The Role of Rehabilitation for Early-Stage Alzheimer's Disease and Related Dementias: Practice and Priorities.

The World Health Organization describes rehabilitation as interventions that focus on addressing disability through optimizing functional ability for individuals living with various health challenges in their unique daily life contexts. Rehabilitation services are typically seeking to enhance functional capacity and health, either in concert with, or in place of pharmacologic interventions. These services typically fall into 2 categories, restorative, where the client endeavors to return to a prior level of independent function, and compensatory, where s/he may not. In the latter case, clients might receive, and be trained to use, technology aids or other external supports to enable them to engage in a safe, healthy, and meaningful day-to-day life. For some populations, however, even enhanced functional capacity can present in the form of an insidious, albeit slower decline. So, what is, or should, rehabilitation's role be in progressive neurologic conditions? Specifically, what are the policy and practice implications of rehabilitation for (not in the presence of, but for) the care of persons living with neurodegenerative conditions such as Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD)?

Impact of coronary bifurcation angle on computed tomography derived fractional flow reserve in coronary vessels with no apparent coronary artery disease.

OBJECTIVES: Computed tomography (CT) derived fractional flow reserve (FFRCT) decreases from the proximal to the distal part due to a variety of factors. The energy loss due to the bifurcation angle may potentially contribute to a progressive decline in FFRCT. However, the association of the bifurcation angle with FFRCT is still not entirely understood. This study aimed to investigate the impact of various bifurcation angles on FFRCT decline below the clinically crucial relevance of 0.80 in vessels with no apparent coronary artery disease (CAD). METHODS: A total of 83 patients who underwent both CT angiography including FFRCT and invasive coronary angiography, exhibiting no apparent CAD were evaluated. ΔFFRCT was defined as the change in FFRCT from the proximal to the distal in the left anterior descending artery (LAD) and left circumflex artery (LCX). The bifurcation angle was calculated from three-dimensional volume rendered images. Vessel morphology and plaque characteristics were also assessed. RESULTS: ΔFFRCT significantly correlated with the bifurcation angle (LAD angle, r = 0.35, p = 0.001; LCX angle, r = 0.26, p = 0.02) and vessel length (LAD angle, r = 0.30, p = 0.005; LCX angle, r = 0.49, p < 0.0001). In LAD, vessel length was the strongest predictor for distal FFRCT of ≤ 0.80 (ß-coefficient = 0.55, p = 0.0003), immediately followed by the bifurcation angle (ß-coefficient = 0.24, p = 0.02). The bifurcation angle was a good predictor for a distal FFRCT ≤ 0.80 (LAD angle, cut-off 31.0°, AUC 0.70, sensitivity 74%, specificity 68%; LCX angle, cut-off 52.6°, AUC 0.86, sensitivity 88%, specificity 85%). CONCLUSIONS: In vessels with no apparent CAD, vessel length was the most influential factor on FFRCT, directly followed by the bifurcation angle. KEY POINTS: • Both LAD and LCX bifurcation angles are factors influencing FFR CT. • Bifurcation angle is one of the predictors of a distal FFRCT of ≤ 0.80 and an optimal cut-off value of 31.0° for the LAD and 52.6° for the LCX. • Bifurcation angle should be taken into consideration when interpreting numerical values of FFRCT.

Driving Automation for Older Adults with Preclinical Alzheimer's Disease.

INTRODUCTION: Older adults with preclinical Alzheimer's disease (AD) show changes in on-road driving performance. The impact of preclinical AD on using automated vehicle (AV) technology is unknown. The aim was to evaluate safety and cognitive workload while operating AV technology in drivers with preclinical AD. INTRODUCTION: This cross-sectional study included 40 participants: 19 older adults (age 74.16 ± 4.78; MOCA scores 26.42 ± 2.52) with preclinical AD, evidenced by elevated cortical beta-amyloid; and 21 controls (age 73.81 ± 5.62; MOCA scores 28.24 ± 1.67). All participants completed two scenarios in a driving simulator. Scenario 1 included conditional automation with an emergency event that required a manual take-over maneuver. Scenario 2 was identical but with a cognitive distractor task. Emergency response time was the main safety outcome measure. Cognitive workload was calculated using moment-to-moment changes in pupillary size and converted into an Index of Cognitive Activity (ICA). Mann-Whitney U and independent t tests were used to compare group differences. RESULTS: Emergency response times were similar between drivers with preclinical AD and controls in scenario 1 (20.85 s ± 1.08 vs. 20.52 s ± 3.18; p = 0.83) and scenario 2 (14.83 s ± 7.37 vs. 13.45 s ± 10.43; p = 0.92). Likewise, no differences were found in ICA between drivers with preclinical AD and controls in scenario 1 (0.34 ± 0.08 vs. 0.33 ± 0.17; p = 0.74) or scenario 2 (0.30 ± 0.07 vs. 0.29 ± 0.17; p = 0.93). CONCLUSIONS: Older drivers with preclinical AD may safely operate AV technology, without increased response times or cognitive workload. Future on-road studies with AV technology should confirm these preliminary results in drivers with preclinical AD.

Frailty and Falls in People Living With Multiple Sclerosis.

OBJECTIVE: To explore the association between frailty and history of falls in people living with multiple sclerosis (MS). DESIGN: Secondary analysis. SETTING: University research laboratories in the United States and Israel. PARTICIPANTS: A total of 118 people (N=118) with relapsing-remitting MS (mean age, 48.9±10.0 years; 74.6% female; Expanded Disability Status Scale [EDSS] range, 1.0-6.0) were studied in this cross-sectional analysis. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: A frailty index was calculated from 40 health deficits by following standard validated procedures. The number of falls (12-month history) was recorded. RESULTS: Overall, 33.9%, 29.7%, and 36.4% of participants were classified as nonfrail, moderately frail, and severely frail, respectively. The frailty index was significantly correlated (ρ=0.37, P<.001) with higher scores on the EDSS. In univariable negative binomial regression analysis, the frailty index was associated with a higher number of falls (incidence rate ratio [IRR]=3.33; 95% CI, 1.85-5.99; P<.001). After adjustment for age, sex, and EDSS, frailty remained strongly associated with history of falls (IRR=2.78; 95% CI, 1.51-5.10; P=.001). CONCLUSIONS: The current study identifies a significant relationship between frailty and history of falls in MS, independent of age, sex, and disease severity. These findings support the notion that frailty is a syndrome related to but independent of disability in MS.

Cortical Correlates of Increased Postural Task Difficulty in Young Adults: A Combined Pupillometry and EEG Study.

The pupillary response reflects mental effort (or cognitive workload) during cognitive and/or motor tasks including standing postural control. EEG has been shown to be a non-invasive measure to assess the cortical involvement of postural control. The purpose of this study was to understand the effect of increasing postural task difficulty on the pupillary response and EEG outcomes and their relationship in young adults. Fifteen adults completed multiple trials of standing: eyes open, eyes open while performing a dual-task (auditory two-back), eyes occluded, and eyes occluded with a dual-task. Participants stood on a force plate and wore an eye tracker and 256-channel EEG cap during the conditions. The power spectrum was analyzed for absolute theta (4−7 Hz), alpha (8−13 Hz), and beta (13−30 Hz) frequency bands. Increased postural task difficulty was associated with greater pupillary response (p < 0.001) and increased posterior region alpha power (p = 0.001) and fronto-central region theta/beta power ratio (p = 0.01). Greater pupillary response correlated with lower posterior EEG alpha power during eyes-occluded standing with (r = −0.67, p = 0.01) and without (r = −0.69, p = 0.01) dual-task. A greater pupillary response was associated with lower CoP displacement in the anterior−posterior direction during dual-task eyes-occluded standing (r = −0.60, p = 0.04). The pupillary response and EEG alpha power appear to capture similar cortical processes that are increasingly utilized during progressively more challenging postural task conditions. As the pupillary response also correlated with task performance, this measurement may serve as a valuable stand-alone or adjunct tool to understand the underlying neurophysiological mechanisms of postural control.

Reliability and Validity of Pupillary Response During Dual-Task Balance in Parkinson Disease.

OBJECTIVE: To investigate the reliability and validity of pupillary response during dual-task balance conditions in individuals with Parkinson disease (PD). DESIGN: Cross-sectional study. SETTING: University of Kansas Medical Center Parkinson's Disease and Movement Disorder Center. PARTICIPANTS: Participants (N=68) included individuals with PD (n=33) and healthy controls (n=35). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Pupillary response was the main outcome measure that was measured during the following conditions: single-task balance eyes open, single-task balance eyes occluded, dual-task eyes open, and dual-task eyes occluded. After each condition, the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) was administered to assess self-reported cognitive workload. To examine the test-retest reliability of the pupillary response, the conditions were administered twice for each individual within 2 hours. Intraclass correlation coefficients (ICC) were used to analyze the test-retest reliability of pupillary response in each condition for both groups. Pearson's r correlation was used to assess the convergent validity of pupillary response against the NASA-TLX. RESULTS: The test-retest reliability was excellent for both groups in almost all conditions (ICC>0.75). There were no correlations between pupillary response and the NASA-TLX. However, increased mental demand (a subitem of the NASA-TLX) significantly correlated with increased pupillary response in individuals with PD (r=0.38; P=.03). CONCLUSIONS: Pupillary response showed excellent test-retest reliability and validity during dual-task balance for individuals with PD and healthy controls. Overall, these results suggest that pupillary response represents a stable index of cognitive workload during dual-task balance in individuals with PD.

Cognitive workload during verbal abstract reasoning in Parkinson's disease: a pilot study.

BACKGROUND: Pupillary response reflects cognitive workload during processing speed, working memory, and arithmetic tasks in Parkinson's disease (PD). Abstract reasoning, a higher-order cognitive function that relates different objects, events, or thoughts in a similar manner, may also be compromised in PD. The aim of this study was to compare pupillary response as a measure of cognitive workload while completing a verbal abstract reasoning test between patients with PD and age-matched controls. METHODS: Nineteen non-demented individuals with PD (66.6 ± 8.9 years) and 10 healthy controls (65.3 ± 7.3 years) were recruited. A remote eye tracker recorded the pupillary response at 60 Hz, while the participants were performing the Similarities test of Wechsler Adult Intelligence Scale-IV. Outcome measures included pupillary response, evaluated by the Index of Cognitive Activity (ICA), and behavioral responses of the Similarities test. RESULTS: The PD group (scaled scores = 8.9 ± 2.2) did not show impairment in behavioral performance on Similarities test compared with healthy controls (scaled scores = 8.8 ± 2.3; p = .91). However, the PD group (ICA = .32 ± .09) demonstrated significantly greater cognitive workload during the Similarities test compared to controls (ICA = .24 ± .08; p = .03). CONCLUSIONS: Non-demented individuals with PD exerted greater cognitive workload to complete a verbal abstract reasoning task despite similar behavioral performance compared to healthy controls. Clinical utilities of pupillary response to detect and monitor early impairment in higher-order executive function will be the subject of further study in the PD population.

Classification of Parkinson's disease and essential tremor based on balance and gait characteristics from wearable motion sensors via machine learning techniques: a data-driven approach.

BACKGROUND: Parkinson's disease (PD) and essential tremor (ET) are movement disorders that can have similar clinical characteristics including tremor and gait difficulty. These disorders can be misdiagnosed leading to delay in appropriate treatment. The aim of the study was to determine whether balance and gait variables obtained with wearable inertial motion sensors can be utilized to differentiate between PD and ET using machine learning. Additionally, we compared classification performances of several machine learning models. METHODS: This retrospective study included balance and gait variables collected during the instrumented stand and walk test from people with PD (n = 524) and with ET (n = 43). Performance of several machine learning techniques including neural networks, support vector machine, k-nearest neighbor, decision tree, random forest, and gradient boosting, were compared with a dummy model or logistic regression using F1-scores. RESULTS: Machine learning models classified PD and ET based on balance and gait characteristics better than the dummy model (F1-score = 0.48) or logistic regression (F1-score = 0.53). The highest F1-score was 0.61 of neural network, followed by 0.59 of gradient boosting, 0.56 of random forest, 0.55 of support vector machine, 0.53 of decision tree, and 0.49 of k-nearest neighbor. CONCLUSIONS: This study demonstrated the utility of machine learning models to classify different movement disorders based on balance and gait characteristics collected from wearable sensors. Future studies using a well-balanced data set are needed to confirm the potential clinical utility of machine learning models to discern between PD and ET.

Fat misbehaving in the abdominal cavity: a pictorial essay.

Intra-abdominal fat is abundantly present in both the peritoneum and retroperitoneum. Fat necrosis or inflammation are common findings in abdominal imaging. The most common pathologies that we encounter are epiploic appendagitis, omental infarction, mesenteric panniculitis, and encapsulated fat necrosis. Less common entities that can occur are pancreatic saponification, heterotopic mesenteric ossification, and pseudolipoma of the capsule of Glisson. These entities can mimic more urgent pathologies such as appendicitis, diverticulitis, or malignancies.

Pupillary response: cognitive effort for breast cancer survivors.

PURPOSE: The purpose of this cross-sectional comparative pilot study was to evaluate cognitive effort, indexed by pupillary response (PR), for breast cancer survivors (BCS) with complaints of cognitive dysfunction following chemotherapy. STUDY AIMS: Compare the cognitive effort employed by BCS to healthy controls (HC) during neuropsychological tests (NPT) for memory, sustained attention, verbal fluency, visuospatial ability, processing speed and executive function; and Investigate the relationship between PR-indexed cognitive effort and participants' self-report of cognitive function. METHODS: Self-report of cognitive function was collected from 23 BCS and 23 HC. PR was measured during NPT. Independent two-sample t tests or Wilcoxon rank sum tests were used to compare group scores. Between-group effect size (Cohen's d) was calculated for each outcome. Correlation between mean self-report scores and PR values, as well as 95% confidence intervals, was calculated. RESULTS: No group differences were demonstrated for NPT performance. BCS reported more issues with cognitive function than HC (p < .0001). A group effect for BCS was seen with PR-indexed cognitive effort for components of most NPT (p < .05). PR was correlated with most self-report measures of cognitive function (r = 0.33-0.45). CONCLUSIONS: PR sensitivity to cognitive effort across a variety of NPT and correlation with self-report of cognitive function was demonstrated. The portability, affordability, and "real-time" aspects of PR are attractive for potential use in the clinic setting to assess cognitive function. A larger study is needed to confirm these results. Prospective investigation of PR in BCS is needed to demonstrate sensitivity to cognitive function changes over time.

Post-concussion driving management among athletic trainers.

Primary objective: To describe and compare athletic trainer (AT) post-concussion driving management practices and opinions.Research design: Cross-sectional.Methods & procedures: A survey was sent via email to 8,723 ATs (10.8% response rate[945/8723]) to capture demographics, management practices, and opinions (agreement on a seven-point Likert scale). We used Kruskal-Wallis tests to compare the percentage of patients instructed to refrain from driving across the highest earned a degree, setting, and years certified (alpha = 0.05).Main outcomes & results: When asked whether they recommended patients with concussion refrain from driving, 58.5%(n = 553/945) of ATs responded "sometimes", 37.9%(n = 358/945) responded "always", and 3.6%(n = 34/945) responded "never". ATs responding "sometimes" or "always" estimated that they instruct 57.6 ± 37.6% of patients with concussion to refrain from driving. ATs most commonly: recommended that patients refrain from driving until symptom resolution(44.7%,n = 399/892); utilized their clinical exam (patient interview/history) to determine when a patient could resume driving(64.9%,n = 579/892); and provided instructions verbally(94.2%,n = 840/892). High school(60.5 ± 37.6%) and clinical ATs(66.5 ± 31.2%) trended toward higher percentages of patients they instruct to refrain from driving relative to college(52.3 ± 38.2%; χ2(2) = 5.92,p = .052).Conclusions: ATs recommend driving restrictions to some, but not all, patients with concussion. Overall, ATs recognize post-concussion driving dangers, but do not strongly endorse refraining from driving after a concussion. High school and clinical ATs may manage more adolescent novice drivers and, therefore, act more conservatively.

Visceral Fibromuscular Dysplasia: From asymptomatic disorder to emergency.

Fibromuscular dysplasia (FMD) is an idiopathic, segmental, non-atherosclerotic and non-inflammatory disease of the musculature of arterial walls, leading to stenosis of small and medium-sized arteries, mostly involving renal and cervical arteries. As a result of better and more systematic screening, it appears that involvement of the splanchnic vascular bed is more frequent than originally assumed. We review epidemiology, pathogenesis, clinical picture as well as diagnosis and treatment of visceral artery (VA) FMD. The clinical picture is very diverse, and diagnosis is based on CT-, MR- or conventional catheter-based angiography. Involvement of VAs generally occurs among patients with multi-vessel FMD. Therefore, screening for VA FMD is advised especially in renal artery (RA) FMD and in case of aneurysms and/or dissections. Treatment depends on the clinical picture. However, the level of evidence is low, and much of the common practice is extrapolated from visceral atherosclerotic disease.

The Impact of Advanced Age on Driving Safety in Adults with Medical Conditions.

BACKGROUND: Adults aged 85 and older, often referred to as the oldest-old, are the fastest-growing segment of the population. The rapidly increasing number of older adults with chronic and multiple medical conditions poses challenges regarding their driving safety. OBJECTIVE: To investigate the effect of advanced age on driving safety in drivers with medical conditions. METHODS: We categorized 3,425 drivers with preexisting medical conditions into four age groups: middle-aged (55-64 years, n = 1,386), young-old (65-74 years, n = 1,013), old-old (75-84 years, n = 803), or oldest-old (85 years and older, n = 223). All underwent a formal driving evaluation. The outcome measures included fitness to drive recommendation by the referring physician, comprehensive fitness to drive decision from an official driving evaluation center, history of motor vehicle crashes (MVCs), and history of traffic violations. RESULTS: The oldest-old reported more cardiopulmonary and visual conditions, but less neurological conditions than the old-old. Compared to the middle-aged, the oldest-old were more likely to be considered unfit to drive by the referring physicians (odds ratio [OR] = 4.47, 95% confidence interval [CI] 2.20-9.10) and by the official driving evaluation center (OR = 2.74, 95% CI 1.87-4.03). The oldest-old reported more MVCs (OR = 2.79, 95% CI 1.88-4.12) compared to the middle-aged. CONCLUSION: Advanced age adversely affected driving safety outcomes. The oldest-old are a unique age group with medical conditions known to interfere with safe driving. Driving safety strategies should particularly target the oldest-old since they are the fastest-growing group and their increased frailty is associated with severe or fatal injuries due to MVCs.

Interdisciplinary Approaches to Facilitate Return to Driving and Return to Work in Mild Stroke: A Position Paper.

Adults with mild stroke face substantial challenges resuming valued roles in the community. The term "mild" provides false representation of the lived experience for many adults with mild stroke who may continue to experience persistent challenges and unmet needs. Rehabilitation practitioners can identify and consequently intervene to facilitate improved independence, participation, and quality of life by facilitating function and reducing the burden of lost abilities among adults with mild stroke. The Health and Wellness Task Force identified 2 important, and often interdependent, goals that frequently arise among adults living with mild stroke that must be addressed to facilitate improved community reintegration: (1) return to driving and (2) return to work. Adults with mild stroke may not be receiving adequate rehabilitative services to facilitate community reintegration for several reasons but primarily because current practice models are not designed to meet such needs of this specific population. Thus, the Health and Wellness Task Force convened to review current literature and practice trends to (1) identify opportunities based on the evidence of assessment and interventions, for return to driving and return to work; and (2) identify gaps in the literature that must be addressed to take advantage of the opportunities. Based on findings, the task force proposes a new interdisciplinary practice model for adults with mild stroke who are too often discharged from the hospital to the community without needed services to enable successful return to driving and work.