Randomized Trial of Two Exercise Programs to Increase Physical Activity and Health-Related Quality of Life for Persons With Spinal Cord Injury.

Objectives: To compare the effectiveness of two different interventions that promote physical activity in individuals with traumatic spinal cord injury (SCI) and determine the effect of relapse prevention. Methods: A sequential, multiple assignment, randomized trial was conducted at a universally designed community-based exercise facility. Participants were individuals with traumatic SCI, >3 months post injury, levels C5 to T12, age ≥18 years (N = 79). After randomization, Bridge Program participants completed an 8-week personalized, less intense, exercise program informed by American College of Sports Medicine (ACSM) guidelines and supported with hands-on peer mentoring, exercise of choice, and caregiver training. Structured Exercise participants completed an 8-week program in a group format based on ACSM guidelines. After intervention, participants were randomized to receive or not receive relapse prevention for 6 months. The time and intensity of physical activity and psychological change in depression, anxiety, self-efficacy, and function were assessed with self-reported measures. Results: Compared to baseline, physical activity increased post intervention for both the Bridge and Structured Exercise programs. Compared to baseline, participants in the Bridge Program recorded fewer anxiety symptoms. No significant changes were noted for either program in depressive symptoms, self-efficacy, or function. There was no difference in relapse prevention between the two groups at 6 months. Conclusions: The Bridge Program, a novel personalized exercise program with peer support, exercise of choice, and caregiver training, and a structured exercise program both improved self-reported physical activity, but the Bridge Program also reduced anxiety symptoms. This study provides important insight into the limitations of commonly used measures of physical activity and psychosocial domains in people with SCI.

Exploratory examination of the scale structure of the Moorong Self-Efficacy Scale: Application of Rasch Measurement Theory.

OBJECTIVE: Exploratory application of the Rasch Measurement (RM) Model for evidence for reproducibility, conceptual/content validity, and structural validity of the Moorong Self-Efficacy Scale (MSES). STUDY DESIGN: Secondary RM analysis of data collected in a randomized controlled trial comparing two exercise interventions for persons living with spinal cord injury (SCI). SETTING: Community-dwelling persons living with SCI enrolled in an exercise study. PARTICIPANTS: Adults (n = 79) enrolled in the parent study had a traumatic SCI > 3 months prior, injury level C5 to T12. INTERVENTIONS: Not applicable. OUTCOME MEASURE: The original MSES is a 16-item measure of self-efficacy with a 7-level response scale for un/certainty which was developed for use with persons living with SCI. RESULTS: We addressed item misfit, infrequent category endorsement, and category step disorder by removing two items and reorganizing the rating scale. Rating scale changes removed category 4 (Neutral), combined categories 1-3 (Very Uncertain, Somewhat Uncertain, and Uncertain) for all items, and further combined certainty categories for two items. Principal components analysis of the residuals indicated a possible second dimension with a first-contrast Eigenvalue of 2.4. However, the contrasted item groups had explained variance <10% and a dis-attenuated correlation = 0.92 indicating they measure the same underlying trait. The small sample size precluded examination of differential item functioning. CONCLUSIONS: Exploratory RM analysis of MSES produced a 14-item Rasch version which identified structural and content validity evidence concerns inherent in the original MSES. However, results could be biased by a small sample size and further study should examine the item content and rating scale structure with larger, more diverse samples of persons living with SCI.

Prognosis of Individual-Level Mobility and Daily Activities Recovery From Acute Care to Community, Part 2: A Proof-of-Concept Single Group Prospective Cohort Study.

OBJECTIVE: To demonstrate a proof-of-concept for prognostic models of post-stroke recovery on activity level outcomes. DESIGN: Longitudinal cohort with repeated measures from acute care, inpatient rehabilitation, and post-discharge follow-up to 6 months post-stroke. SETTING: Enrollment from a single Midwest USA inpatient rehabilitation facility with community follow-up. PARTICIPANTS: One-hundred fifteen persons recovering from stroke admitted to an acute rehabilitation facility (N=115). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Activity Measure for Post-Acute Care Basic Mobility and Daily Activities domains administered as 6 Clicks and patient-reported short forms. RESULTS: The final Basic Mobility model defined a group-averaged trajectory rising from a baseline (pseudo-intercept) T score of 35.5 (P<.001) to a plateau (asymptote) T score of 56.4 points (P<.001) at a negative exponential rate of -1.49 (P<.001). Individual baseline scores varied by age, acute care tissue plasminogen activator, and acute care length of stay. Individual plateau scores varied by walking speed, acute care tissue plasminogen activator, and lower extremity Motricity Index scores. The final Daily Activities model defined a group-averaged trajectory rising from a baseline T score of 24.5 (P<.001) to a plateau T score of 41.3 points (P<.001) at a negative exponential rate of -1.75 (P<.001). Individual baseline scores varied by acute care length of stay, and plateau scores varied by self-care, upper extremity Motricity Index, and Berg Balance Scale scores. CONCLUSIONS: As a proof-of-concept, individual activity-level recovery can be predicted as patient-level trajectories generated from electronic medical record data, but models require attention to completeness and accuracy of data elements collected on a fully representative patient sample.

Prognosis of Individual-Level Mobility and Self-Care Stroke Recovery During Inpatient Rehabilitation, Part 1: A Proof-of-Concept Single Group Retrospective Cohort Study.

OBJECTIVE: To demonstrate feasibility of generating predictive short-term individual trajectory recovery models after acute stroke by extracting clinical data from an electronic medical record (EMR) system. DESIGN: Single-group retrospective patient cohort design. SETTING: Stroke rehabilitation unit at an independent inpatient rehabilitation facility (IRF). PARTICIPANTS: Cohort of 1408 inpatients with acute ischemic or hemorrhagic stroke with a mean ± SD age of 66 (14.5) years admitted between April 2014 and October 2019 (N=1408). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: 0-100 Rasch-scaled Functional Independence Measure (FIM) Mobility and Self-Care subscales. RESULTS: Unconditional models were best-fit on FIM Mobility and Self-Care subscales by spline fixed-effect functions with knots at weeks 1 and 2, and random effects on the baseline (FIM 0-100 Rasch score at IRF admission), initial rate (slope at time zero), and second knot (change in slope pre-to-post week 2) parameters. The final Mobility multivariable model had intercept associations with Private/Other Insurance, Ischemic Stroke, Serum Albumin, Motricity Index Lower Extremity, and FIM Cognition; and initial slope associations with Ischemic Stroke, Private/Other and Medicaid Insurance, and FIM Cognition. The final Self-Care multivariable model had intercept associations with Private/Other Insurance, Ischemic Stroke, Living with One or More persons, Serum Albumin, and FIM Cognition; and initial slope associations with Ischemic Stroke, Private/Other and Medicaid Insurance, and FIM Cognition. Final models explained 52% and 27% of the variance compared with unconditional Mobility and Self-Care models. However, some EMR data elements had apparent coding errors or missing data, and desired elements from acute care were not available. Also, unbalanced outcome data may have biased trajectories. CONCLUSIONS: We demonstrate the feasibility of developing individual-level prognostic models from EMR data; however, some data elements were poorly defined, subject to error, or missing for some or all cases. Development of prognostic models from EMR will require improvements in EMR data collection and standardization.

Gait and Balance Outcome Measures Are Responsive in Severely Impaired Individuals Undergoing Inpatient Stroke Rehabilitation.

OBJECTIVE: To investigate whether gait and balance outcome measures in patients with severe gait and balance impairments at admission to inpatient rehabilitation provided additional and meaningful information beyond customary measures. Specifically, this study investigated whether individuals who obtained low scores at admission exhibited improvements that exceeded the established minimal detectable change during inpatient rehabilitation. We also investigated whether gait outcomes would capture changes in function not identified by customary measures. DESIGN: Secondary analysis of a knowledge translation project aimed at increasing the systematic collection of these outcome measures in a poststroke cohort. SETTING: Subacute inpatient rehabilitation facility. PARTICIPANTS: Individuals<2 months poststroke (N=157) with 34-43 with severe deficits including Berg Balance Scale≤5, 10-meter walk test=0 m/s, or 6-minute walk test=0 m. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Berg Balance Scale, 10-meter walk test, 6-minute walk test. RESULTS: After 1 week of rehabilitation, 41%-53% of severely impaired individuals had changes above minimal detectable changes in gait and balance outcomes, which increased to 68%-84% at discharge. Across the entire cohort, FIM locomotion scores failed to identify changes in gait function for 35% of participants after 1 week of rehabilitation. CONCLUSIONS: Routine assessment of gait and balance outcome measures in patients with severe deficits early poststroke may be beneficial. These measures were responsive after 1 week of rehabilitation and detected changes not captured by customary measures. Routine use of a standardized gait and balance assessments may provide clinicians with important information to guide clinical decision making.

Commentary on the Challenges and Benefits of Implementing Standardized Outcome Measures.

The Institute of Medicine (now the National Academy of Medicine) has proposed a Learning Heath system (LHS) as a model to improve health care. A LHS focuses on capturing data from the clinical encounter and applying those data to improve practice. The process can be described as an iterative learning cycle composed of 3 areas: performance to data, data to knowledge, and knowledge to performance or often knowledge translation. Adoption of new knowledge in medicine is notoriously slow, and the relatively new field of knowledge translation is systematically examining the critical success factors. In this issue of the Archives, Moore reports a knowledge translation project in a key aspect of rehabilitation: implementing standardized outcome measures. We report on the challenges and benefits of that project from a practical perspective and identify the critical success ingredient, leadership for implementation, which was composed of 3 key behaviors: setting clear expectations, engaging stakeholders, and providing support. Furthermore, the additional benefits, challenges, and costs are addressed.

Applying the Knowledge-to-Action Framework to Implement Gait and Balance Assessments in Inpatient Stroke Rehabilitation.

OBJECTIVES: The overall objectives of this project were to implement and sustain use of a gait assessment battery (GAB) that included the Berg Balance Scale, 10-meter walk test, and 6-minute walk test during inpatient stroke rehabilitation. The study objective was to assess the effect of the study intervention on clinician adherence to the recommendations and its effect on clinician perceptions and the organization. DESIGN: Pre- and post-training intervention study. SETTING: Subacute inpatient rehabilitation facility. PARTICIPANTS: Physical therapists (N=6) and physical therapist assistants (N=2). INTERVENTION: The intervention comprised a bundle of activities, including codeveloping and executing the plan with clinicians and leaders. The multicomponent implementation plan was based on the Knowledge-to-Action Framework and included implementation facilitation, implementation leadership, and a bundle of knowledge translation interventions that targeted barriers. Implementation was an iterative process in which results from one implementation phase informed planning of the next phase. MAIN OUTCOME MEASURES: Clinician administration adherence, surveys of perceptions, and organizational outcomes. RESULTS: Initial adherence to the GAB was 46% and increased to more than 85% after 6 months. These adherence levels remained consistent 48 months after implementation. Clinician perceptions of measure use were initially high (>63%), with significant improvements in knowledge and use of one measure after implementation. CONCLUSIONS: We successfully implemented the assessment battery with high levels of adherence to recommendations, likely because of using the bundle of knowledge translation activities, facilitation, and use of a framework to codevelop the plan. These changes in practice were sustainable, as determined by a 4-year follow-up.

Participation by design: Integrating a social ecological approach with universal design to increase participation and add value for consumers.

BACKGROUND: Physical activity is an essential component of a healthy lifestyle. Health clubs encourage sustained healthy lifestyles but are still largely not accessible to people with disabilities. Cost is a barrier for accessibility enhancements. HYPOTHESIS: We postulate that: (A) universal design coupled with a social ecological approach improves measured accessibility compared with existing fitness facilities constructed since the adoption of the ADA; (B) increased accessibility coupled with an environment friendly to people with disabilities attracts more participants to a YMCA than predicted by traditional industry market research producing a recovery of the cost of increased accessibility; and (C) attitudes of facility members toward people with disabilities may improve if an accessible facility facilitates more personal interactions between people with and without disabilities. METHODS: Accessibility is measured with the Accessibility Instruments Measuring Fitness and Recreation Environments (AIMFREE). Cost recovery is determined by comparing excess membership revenue to the cost of universal design elements beyond regulatory requirements, and attitudes toward people with disabilities are measured with the Attitudes Toward Disabled Persons Scale. RESULTS: AIMFREE scores were significantly higher than comparison facilities in all areas except for equipment, parking, training, and programs. Excess revenue exceeded the extra cost of accessibility enhancements and attitudes toward people with disabilities did not change. CONCLUSIONS: Universal design coupled with a social ecological approach improves accessibility in fitness facilities and results in a reasonable payback time. Attitudes toward people with disabilities did not change in a YMCA designed to accommodate people with disabilities.

Measuring Value in Postacute Care.

The value of postacute care (PAC) is unclear. While experienced clinicians understand the appropriateness of each specific site of PAC, clear evidence-based guidelines are not available, and many referrals to PAC today are made based on bed availability rather than patient need. Measuring value (value=outcomes/cost) for the entire episode of care has been proposed as an effective method to both evaluate and enable faster innovation in care. Instituting value-based care will increase patient engagement, improve quality and reduce cost with the potential of unifying the goals for all stakeholders-patients and families, providers, and payers. To achieve a goal of value-based care, rehabilitation researchers will need to measure outcomes and cost for the entire episode of care. Recent laudable efforts by the Centers for Medicare & Medicaid Services (CMS) to standardize data across PAC may not include the entire episode of care since outpatient care and measurement from home are not included. In addition, the true cost of services delivered is rarely measured. To implement value-based care in rehabilitation and facilitate cost-effective care improvements, outcomes research in PAC should focus on 4 areas. First, outcome measures need to reflect the patient's perspective. Second, new methods must be implemented to acquire comparable valid and reliable data from all postacute settings and the home. Third, a predictive model for individual patients should be utilized to guide patient referral from acute care to PAC and monitor progress. And fourth, timely specific measures of true cost (resources consumed) for the outcomes achieved are needed.