Two Symptoms to Triage Acute Concussions: Using Decision Tree Modeling to Predict Prolonged Recovery After a Concussion.

OBJECTIVE: The objective was to examine the 22 variables from the Sport Concussion Assessment Tool's 5th Edition Symptom Evaluation using a decision tree analysis to identify those most likely to predict prolonged recovery after a sport-related concussion. DESIGN: A cross-sectional design was used in this study. A total of 273 patients (52% men; mean age, 21 ± 7.6 yrs) initially assessed by either an emergency medicine or sport medicine physician within 14 days of concussion (mean, 6 ± 4 days) were included. The 22 symptoms from the Sport Concussion Assessment Tool's 5th Edition were included in a decision tree analysis performed using RStudio and the R package rpart. The decision tree was generated using a complexity parameter of 0.045, post hoc pruning was conducted with rpart, and the package carat was used to assess the final decision tree's accuracy, sensitivity and specificity. RESULTS: Of the 22 variables, only 2 contributed toward the predictive splits: Feeling like "in a fog" and Sadness. The confusion matrix yielded a statistically significant accuracy of 0.7636 (P [accuracy > no information rate] = 0.00009678), sensitivity of 0.6429, specificity of 0.8889, positive predictive value of 0.8571, and negative predictive value of 0.7059. CONCLUSIONS: Decision tree analysis yielded a statistically significant decision tree model that can be used clinically to identify patients at initial presentation who are at a higher risk of having prolonged symptoms lasting 28 days or more postconcussion.

Exploring the Feasibility and Effectiveness of a Childcare PhysicaL ActivitY (PLAY) Policy: Rationale and Protocol for a Pilot, Cluster-Randomized Controlled Trial.

Background: Young children are prone to low levels of physical activity in childcare. This environment, inclusive of equipment, policies, and staff, has been identified as influencing young children's activity behaviours. To date, no study has examined the feasibility and effectiveness of such policies in Canadian childcare centres, while the provision of physical activity policies in other countries has shown some promise for improving the activity levels of young children. As such, the primary objective of the Childcare PhysicaL ActivitY (PLAY) Policy study is to examine the feasibility of an evidence-based, stakeholder-informed, written physical activity and sedentary time policy for centre-based childcare (i.e., at the institutional level). The secondary objectives are to examine the impact of policy implementation on the physical activity levels and sedentary time of young children, subsequent environmental changes in childcare centres, and childcare providers' self-efficacy to implement a physical activity policy. This study will examine both policy implementation and individual (behavioural) outcomes. Methods/Design: The Childcare PLAY Policy study, a pilot, cluster-randomized controlled trial, involves the random allocation of childcare centres to either the experimental (n = 4) or control (n = 4) group. Childcare centres in the experimental group will adopt a written physical activity policy for eight weeks (at which time they will be asked to stop enforcing the policy). Physical activity levels and sedentary time in childcare will be assessed via ActiGraph™ accelerometers with measurements at baseline (i.e., week 0), mid-intervention (i.e., week 4), immediately post-intervention (i.e., week 9), and at six-month follow-up. Policy implementation and feasibility will be assessed using surveys and interviews with childcare staff. The Environment and Policy Assessment and Observation Self-Report tool will capture potential changes to the childcare setting. Finally, childcare providers' self-efficacy will be captured via a study-specific questionnaire. A nested evaluation of the impact of policy implementation on young children's physical activity levels will be completed. A linear mixed effects models will be used to assess intervention effects on the primary and secondary outcomes. Descriptive statistics and thematic analysis will be employed to assess the feasibility of policy implementation. Discussion: The Childcare PLAY Policy study aims to address the low levels of physical activity and high sedentary time observed in childcare centres by providing direction to childcare staff via a written set of evidence-informed standards to encourage young children's activity and reduce sedentary time. The findings of this work will highlight specific aspects of the policy that worked and will inform modifications that may be needed to enhance scalability. Policy-based approaches to increasing physical activity affordances in childcare may inform future regulations and programming within this environment.

Halstead-Reitan characteristics of nonimpact and impact mTBI litigants and insurance claimants.

The purpose of this study was to investigate possible neuropsychological differences in Halstead-Reitan characteristics between motor vehicle accident litigants and insurance claimants that sustained uncomplicated mild traumatic brain injury (mTBI) and did or did not sustain direct impact to the head (i.e., Impact vs. Nonimpact mTBI), and to compare these clinical groups with a control group that did not suffer mTBI (No mTBI). The Tactile Form Recognition Test (TFR) was the only level of performance test in the Halstead-Reitan Battery (HRB) that generated statistically significant differences. The TFR resembles a complex reaction time test. TFR response time was significantly longer for Nonimpact mTBI patients than for Impact mTBI and No mTBI participants. Frequency comparisons of abnormal score patterns demonstrated that Nonimpact patients produced significantly more aberrant Impairment Index vs. FSIQ score patterns than Impact and No mTBI participants. Given the components of the score pattern, this finding suggests that Nonimpact patients may experience less recovery from neuropsychological deficits than Impact participants. Complex perceptual reaction times and score patterns comparing sensitive and "hold" test results may represent heuristic avenues of future research in the study of compensation-seeking Nonimpact and Impact mTBI patients.

An index of decline or recovery following nonimpact and impact mTBI.

This study investigated the degree to which litigants/insurance claimants sustaining Nonimpact mild traumatic brain injury (mTBI) in motor vehicle accidents differed from compensation-seeking motor vehicle accident victims that suffered Impact mTBI in terms of neuropsychological decline/recovery, using as a control litigants/insurance claimants that did not experience mTBI in motor vehicle accidents. A clinical index (C-Voc) was employed as the dependent measure for decline/recovery, consisting of T-score algebraic differences between a highly sensitive neurocognitive measure (Category Test) and a relatively insensitive "hold" measure (Wechsler Adult Intelligence Scale Vocabulary subtest). Nonimpact mTBI subjects showed significantly greater neurocognitive decline than Impact mTBI participants and, interestingly, Impact mTBI individuals did not differ significantly from individuals with no diagnosis of mTBI. These findings suggest that Nonimpact subjects may experience significantly greater persistent neurocognitive residua of mTBI than Impact participants.

The Implementation and Feasibility of the Supporting Physical Activity in the Childcare Environment (SPACE) Intervention: A Process Evaluation.

This study describes the process evaluation of the Supporting Physical Activity in the Childcare Environment (SPACE) intervention, consisting of educator physical activity training, provision of portable play equipment, and a modified outdoor schedule (i.e., 4 × 30-minute periods). Educators ( N = 49) from 11 childcare centers in London, Ontario, Canada, delivered the 8-week intervention to 200 preschoolers ( Mage = 3.38 years). Workshop attendance was documented while adherence to the outdoor schedule and number and timing of outdoor sessions offered (i.e., dose) were recorded in a daily log. Questionnaire-based program evaluation ( n = 41) and in-person group interviews ( n = 7) were completed postintervention to assess educator perspectives on the barriers and facilitators to implementation (i.e., context), the feasibility and perceived effectiveness of the intervention, educator and preschooler enjoyment, communication among researchers and childcare personnel, and the future implementation of the intervention. Descriptive statistics were calculated, and responses to open-ended questions were inductively coded. Educator workshop attendance was 96%, and 88% of classrooms adhered to the four daily outdoor periods. Educators delivered 90% of the scheduled outdoor sessions, and 87% of these met the 30-minute criteria. Educators expressed that the increase in number of transitions made the outdoor playtimes challenging to implement, yet rated the feasibility of the training and equipment as high. Educators perceived the intervention to be both enjoyable and effective at increasing preschoolers' physical activity. They indicated effective communication and revealed that they intended to continue to use their physical activity knowledge and to offer the play equipment once the intervention had concluded. These findings demonstrate that the SPACE intervention is viable in center-based childcare.

Clinical Assessment of Physical Examination Maneuvers for Superior Labral Anterior to Posterior Lesions.

Purpose Shoulder pain and disability pose a diagnostic challenge owing to the numerous etiologies and the potential for multiple disorders to exist simultaneously. The evidence to support the use of clinical tests for superior labral anterior to posterior complex (SLAP) is weak or absent. The purpose of this study is to determine the diagnostic validity of physical examination maneuvers for SLAP lesions by performing a methodologically rigorous, clinically applicable study. Methods We recruited consecutive new shoulder patients reporting pain and/or disability. The physician took a history and indicated their certainty about each possible diagnosis ("certain the diagnosis is absent/present," or "uncertain requires further testing"). The clinician performed the physical tests for diagnoses where uncertainty remained. Magnetic resonance imaging arthrogram and arthroscopic examination were the gold standards. We calculated sensitivity, specificity, and likelihood ratios (LRs) and investigated whether combinations of the top tests provided stronger predictions. Results Ninety-three patients underwent physical examination for SLAP lesions. When using the presence of a SLAP lesion (Types I-V) as disease positive, none of the tests was sensitive (10.3-33.3) although they were moderately specific (61.3-92.6). When disease positive was defined as repaired SLAP lesion (including biceps tenodesis or tenotomy), the sensitivity (10.5-38.7) and specificity (70.6-93.8) of tests improved although not by a substantial amount. None of the tests was found to be clinically useful for predicting repairable SLAP lesions with all LRs close to one. The compression rotation test had the best LR for both definitions of disease (SLAP tear present = 1.8 and SLAP repaired = 1.67). There was no optimal combination of tests for diagnosing repairable SLAP lesions, with at least two tests positive providing the best combination of measurement properties (sensitivity 46.1% and specificity 64.7%). Conclusion Our study demonstrates that the physical examination tests for SLAP lesions are poor diagnostic indicators of disease. Performing a combination of tests will likely help, although the magnitude of the improvement is minimal. These authors caution clinicians placing confidence in the physical examination tests for SLAP lesions rather we suggest that clinicians rely on diagnostic imaging to confirm this diagnosis.

Impact of the Supporting Physical Activity in the Childcare Environment (SPACE) intervention on preschoolers' physical activity levels and sedentary time: a single-blind cluster randomized controlled trial.

BACKGROUND: Physical activity levels among preschoolers in childcare are low and sedentary time high. The Supporting Physical Activity in the Childcare Environment (SPACE) intervention had three components: 1. portable play equipment; 2. staff training; and, 3. modified outdoor playtime (i.e., shorter, more frequent periods). This study aimed to examine the effectiveness of the SPACE intervention on preschoolers' physical activity levels and sedentary time during childcare hours (compared to standard care). METHODS: Via a single-blind cluster randomized controlled trial, 338 preschoolers (39.86 ± 7.33 months; 52% boys) from 22 centre-based childcare facilities (11 experimental, 11 control) were enrolled. Preschoolers wore an Actical™ accelerometer for 5 days during childcare hours at baseline, post-intervention, and 6- and 12-month follow-up, and were included in the analyses if they had a minimum of two valid days (5 h each day) at baseline and one additional time point. Intervention effectiveness was tested using a linear mixed effects model for each of the four outcome variables (i.e., sedentary time, light physical activity [LPA], moderate-to-vigorous physical activity [MVPA], and total physical activity [TPA]). Fixed effects were further evaluated with t-tests, for which degrees of freedom were estimated using a Satterthwaite approximation. RESULTS: One hundred and ninety-five preschoolers were retained for analyses. The intervention did not significantly impact LPA. MVPA was significantly greater among children in the experimental group when comparing post-intervention to pre-intervention, t(318) = 3.50, p = .0005, but no intervention effects were evident at 6- or 12-month follow-up. TPA was significantly greater for children in the intervention group at post-intervention when compared to pre-intervention, t(321) = 2.70, p = .007, with no intervention effects evident at later time periods. Finally, sedentary time was significantly lower among preschoolers in the experimental group when comparing post-intervention to pre-intervention, t(322) = 2.63, p = .009, with no significant effects at follow-up. CONCLUSIONS: The SPACE intervention was effective at increasing MVPA and TPA among preschoolers, while simultaneously decreasing sedentary time. The ability of the SPACE intervention to target higher intensity activity is promising, as MVPA levels have been documented to be low in centre-based childcare. The changes in physical activity were not sustained long term (6- or 12-month follow-up). TRIAL REGISTRATION: ISRCTN70604107 (October 8, 2014).

Assessment of Caregiving Constructs: Toward a Personal, Familial, Group, and Cultural Construction of Dementia Care through the Eyes of Personal Construct Psychology.

Conditions that cause cognitive impairment and behavioural and personality changes, such as Alzheimer's disease (AD) and related dementia, have global impact across cultures. However, the experience of dementia care can vary between individuals, families, formal caregivers, and social groups from various cultures. Self-reported measures, caregiving stress models, and conceptual theories have been developed to address the physical, financial, psychological, and social factors associated with the experience of dementia care. Given the cross-cultural variability in the experience of dementia care, it is important for such methodologies to take individual and cultural construct systems into account. We contend that personal and group constructs associated with dementia care should be explored in both the formal and informal caregiving contexts. Therefore, in this paper we introduce the theory of Personal Construct Psychology (PCP) with its explicit philosophy, well-elaborated theory, and derived assessment methods as a potential constructivist research approach to examine the personal, familial, group, and cultural construct systems that determine the experience of dementia caregiving. These concepts and assessment procedures are illustrated in this paper through case study examples and scenarios from the context of dementia care with a focus on family home caregivers. This paper elaborates the assessment and therapeutic approaches of personal construct theory (PCT) to further expand alternatives for support services and program interventions and to amplify policies for dementia care within and across cultures.

Halstead-Reitan Deficit Scores in Assessment of Nonimpact Head Injury.

Comparisons were made between neuropsychological deficit scores generated by the Reitan-Wolfson system of interpretation (1993) and the computerized Revised Comprehensive Norms for an Expanded Halstead-Reitan Battery (Heaton, Miller, Taylor, Grant, & PAR Staff, 2005 ). The scores were obtained from seat-belted litigants and insurance claimants subjected to extreme physical forces in motor vehicle accidents. Subjects had not sustained direct impact to the head but met criteria for mild traumatic brain injury. The word "nonimpact" has been used to describe this form of head injury. Consistent with previous studies, the Reitan-Wolfson system generated deficit scores suggestive of a greater degree of impairment than the Revised Comprehensive Norms. Demographic characteristics of the normative data used in each interpretive system and the operational definition of impairment were scrutinized. Likely or possible determinants of deficit score discrepancies were identified. On the basis of this information, a method of using the two interpretive procedures in an integrated manner to assess nonimpact head injury was suggested.

MoCA cutoff score in relation to the functional assessment of seniors living in a rural Canadian community.

INTRODUCTION: Research suggests that the Montreal Cognitive Assessment (MoCA) normal cutoff score of 26 may not be appropriate for all populations and ages. We sought to determine an appropriate MoCA cutoff score for community-dwelling seniors living in a rural Canadian community. METHODS: We conducted a retrospective chart review at a health centre in rural northern Ontario. The sample included community-dwelling seniors presenting between Dec. 1, 2013, and July 31, 2015. We generated a receiver operating characteristic curve to evaluate MoCA cutoff scores in relation to functional assessment, using the dichotomous categories of "no deficiencies in activities of daily living/instrumental activities of daily living (ADL/IADL) and "deficiencies in ADL/IADL." RESULTS: A total of 95 charts were included in the chart review. We identified MoCA scores of 20 (sensitivity 85%, specificity 62%) and 21 (sensitivity 77%, specificity 77%) as cutoff scores for the identification of impairment in this rural population. CONCLUSION: Our results suggest the normal range in MoCA score for the community-dwelling rural senior to be between 22 and 30. Although the MoCA demonstrated satisfactory performance as a screening measure, the importance of including ADL and IADL functional assessments before making clinical decisions cannot be overemphasized.

INTRODUCTION: Des études semblent indiquer que le seuil habituellement utilisé dans la Montreal Cognitive Assessment (MoCA), soit un score de 26, pourrait ne pas convenir à tous les groupes et à toutes les tranches d'âges. Nous avons cherché à déterminer un seuil approprié pour l'évaluation des personnes âgées habitant dans la communauté d'une région rurale canadienne. METHODS: Nous avons mené un examen rétrospectif des dossiers dans un centre de santé d'une région rurale du Nord de l'Ontario. Notre échantillon était composé des personnes âgées habitant dans la communauté qui se sont présentées au centre entre le 1er décembre 2013 et le 31 juillet 2015. Nous avons généré une courbe caractéristique de la performance afin d'évaluer la validité des scores MoCA par rapport à une évaluation fonctionnelle reposant sur des catégories dichotomiques, soit « aucune déficience dans les activités de la vie quotidienne (AVQ)/activités instrumentales de la vie quotidienne (AIVQ) ¼ et « déficiences dans les AVQ/AIVQ ¼. RESULTS: En tout, 95 dossiers ont été examinés. Nous avons conclu que des scores MoCA de 20 (sensibilité de 85 %, spécificité de 62 %) et de 21 (sensibilité de 77 %, spécificité de 77 %) seraient des seuils appropriés pour détecter la déficience chez cette population rurale. CONCLUSION: Nos résultats indiquent que la plage normale de scores MoCA chez les personnes âgées habitant dans la communauté en milieu rural est de 22 à 30. Bien que la MoCA se soit révélée d'une efficacité satisfaisante comme outil de dépistage, nous nous devons d'insister sur l'importance capitale de tenir compte de l'évaluation fonctionnelle des AVQ et des AIVQ dans la prise de décisions cliniques.

Clinical Assessment of Physical Examination Maneuvers for Rotator Cuff Lesions.

BACKGROUND: Shoulder pain and disability pose a diagnostic challenge for clinicians owing to the numerous causes that exist. Unfortunately, the evidence in support of most clinical tests is weak or absent. PURPOSE: To determine the diagnostic validity of physical examination maneuvers for rotator cuff lesions. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 1. METHODS: Consecutive shoulder patients recruited for this study were referred to 2 tertiary orthopaedic clinics. A surgeon took a thorough history and indicated his or her certainty about each possible diagnosis. A clinician performed the physical examination for diagnoses where uncertainty remained. Arthroscopy was considered the reference standard for patients who underwent surgery, and MRI with arthrogram was considered the reference for patients who did not. The sensitivity, specificity, and likelihood ratios were calculated to investigate whether combinations of the top tests provided stronger predictions of the presence or absence of disease. RESULTS: There were 139 participants. None of the tests were highly sensitive for diagnosing rotator cuff tears or tendinosis. Tests for subscapularis tears were all highly specific. No optimal combination of tests improved the ability to correctly diagnose rotator cuff tears. Closer analysis revealed the internal rotation and lateral rotation lag sign did not improve the ability to diagnose subscapularis or supraspinatus tears, respectively, although the lateral rotation lag sign demonstrated a discriminatory ability for tear size. CONCLUSION: No test in isolation is sufficient to diagnose a patient with rotator cuff damage. A combination of tests improves the ability to diagnose damage to the rotator cuff. It is recommended that the internal rotation and lateral rotation lag signs be removed from the gamut of physical examination tests for supraspinatus and subscapularis tears.

Validity of the Nintendo Wii® balance board for the assessment of standing balance in Parkinson's disease.

BACKGROUND: Impaired postural stability places individuals with Parkinson's at an increased risk for falls. Given the high incidence of fall-related injuries within this population, ongoing assessment of postural stability is important. OBJECTIVE: To evaluate the validity of the Nintendo Wii(®) balance board as a measurement tool for the assessment of postural stability in individuals with Parkinson's. SUBJECTS: Twenty individuals with Parkinson's participated. INTERVENTION: Subjects completed testing on two balance tasks with eyes open and closed on a Wii(®) balance board and biomechanical force platform. MAIN MEASURES: Bland-Altman plots and a two-way, random-effects, single measure intraclass correlation coefficient model were used to assess concurrent validity of centre-of-pressure data. RESULTS: Concurrent validity was demonstrated to be excellent across balance tasks (intraclass correlation coefficients = 0.96, 0.98, 0.92, 0.94). CONCLUSIONS: This study suggests that the Wii(®) balance board is a valid tool for the quantification of postural stability among individuals with Parkinson's.