Repeated Treatments With Botulinum Toxin Type A Produce Sustained Decreases in the Limitations Associated With Focal Upper-Limb Poststroke Spasticity for Caregivers and Patients
A number of studies have demonstrated that botulinum toxin type A (BTX-A) injections reduce the spasticity and improve the function of the muscles of people with upper motoneuron dysfunction. Many, in fact, receive repeated injections, but, as Elovic and colleagues note, less is known about the effects of repeated injections over time. The authors investigate this issue in a multicenter, multi-injection, open-label study involving 275 patients with subacute stroke. Participants received up to 5 BTX-A injections over a 1-year period. Subjects displayed statistically and clinically significant improvements in muscle tone and function that were detectable at the study's midpoint and persisted to its end. Mild-to-moderate treatment-related adverse events related to weakness and pain were considered by the investigators to have occurred in 18 (6%) of the patients; 1 subject discontinued the study due to finger weakness. The findings are encouraging but further research on the effectiveness of repeated injections appears warranted. • SEE PAGE 799
Nancy K. Latham, PhD, PT
Alan M. Jette, PhD, PT
Long H. Ngo, PhD
Jane Soukup, MS
Lisa I. Iezzoni, MD, MS
Did the 1997 Balanced Budget Act Reduce Use of Physical and Occupational Therapy Services?
The Balanced Budget Act of 1997 (BBA) had a goal of reducing the growing cost of Medicare, but its effect on the delivery rehabilitation services has been unclear. Latham and colleagues address this issue by using the Medicare Current Beneficiary Survey and claims data to analyze the utilization of physical (PT) and occupational therapy (OT) by almost 8000 patients with a selection of chronic diseases. Three time points (1995, 1999, 2001) were assessed and inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), outpatient providers, and home health agencies were included in the analysis. The investigators found that the proportion of people receiving PT or OT services from home health providers was similar across the 3 time points. Furthermore, the chances of a patient receiving PT in an SNF increased both during the introduction of the BBA (1995–1999) as well as during 1995–2001 (OR=1.4. OR=1.7, respectively). Increases were also noted throughout the study period in IRFs and outpatient facilities. OT services displayed a similar picture, although increases in IRF and outpatient settings were limited to 1995–2001. The total amount of therapy delivered increased in all settings but IRFs. These findings suggest that the delivery of rehabilitation services has increased since the BBA, but that there has been a shift from the inpatient setting to other providers. • SEE PAGE 807
Christopher J. Standaert, MD
Paul A. Manner, MD
Stanley A. Herring, MD
Expert Opinion and Controversies in Musculoskeletal and Sports Medicine: Femoroacetabular Impingement
Although hip osteoarthritis (OA) is a common cause of disability, its etiology may be more obscure than many of us think. Standaert and colleagues address a mechanism of hip OA that is based on the concept that it may be ultimately due to an abnormal and repeated contact between the proximal femur and acetabular rim (ie, femoroacetabular impingement). This contact, in turn, is thought to lead to the development of labrochondral lesions and ultimately full-blown disease. Two mechanisms are proposed. One, cam impingement, is thought to occur when an abnormally shaped femoral head produces and eccentric center of rotation forces the femoral neck against the acetabular lip. The other, pincer impingement, is based on the idea that acetabular abnormalities can generate a pincer-like force between the femur and the acetabulum. Presumably, both mechanisms may occur. The data, however, are limited and, as Standaert points out, little is known about the natural history of the syndrome or the long-term effects of treatment. • SEE PAGE 890
Tamara Bushnik, PhD
Traumatic Brain Injury Model Systems of Care 2002–2007
The Traumatic Brain Injury Model Systems (TBIMS) program has been in existence for 20 years and, over this period of time, has grown from an initial 4 centers to 16 in 2007. The National Institute on Disability and Rehabilitation Research–funded centers represent a large research infrastructure, with each center contributing to a common database that now includes more than 7000 people with TBI. As such, it serves as a unique source of longitudinal information and aid to the understanding of the outcomes and rehabilitation of people with TBI. The TBIMS's research goals are particularly important given the growing emphasis on brain injury arising out of the warfare in the Middle East. Thus, this special collection of 14 articles, reviewing the research and activities of the centers over the last 5 years, is particularly timely. • SEE PAGES 894–1003
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