioceptive event of passive wrist movement was followed by a motor response event of mirror copying or not copying the movement with the other wrist.

Results: The behavioural results indicated better perception of movement magnitude with the right wrist (p = 0.002), and a noisier performance (p = 0.021) with the left wrist. Proprioception-related brain activation included the right supramarginal gyrus (SMG) and the contralateral dorsal premotor cortex (PMd) with greater bilateral activation during right than left wrist proprioceptive stimulation. Greater bilateral primary sensorimotor activation was found during right compared to left wrist proprioceptive stimuli.

Conclusion: Our findings indicate dominance of the right hemisphere, particularly the right SMG for processing of proprioceptive perception. Lesion studies of neglect patients have also implicated the right SMG in conscious processing of spatial stimuli. Findings from the behavioural studies provide further support for right hemispheric dominance in the processing of proprioceptive inputs. We have shown that conscious perception of proprioceptive stimuli engages ventral (right SMG) and dorsal (contralateral PMd) parieto-frontal networks. These networks are known to activate during detection of spatial visual stimuli. Our findings extend current knowledge to include spatial processing of (proprioceptive) inputs in these networks.

Abstract Id: 196

Depressive Symptoms Following Discharge After Traumatic Brain Injury: Support for a Reactive Model?

Ownsworth T¹, Fleming J^2,3,4

¹School of Psychology, Griffith University, Mt Gravatt, QLD, Australia

²Occupational Therapy Department, Princess Alexandra Hospital, Brisbane, QLD, Australia

³School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, QLD, Australia

⁴Centre for Functioning and Health Research, Metro South Health Service District, Brisbane, QLD, Australia

Background and Aims: Early depression after traumatic brain injury (TBI) is associated with poorer long-term functional outcomes; however, the nature of this relationship is unclear. This study aimed to better understand the relationship between progress in resuming pre-injury lifestyle (i.e., transition events such as return to work, independent living and relationship maintenance), perceived functioning and depressive symptoms at time of discharge and 3 months post-discharge.

Methods: A prospective cohort of 96 individuals with TBI was consecutively discharged from the brain rehabilitation injury unit and acute neurosciences ward of a major metropolitan hospital. Participants completed the Sentinel Events Questionnaire, Mayo-Portland Adaptability Inventory-4 (MPAI-4 Ability and Adjustment indices) and Depression Anxiety Stress Scale at discharge and 3-month follow-up.

Results: After controlling for age and discharge depressive symptoms, change in perceived functioning (MPAI-4 change score) mediated the relationship between transition events and depressive symptoms at 3 months post-discharge (beta reduced from .21 to .14), with a significant indirect effect observed.

Conclusions: Such findings indicate that lack of progress in resuming pre-injury lifestyle alters individuals’ perceptions of their post-injury abilities, which in turn, contributes to greater depressive symptoms at 3-month post-discharge. The implications of these findings for conceptualising post-TBI depression will be highlighted.

Abstract Id: 245

Exploring Tensions Associated with Supported Decision Making in Adults with Severe TBI

Knox L, Douglas J, Bigby C

La Trobe University, Melbourne, VIC, Australia

Background and Aims: The opportunity to make decisions about one’s own life has been linked with improved quality of life, psychological wellbeing, and positive development of one’s own identity. Clinicians in brain injury rehabilitation play a critical role in supporting adults with severe traumatic brain injury (TBI) to make decisions about their lives over their rehabilitation journey. The aim of this project was to undertake a systematic review of the literature in order to better understand how adults with severe TBI experience participation in decision making over the course of their rehabilitation journey. A particular focus of the review was to identify factors that influence participation in decision making.

Method: A review of English language literature via computerised literature search and manual cross-referencing was conducted. Relevant articles were identified using a combination of search strategies, based on specific search terms related to the central components of the research topic (TBI and decision making). Relevant government reports, policy statements and issues papers were also identified and reviewed.

Results: The literature highlighted several themes relevant to supporting decision making in people with severe TBI. These themes reflected tensions that arose from competing philosophies of rehabilitation, assumptions about capacity, and avoidance or acceptance of risk. In addition, limited resource availability was found to have a significant impact on both the opportunities for and experiences of decision making.

Conclusion: Ensuring participation in decision making is central to providing holistic and person-centred care. There are a number of systemic factors that influence the approaches to supporting the participation of adults with TBI in decision making. Increased knowledge and understanding of their implications for policy and practice are required. Additionally, further research is required to better understand the experiences of individuals with TBI, and ensure that rehabilitation practice maximises decision-making opportunities.

Abstract Id: 356

Predictors and Outcomes of Occupational Therapy Driver Assessments and Rehabilitation After Traumatic Brain Injury

Ross P¹, Ponsford J²

¹Epworth Healthcare, Richmond, VIC, Australia

²Monash University, Clayton, VIC, Australia

Background and Aims: There is little research into the outcomes of the occupational therapy (OT) driver assessment and rehabilitation process and post assessment driving behaviour and safety following traumatic brain injury (TBI). The aim of this study was to improve knowledge about predictors for return to driving after TBI, in order to maximise road safety and quality of driver assessment and rehabilitation for this group.

Methods: Outcome data of all OT driver assessments (n = 207) conducted on patients with a TBI in a rehabilitation setting over the last 8 years were documented retrospectively. Injury severity measured by GCS and PTA, years licensed, physical and visual impairments and reaction times were recorded. Outcome data included number of on road assessments and driving lessons required, number of conditional licenses issued and time from injury to return to driving. Self-reported changes in driving behaviour and number of pre and post injury traffic accidents were recorded by questionnaire.

Results: Two groups were identified: the ‘pass’ group who passed the on road assessment and the ‘rehabilitation’ group who required lessons. Logistic regression analysis revealed that the significant variables for classifying who will pass a driving assessment included PTA duration, upper limb injury, years licensed and reaction times. These variables correctly classified 88% of pass cases but only 54% of rehabilitation cases. No significant differences were found between pre- and post-injury accident rates. Compared to the pass group, the rehabilitation group was twice as likely to report difficulty with navigation and more nears misses.

Conclusions: Delaying driving for a minimum of 3 months post injury appeared appropriate as TBI drivers did not appear to be at greater risk of accidents and many modified their driving behaviour. PTA duration of less than 28 days was associated with passing an OT driving assessment.

Symposia Session 3f: Motor Rehabilitation and Plasticity Across Cns Impairments: Not All Training Is Good (Or Good Enough)

Adkins DL¹, Kozlowski D², Magnuson DSK³, Kleim J⁴

¹Medical University of South Carolina, Charleston, SC, USA

²Department of Biological Sciences and Department of Health Sciences, Chicago, IL, USA

³Kentucky Spinal Cord Injury Research Center, University of Louisville, USA

⁴School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA

Not all motor impairments are created equally. Degeneration and injury to the CNS results in a host of behavioral impairment, some of which are similar in appearance, but result in different patterns of behavioral recovery and neural plasticity. Motor experience or training can, in some cases, induce robust neural plasticity and a reduction in these impairments; however, not all motor experience or training is beneficial, and, depending on the etiology of the impairments and site of tissue loss, interventions may actually reduce behavioral improvements and supportive plasticity. For instance, training which focuses on forelimb compensation can induce aberrant plasticity and a reduction in the capacity for the impaired limb to recover. In other cases, motor training that is highly effective in one injury model is insufficient in another injury model. In this session, experts in animal models of motor rehabilitation and neural plasticity following stroke, TBI, spinal cord injury and Parkinson’s disease will discuss their recent findings that touch on the growing appreciation that each injury/disease model may require a unique set of rehabilitative training approaches and adjunctive treatments and that not all training paradigms are sufficient or beneficial.

Dr. DeAnna Adkins will present data demonstrating that motor training of the less impaired forelimb following a unilateral ischemic motor cortical stroke interferes with subsequent impaired limb recovery. Dr. Dorothy Kozlowski will discuss the effects and limitations of motor rehabilitation following focal traumatic brain injury and how these results differ from similar injuries caused by stroke-like damage. Dr. David Magnuson will discuss how, following spinal cord injury, the locomotor circuitry below the site of injury interprets afferent input, inducing both positive and negative functional outcomes. Dr. Jeffrey Kleim will discuss findings that illustrate that rehabilitation differentially effects forelimb and cranial motor function and corticospinal and corticobulbar plasticity. Following individual presentations, the speakers will discuss some of the similarities and differences across CNS disease/injury models.

Theme: Imaging and Plasticity

Abstract Id: 121

Longitudinal Language Recovery Subsequent to Low-Frequency rTMS in Chronic Aphasia: Implications for Neurorehabilitation

Barwood CHS¹, Murdoch BE¹, Riek S², O’Sullivan J³, Wong A³

¹Centre for Neurogenic Communication Disorders Research, School of Health and Rehabilitation Sciences, University of Queensland, Australia

²School of Human Movement Studies, University of Queensland, Australia

³Department of Neurology, Royal Brisbane and Women’s Hospital, Queensland, Australia

Background and Aims: Low-frequency repetitive transcranial magnetic stimulation (rTMS) has emerged as a potential tool for the neurorehabilitation of language in chronic non-fluent aphasia post-stroke. Inhibitory (1 Hz) rTMS has been applied to homologous language sites to facilitate behavioural language changes over time. This research aims to measure behavioural language outcomes up to 12 months post stimulation.

Methods: Low-frequency (1 Hz) rTMS was applied to six active stimulation and six placebo patients for 20 min per day, for 10 days. Behavioural language outcome measures were taken at baseline (pre-stimulation) and 1 week, 2 months, 8 months and 12 months post-stimulation.

Results: The findings demonstrate treatment-related changes observed in the stimulation group when compared to the placebo control group over time for naming performance, expressive language and auditory comprehension.

Conclusions: These outcomes provide considerable evidence to support the theory of rTMS modulating mechanisms of transcallosal disinhibition in the aphasic brain and highlight the potential clinical applications for TMS for language rehabilitation in chronic aphasia.

Theme: Neuro-Oncology

Abstract Id: 584

Effect of Interactive Video Games on Activities of Daily Living in Children with Brain Tumors

Broeren J¹, Blomgren K¹, Emanuelson I², Gillenstrand J³, Lannering B³, Ljungberg C⁴, Sabel M³, Saury JM³, Simmons C³, Sjölund A³

¹The Sahlgrenska Academy at the University of Gothenburg, Västra Götaland County, Sweden

²Habilitation & Health, Gothenburg, Västra Götaland County, Sweden

³The Queen Silvia Children’s Hospital Sahlgrenska University hospital, Gothenburg, Västra Götaland County, Sweden

⁴University West, Trollhättan, Västra Götaland County, Sweden

Background and Aims: The survival of children with cancer has improved considerably over the last decade, and currently three out of four children suffering from cancer become long-term survivors. However, the late effects of radiotherapy to the brain may lead to functional limitations in activities needed for daily living. The data presented here are part of a larger study, which investigates the effects of a telerehabilitation program on physical activity with low-cost motion interactive games with weekly coaching based on video-conferencing technologies in order to promote cognitive abilities and motor performance in children with radiotherapy damages after brain tumor treatment. Here we report on preliminary results describing the impact of the program on activities of daily life.

Methods: To date, we have evaluated 7 children who had received radiation treatment for a brain tumor, 11-16 years old, and practiced with Nintendo Wii in their homes during 10 weeks. The Assessment of Motor and Process Skills (AMPS), an observational, standardized, occupational therapy assessment tool, was used to evaluate activities of daily living. All values are as mean and standard deviation (SD) and AMPS data were processed in a Rasch analysis.

Results: On admission, mean performance for the whole group was 1.2 ± 0.7 logits for motor skills and 0.9 ± 0.6 logits for process skills. Motor skills increased to 1.8 ± 0.5 logits and process skills increased to 1.4 ± 0.3 after 10 weeks of home-based training. The cutoff level for independent living is regarded to be 2.0 logits for motor skills and 1.0 logits for process skills.

Conclusion: The results suggest that a telerehabilitation program using Wii Fit with balance board could improve activities needed for daily living in children with cancer.

Theme: Multiple Sclerosis

Abstract Id: 343

Interpretation of Changes on Walking Tests in Persons with Different Ambulatory Dysfunction: Within-Day Variability in Persons with Multiple Sclerosis

Feys P^1,2, Gijbels D^1,2, Dalgas U³, Bibby BM⁴, in collaboration with a RIMS working group on walking

¹REVAL Rehabilitation Research Centre, PHL University College, Diepenbeek, Belgium

²BIOMED Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium

³Section of Sport Science, Department of Public Health, Aarhus University, Aarhus, Denmark

⁴Section of Biostatistics, Department of Public Health, Aarhus University, Aarhus, Denmark

Background and Aims: Walking tests are increasingly applied as a primary outcome measure in clinical trials of multiple sclerosis (MS), but interpretation of changes is still unclear. The study aim was to reveal important changes in persons with different ambulatory dysfunction for short as well as long walking tests.

Methods: 102 ambulatory persons with MS (PwMS; Expanded Disability Status Scale 0-6.5) performed the 10 m at usual and fastest speed, and both 2- and 6-minute walk test (2&6MWT) in the morning, at noon, and in the afternoon. Ninety-five percent prediction intervals for timed walking distance scores were computed using a random effects model with individual pwMS as the random effect. Following this model, expected scores on retest should be the same as baseline, within a range determined by measurement variability.

Results: For the long walking distance tests and short 10 m walking at fastest speed, the variation was quite constant in absolute units across the overall study sample with different ambulatory dysfunction. As a result, 95% prediction intervals were independent of the different distances walked by pwMS. Our data predict that for the 2MWT and 6MWT, scores vary between the pwMS baseline performance with ±19 and 54 meters, respectively, independent of severity of ambulatory dysfunction. For the 10-m test (fastest speed), scores vary between the pwMS baseline performance with ±0.26 m/s. However, within-day variability of the 10 m at usual speed was ±31% for all pwMS, indicating greater variability in absolute values with increasing disability level.

Conclusions: Proportional within-day variability on walking tests at fastest speed increases with increasing disability level, but remains constant when measured at usual speed. Changes that exceed the outer limits defined by the present study are more likely to represent a true change in walking distance capacity, as they are unlikely related to within-day variability.

Study Group on Walking in Ms (Part I):

P. Feys,¹ D. Gijbels,¹ A. Romberg,² U. Dalgas,³ B. Gebara,⁴ V. de Groot,⁵ C. Santoyo,⁶ B. Maertens de Noordhout,⁷ F. Bethoux,⁸ K. Knuts,⁹ C. Vaney,¹⁰ E. Jensen¹¹

¹BIOMED, Hasselt University and REVAL Research Institute, PHL University College, Belgium

²Masku Neurological Rehabilitation Center, Masku, Finland

³Section of Sport Science, Department of Public Health, Aarhus University, Aarhus, Denmark

⁴National MS center, Melsbroek, Belgium

⁵Department of Rehabilitation Medicine, VU University Medical Center, Amsterdam, The Netherlands

⁶Hospital de Dia de Barcelona, CEM-Cat, Spain

⁷Centre Neurologique et de Réadaptation Fonctionelle, Fraiture-en-Condroz, Belgium

⁸The Mellen Center for Multiple Sclerosis Treatment and Research, the Cleveland Clinic, Cleveland, OH

⁹Rehabilitation and MS Center Overpelt, Belgium

¹⁰Neurologische Rehabilitations- & MS-Abteilung, Berner Klinik, Montana, Switzerland

¹¹MS center in Haslev and RY, Denmark

Theme: Stroke

Abstract Id: 621

Could Motor Cortex Activity Predict Motor Stroke Recovery? an fMRI Study on Subacute Lacunar Stroke

Jaillard A^1,4,5, Delon Martin C², Carey L³, Lalamalle L⁴, Hommel M¹, LeBas JF^1,4, Zeffiro TA⁵

¹CHU Grenoble, Grenoble, France

²Grenoble Neuroscience Institut, Grenoble, France

³Division of Neurorehabilitation and Recovery National Stroke Research Institute, Melbourne, VIC, Australia

⁴RMN Biomédicale et Neurosciences, Grenoble, France

⁵Neural System Center, Massachusetts General Hospital, Boston, MA, USA

Background: We used functional MRI (fMRI) to investigate the neural mechanisms of stroke recovery. While the primary motor cortex (M1) has been demonstrated to be a crucial area for motor recovery in a recent meta-analysis including both fMRI and TMS studies other fMRI studies have reported changes in the whole motor network to correlate with motor recovery. The heterogeneity of stroke lesions and the small sample size of many studies could account for these discrepancies.

Hypothesis: The strength of task-related activity in primary motor cortex predicts motor recovery in a clinically homogenous population of acute lacunar stroke patients.

Methods: We studied 18 stroke patients (4 females, 14 males) after their first single lacunar stroke (7 right and 11 left hemisphere). The lesions caused pure limb weakness one week after stroke onset (mean 7.2 days range 2 -15). Stroke lesion was limited to the deep territory of the anterior choroid artery involving the corticospinal tract at the level of the internal capsula or the corona radiata. Patients were matched to 18 healthy controls for age and gender. Motor impairment was assessed using the NIH Stroke Scale (NIHSS), the Fugl-Meyer scale (FMS), Finger Tapping Score (FTS), pegboard and motor reaction times at day 7 and at 6 months after stroke. At 6 months, a global motor recovery score was computed using the FMS and the FTS to assess motor recovery. Functional MRI scans were obtained using a self-paced finger tapping (FT) task implemented as a block design alternating right FT, left FT and rest. Data were processed using SPM8. In the first level analysis “FT minus fixation” contrasts were computed for the impaired hand. At the second level, multiple regression was used to assess the effect of the motor recovery score on the FT-related motor activity (threshold p < 0.05 FWE; extent threshold k = 5). Age and FT rate recorded during the experiment were included as covariates in the second level model.

Results: As a group, the stroke patients showed good recovery at 6 months. Both patients and controls showed the canonical motor pattern of activity for the FT task. Primary motor cortex was the only region predictive of motor recovery at 6 months, after adjustment for age and FT rate. [x;y;z] MNI coordinates = [−34;−14;48].

Conclusions: Primary motor cortex activity, measured soon after stroke onset, predicts motor recovery assessed at 6 months post-stroke. With measurements made in the early phase of stroke recovery, fMRI could be used to acquire prognostic biomarkers in clinical trials investigating novel treatments, such as stem cell administration.

Abstract Id: 620

Focal Dorsolateral Basal Ganglia Lesions Impair Identification of Facial Emotions Signaling Threat

Jaillard A^1,2, Naegele B¹, Saint Martin M¹, Zeffiro TA², Hommel M¹

¹CHU Grenoble, Grenoble, France

²Massachusetts General Hospital, Boston, MA, USA

Background: Survival may depend on the ability to efficiently identify threats signaled by the emotional content of facial expressions. While current neural models of facial emotion processing do not prominently feature the basal ganglia (BG), evidence from clinical and functional imaging studies suggests involvement of the ventral striatum.

Methods: To assess the specific role of the BG in processing emotions, we compared basic facial emotion identification in 23 young patients (mean age 44.9) with a pure focal BG stroke to 68 matched healthy controls (mean age 43.8). We used quantitative MRI lesion analysis to assess the relationship between BG location and basic emotion identification. To assess whether facial emotion identification might be related to non-specific lesion effects, we also assessed a wide range of cognitive and motor abilities and screened participants for possible co-morbid conditions such as depression or anxiety. In addition, we assessed social behavior in terms of social adaptability and the ability to return to work after stroke.

Results: (1) The ability to identify basic emotions was impaired after focal lesions limited to the BG. (2) This impairment was limited to anger, fear and disgust identification, that are threat-related emotions, suggesting a specific role for the BG in threat detection. These findings may reflect altered gating mechanisms for emotions conveying threat signals, with the BG selecting information relevant to individual safety. (3) We found that the observed emotion identification impairments adversely affected social behavior suggesting that emotion identification skills may be of substantial practical importance, and should be considered in the clinical assessment and rehabilitation of patients with BG lesions.

Conclusions: From a clinical perspective, while the impact of emotion identification impairment on social behavior should be verified by further studies, the practical significance of the consequences of BG damage appear to be detectible at the individual level.

Abstract Id: 379

Effects of Pneumatic Abdominal Binder and Calf Compression Versus Elastic Compression Bandaging on Orthostatic Hypotension in Patients with Acute Stroke: a Randomized Clinical Trial

Vijayakumar K¹, Karthikbabu S², Aishwarya S²

Kasturba Medical College, Manipal University, Mangalore, Karnataka, India

Background: Orthostatic hypotension (OH) occurs early following stroke due to impaired venous return, autonomic instability and paretic limb muscles. This orthostatic hemodynamic stress further exacerbates the existing cerebral damage and delayed functional recovery.

Aim: To compare effects of pneumatic abdominal binder (PAB) and pneumatic calf compression (PCC) versus elastic compression bandaging (ECB) for OH during tilt table standing in patients with acute stroke.

Methods: 26 (18 male, 8 female) stroke subjects (duration <3 weeks) with OH as defined by American Academy of Neurology and American Autonomic Society were randomly assigned to receive either experimental (PAB + PCC, n = 13) or control (ECB, n = 13). Tilt table standing was administered for six consecutive sessions and outcomes were measured pre-post intervention. The hemodynamic responses were measured using Omron Digital BP apparatus. The pressure applied using PAB and PCC for the experimental group was maintained at 40 and 30 mm Hg, respectively, while in the control group, ECB was applied to the paretic calf muscles. Primary outcome of percentage of patients who attained orthostatic stability at 60° of tilt was considered for between-group comparison using chi-square test and the secondary outcomes of the modified Rankin Functional Scale (MRS) and length of hospital stay (LOS) were compared using the Mann-Whitney U test.

Results: Comparison of percentage of subjects who had attained orthostatic stability between the groups was significant on the third and sixth days with p < .05. Mean difference in change of SBP in experimental group was from 15 ± 5.5 to 4 ± 3.5 compared to 14 ± 3.5 to 9 ± 5.5 mm Hg in control at p < .05. Pre-post median scores for MRS and LOS had no significant difference between the groups.

Conclusion: Application of pneumatic abdominal binder and calf compression improved orthostatic stability in acute stroke rehabilitation. Further large-scale studies with long-term follow-up are warranted and necessary.

Abstract Id: 622

Effectiveness of Virtual Reality for the Upper Limb Treatment in Stroke Patients

Turolla A, Agostini M, Dam M, Ventura L, Zucconi C, Kiper P, Vendramin A, Tonin P, Piron L

Laboratory of Kinematiks and Robotics, Fondazione IRCCS Ospedale San Camillo, Venezia, Italy, and Department of Statistics, University of Padova, Padova, Italy

Background and Aims: Recent evidence has indicated that virtual reality (VR) is more effective, compared to traditional physical therapy, to improve the upper limb motor function in stroke patients. Nevertheless the quality of the evidence needs to be reinforced due to the small sample sizes in the included studies. This study was to estimate the effectiveness of the VR treatment for the upper limb, in an open population of stroke patients.

Methods: 376 inpatients suffering from different severities of hemiparesis, between 1998 and 2010, were included. The patients were divided in two treatment groups for the upper limb. In the first group, the treatment was based on the interaction with a virtual environment providing enhanced feedbacks (reinforced feedback in virtual environment [RFVE] group), while in the second, the patients were treated by traditional physical therapy approaches. All the subjects were evaluated by means of the Fugl-Meyer Upper Extremity (F-M UE) and the FIM, before and after the treatment. In both groups, the treatment lasted 5 hours a week for 4 weeks. Gamma regression models were used to study differences between groups after the treatment and in subgroups with different motor impairment (MI) and stroke-therapy interval (STI).

Results: Both F-M UE and FIM were systematically higher in the RFVE group, respectively 2.47 ± 0.51 (P < 0.001) and 3.16 ± 1.118 (P = 0.007) points. The RFVE group had higher results also when analyzed for different STI (respectively F-M UE: 4.85 ± 0.85, P < 0.001, 4.63 ± 0.89, P < 0.001 and FIM: 6.44 ± 1.38, P < 0.001, 6.36 ± 1.63, P < 0.001) and MI (respectively F-M UE: 4.42 ± 1.25, P < 0.001, 2.52 ± 2.03, P = 0.21 and FIM: 3.29 ± 1.67, P = 0.04, 4.71 ± 1.59, P = 0.003).

Conclusions: Our results demonstrated the validity of RFVE in the treatment of the upper limb and also when applied to an open population of stroke inpatients. This evidence is encouraging to recommend the introduction of VR technologies in the usual upper limb rehabilitation after stroke.

Theme: Spasticity

Abstract Id: 507

Building Resilience Among Family Members Providing Support to People with Traumatic Brain Injury or Spinal Cord Injury: Evaluation of the ‘Strength 2 Strength’ Program

Simpson GK^1,2, Jones K¹, Unger C³, Pfeiffer D⁴, Francis J⁵, Oosthuizen H⁶, Young D⁷

¹Brain Injury Rehabilitation Unit, Liverpool Hospital, Sydney, NSW, Australia

²Rehabilitation Studies Unit, University of Sydney, NSW, Australia

³Spinal Outreach Service, Royal Rehabilitation Centre Sydney, NSW, Australia

⁴Clinical Education and Training Institute, Sydney, NSW, Australia

⁵Spinal Injuries Unit, Prince of Wales Hospital, Sydney, NSW, Australia

⁶Moorong Spinal Unit, Royal Rehabilitation Centre Sydney, NSW, Australia

⁷MidWestern Brain Injury Rehabilitation Service, Bathurst, NSW, Australia

Background and Aims: To evaluate the Strength to Strength (S2S) program. S2S is a 10-hour psycho-educational program that aims to build resilience among family members supporting relatives with traumatic brain injury (TBI) or spinal cord injury (SCI).

Methods: S2S was evaluated by a multicentre controlled clinical trial conducted among 49 participants supporting a person with TBI (n = 33) or SCI (n = 16). The sample completed the Positive and Negative Affect Schedule, Resilience Scale, Resilience Scale for Adults, Carer Burden Scale, Carer Assessment of Managing Index and General Self-Efficacy Scale pre- and post treatment. A matched Standard Care group (n = 24) also completed the measures at two time points.

Results: There were no significant differences between family members (Treatment vs. SC) or relatives with the traumatic injury (Treatment vs. SC) on injury/demographic variables; or between families supporting the relative with TBI versus the relative with SCI on the outcome measures. Repeated measures analyses found significant group-by-time interactions (pre vs. post) with the Treatment group reporting a significant increase in strategy use (Carer Assessment of Managing Index; F_(1,68) = 11.1, p = 0.001) and general self-efficacy scores (F_(1,68) = 4.02, p = 0.028) compared to SC. The Treatment group was then divided into participants with high versus low resilience, employing a median split based on Resilience Scale scores, and the two groups compared to SC. Repeated measures analyses found significant group-by-time interactions (pre vs. post) for Resilience Scale for Adults (F_(2,67) = 8.6, p = 0.001), the Carer Assessment of Managing Index (F_(2,67) = 8.7, p = 0.001) and PANAS-positive (F_(2,67) = 3.9, p = 0.024) scores. Planned post-hoc comparisons found the low resilience group scores increased relative to the high resilience group, while the SC group scores remained stable.

Conclusions: Results show initial promise for the efficacy of S2S. Including families with high resilience scores in the groups may serve as useful models for families with low resilience scores.